The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 95, Issue 1

Scientific Articles | January 02, 2013

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Follow-up to a Minimum of Sixteen Years of Age

Sujit Kumar, MBBS, MS, MRCS¹; David Ahearne, FRCS(Tr&Orth)¹; David M. Hunt, FRCS(Tr&Orth)¹

¹ Department of Orthopaedics, St. Mary’s Hospital, Praed Street, London W2 1NY, United Kingdom. E-mail address for D.M. Hunt: davidhunt@uk-consultants.co.uk

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Investigation performed at the Department of Orthopaedics, St. Mary’s Hospital, London, and The Wellington Hospital, London, United Kingdom

J Bone Joint Surg Am, 2013 Jan 02;95(1):e1 1-6. doi: 10.2106/JBJS.K.01707

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Abstract

Background:

The evidence in favor of early surgical treatment of anterior cruciate ligament (ACL) injuries in children is increasing. However, the controversy regarding the safety of such a procedure in young athletes with wide open physes remains unresolved.

Methods:

We reviewed prospectively collected outcome data on consecutive patients who had undergone transphyseal ACL reconstruction at either (1) an age of less than fourteen years and Tanner stage 1 or 2, or (2) an age of less than twelve years and Tanner stage 3. Children who had less than four years of follow-up, who were younger than sixteen years at the time of final follow-up, or who had been at Tanner stage 4 at the time of surgery were excluded. Twenty-eight of the thirty-two included patients had been at Tanner stage 1 or 2 at the time of surgery, and the remaining four had been at Tanner stage 3 but had been younger than twelve years of age. The mean age at the time of the surgery was 11.25 years (range, 9.5 to 14.0 years; median, 12.1 years). The mean duration of follow-up was 72.3 months (range, forty-eight to 129 months; median, seventy-two months).

Results:

The mean Lysholm score improved from 71.5 preoperatively to 95.86 postoperatively (p < 0.0001). The mean Tegner activity scale score improved from 4.03 to 7.66 (p < 0.0001), which was comparable with the preinjury score of 8.0. One patient had a mild valgus deformity with no functional disturbance, and none had a limb-length discrepancy. One rerupture occurred, but all other patients had a good or excellent outcome.

Conclusions:

This case series indicates good long-term results of ACL reconstruction with use of a transphyseal technique in young children.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Appendix

A midsubstance tear of the anterior cruciate ligament (ACL) in children is no longer considered a rare injury^1-3. Increasing awareness of the surgical treatment options and higher parental expectations have led to a greater number of these children undergoing ACL reconstruction. There have been many recent publications regarding early reconstruction^4-20. This interest is a consequence of the failure of conservative management in preventing instability and meniscal damage resulting in early degenerative changes^7,21-24. However, fear of growth arrest secondary to a procedure involving the physis has led to the use of alternative extra-articular techniques or modified, physis-sparing intra-articular techniques^11-14,25-28. The modifications to the intra-articular technique require the surgeon to deviate from the familiar transphyseal technique that is commonly used in adults.

Recent animal^29,30, radiologic⁸, and clinical studies^6-10 have shown that a transphyseal technique is safe to use in the presence of open physes. However, the number of patients in the clinical studies was small and follow-up was short. In addition, some series included children who were near or over the age of sixteen years and children who were at Tanner stage 4. The present study of the long-term functional outcome and complications of the transphyseal technique in very young children was designed to take into account the fact that any growth disturbances would depend on the amount of growth remaining³¹. Consequently, all of the children included were either less than fourteen years of age or at a Tanner stage of 2 or less.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Appendix

Eighty-four skeletally immature patients underwent ACL reconstruction between 2000 and 2007. The present case series represents those children in the above group who met the criteria of this study. Any child who was at Tanner stage 4 or had an age of fourteen years or older was excluded. Children at Tanner stage 3 were included only if they had an age of less than twelve years. Children with less than four years of follow-up and those who had an age of less than sixteen years at the time of final follow-up were excluded.

The distribution of chronological age and Tanner stage in the thirty-two included patients is summarized in Table I. The study group contained twenty-eight boys and four girls. The mean age at the time of surgery had been 11.25 years, and the median had been 12.1 years (range, 9.5 to 14.0 years). The right knee was involved in seventeen patients and the left in fifteen.

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TABLE I Distribution of Patient Age and Tanner Stage*

	Tanner Stage
	1			2			3
Chronological Age	Boys	Girls	Total	Boys	Girls	Total	Boys	Girls	Total
Younger than 12 yr	6	2	8	4	2	6	4	0	4
12 or 13 yr	2	0	2	12	0	12	—	—	—
Total	8	2	10	16	2	18	4	0	4

*Patients in Tanner stage 3 who were at least 12 years of age and patients in Tanner stage 4 were excluded.

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TABLE I Distribution of Patient Age and Tanner Stage*

	Tanner Stage
	1			2			3
Chronological Age	Boys	Girls	Total	Boys	Girls	Total	Boys	Girls	Total
Younger than 12 yr	6	2	8	4	2	6	4	0	4
12 or 13 yr	2	0	2	12	0	12	—	—	—
Total	8	2	10	16	2	18	4	0	4

*Patients in Tanner stage 3 who were at least 12 years of age and patients in Tanner stage 4 were excluded.

All patients had been assessed preoperatively in a pediatric knee clinic. Clinical examination included the anterior drawer, Lachman, and pivot-shift tests. Weight-bearing anteroposterior and lateral radiographs of the knee were made. Functional status was assessed with use of the Lysholm knee score³² and Tegner activity scale³³ questionnaires. All patients underwent magnetic resonance imaging (MRI) to confirm the ACL rupture and to diagnose any meniscal injury. Skeletal maturity was assessed with use of the Tanner scale³⁴ (see Appendix) once the patient had been anesthetized for the surgery. All surgical procedures were performed by the senior author.

Operative Technique

After examination of the knee under general anesthesia, an arthroscopy was performed. The stump of the ACL was debrided, and any meniscal injury was treated by repair or excision. Semitendinosus and gracilis tendons were harvested with use of a standard technique, and the two tendons were stitched at each end with use of a whip stitch. The graft was then doubled, and the diameter of the final graft was measured.

The tibial tunnel was drilled with use of an ACUFEX PRO-TRAC tibial guide (Smith & Nephew, Andover, Massachusetts) through the incision made for harvesting the graft. A guidewire was then introduced through the tibial tunnel and across the femur with use of a standard femoral offset guide (Smith & Nephew). The medial arthroscopy portal was not used because of concern about exiting in the region of the perichondral ring, which would cause greater damage to the growth plate. The length of the femoral tunnel was measured, and an appropriate ENDOBUTTON loop (Smith & Nephew) was selected. The graft was threaded through the loop. The tunnels were drilled very slowly, approximately one-quarter of a turn at a time, to minimize the thermal damage to the growth plate. The tunnels were thoroughly cleared of bone fragments. The mean tunnel diameter was 8 mm (range, 7 to 9 mm). The graft was then passed through the tunnels and the ENDOBUTTON was seated appropriately. With the knee in 20° of flexion, the graft was secured distally with use of a spiked washer and screw (Smith & Nephew) placed transversely across the tibia and distal to the growth plate (Fig. 1). The stability of the knee was confirmed, and the graft was inspected for impingement in extension. The notch was cleared of soft tissue; no osseous notchplasty was required.

Fig. 1

Schematic diagram showing the surgical technique. (Reproduced, with modification, from: Liddle AD, Imbuldeniya AM, Hunt DM. Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children. J Bone Joint Surgery Br. 2008;90 Oct;90(10):1317-22. Reproduced with permission.)

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The patient was mobilized with full weight-bearing on the first day after the operation. A brace was not used routinely. Anteroposterior and lateral radiographs of the knee were obtained to confirm the position of the tunnels and the fixation. All patients were treated with a standard rehabilitation that initially focused on knee extension.

All patients were followed on a regular basis, with formal assessment at six months, one year, and annually thereafter. Clinical testing of ligament laxity, limb length measurement, and assessment of deformity were performed. We chose to rely only on clinical evaluation to prevent unnecessary exposure of the child to radiation unless there was a clinical indication for radiography. The limb length was measured clinically by the senior author from the anterior superior iliac spine to the medial malleolus with use of a tape measure marked in 1-mm increments. A discrepancy between the length of the limb and that of the contralateral limb was recorded if present; a difference of >1 cm was considered notable. Functional outcome was assessed objectively with use of the Lysholm score³², Tegner activity scale³³, and International Knee Documentation Committee (IKDC) evaluation form³⁵. We used the Aircast Rolimeter (DJO Global, Vista, California) for objective assessment of anteroposterior laxity³⁶, as we found the KT1000 arthrometer (MEDmetric, San Diego, California) to be large for these children. Any surgical complications were recorded. Standing anteroposterior and lateral radiographs of the knee were made during follow-up to identify physeal injury or deformity, and preoperative radiographs were reviewed. Any clinical deformity was monitored at intervals with use of computed tomography (CT) scout films and long-leg radiographs; this was required in only one child in the present series who was noted clinically to have a valgus knee deformity (Fig. 2-A).

The child who developed a valgus deformity.

Fig. 2-A

Clinical photograph at the one-year follow-up showing the deformity.

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Fig. 2-B

Computed tomography scanogram at the time of final follow-up at age sixteen.

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Statistical Methods

Data were analyzed with use of GraphPad Prism for Windows (version 12.0). The Wilcoxon signed-rank test was used to compare preoperative and postoperative data; a p value of <0.05 was considered significant.

Source of Funding

No external funding was received for this study.

Results

Introduction | Materials and Methods | Results | Discussion | Appendix

The mean duration of follow-up of the thirty-two patients was 72.3 months (range, forty-eight to 129 months; median, seventy-two months). Twenty-five (78%) of these patients had attained skeletal maturity at the time of final follow-up.

The mode of injury involved football in nine patients, rugby in ten, and skiing in seven. A motor-vehicle accident, a fall, and netball, basketball, squash, and trampoline injuries each accounted for one of the remaining cases. Twenty-eight of the thirty-two patients were at Tanner stage 1 or 2. The remaining four were at Tanner stage 3 but were less than twelve years of age.

Twelve patients had associated meniscal tears, which involved the lateral meniscus only in six patients, the medial meniscus only in five, and both menisci in one. Three of these twelve patients had minor tears that were repaired at the same time as the ACL reconstruction, and three had tears that were repaired at a different time. The remaining six patients were treated with partial meniscectomy and ACL reconstruction. The mean time from injury to ACL reconstruction in the thirty-two patients was 7.9 months (range, six weeks to thirty-nine months).

Outcomes

Twenty-three (72%) of the thirty-two patients described the outcome as excellent, and the remaining nine (28%) reported a good outcome. The mean Lysholm score improved from 71.5 preoperatively to 95.86 postoperatively (p < 0.0001). The mean Tegner activity scale score improved from 4.03 after injury to 7.66 (p < 0.0001), which was comparable to the preinjury score of 8.0.

Two patients reported occasional giving-way but still rated the result as good. One failure of the graft fixation occurred; this patient had Ehlers-Danlos syndrome and had undergone reconstruction at the age of 10.5 years. She returned to her previous level of activity after surgery, then fell again in the playground and sustained a rerupture nine months following surgery. She subsequently ruptured the ACL in her other knee, and that reconstruction (which was performed elsewhere) also failed. She elected to modify her activities and has been able to avoid any episodes of instability. Another patient was noted clinically to have a valgus deformity at twelve months of follow-up (Fig. 2-A). This was evaluated on long-leg radiographs, which showed 6.2° of valgus on the operatively treated side compared with 0.5° on the contralateral side. The patient remained asymptomatic clinically but was followed until his sixteenth birthday. Long-leg radiographs at that time showed 7.1° of valgus on the operatively treated side and 0.9° of valgus on the contralateral side. The limb-length measurements on the final scanograms confirmed the above measurements and showed a shortening of 1.6 mm on the operatively treated side (Fig. 2-B).

One patient developed an abscess at the stitch over the tibial screw site; the abscess resolved with drainage and antibiotics. One patient had persistent numbness around the harvest site. The hamstrings in three patients were only sufficient for a three-strand graft. All patients showed elongation of the graft with growth (Fig. 3). All operatively treated knees had a range of motion equal to that of the contralateral knee.

Fig. 3

Anteroposterior radiograph of a patient who underwent bilateral anterior cruciate ligament (ACL) reconstruction. The right (R) ACL reconstruction, which was performed at twelve years of age, shows elongation of the tunnel compared with the left (L) knee reconstruction, which was performed at the age of sixteen years.

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No patient had an obvious physeal bar or deformity suggestive of a growth arrest on follow-up radiographs. No patient had obvious radiographic signs of degenerative joint disease.

Anteroposterior laxity was measured during maximum manual anterior displacement at 30° of flexion. The mean side-to-side difference was <3 mm in thirty patients and 4 to 5 mm in the remaining two patients. The IKDC grade was A in twenty-six patients, B in five, and C in the one patient with failure of the graft.

Discussion

Introduction | Materials and Methods | Results | Discussion | Appendix

There is increasing support for early reconstruction of the ACL in young children^4-20,23,27. If reconstruction is not performed, persistent laxity results in high incidences of meniscal injury and degenerative changes^7,21-24,37. A good argument can be made for operating on these children sooner rather than later to prevent secondary damage. However, should ACL reconstruction in children with open physes be performed with use of a different technique than that in children with closed physes, and if so, why?

Direct repair of the torn ligament does not work^24,38. Concerns about the potential damage to growth plates during reconstruction have resulted in alternative reconstruction techniques being used in children to spare the growth plates. These include extra-articular, “over-the-top” (over the top of the tibia or the femur or both), and epiphyseal-only techniques^{5,6,11-14,16-20,26-28}. The results of these techniques are encouraging but follow-up has been short, sample sizes have been small, and the studies have often included children who were sixteen years of age and children who were at a Tanner stage of 4 or beyond. These procedures are challenging and often unfamiliar, leading to a high chance of error. The reconstruction may not be anatomical and isometric^14,39. Anterior placement of the graft over the front of the tibia may lead to impingement, anterior knee pain, limited extension, and graft failure⁴⁰. A femoral over-the-top position results in an average of 10 mm of graft elongation in extension⁴¹.

A recent MRI study by Sasaki et al.³¹ has shown that the distal femoral and proximal tibial physes are 100% open (in terms of cross-sectional area) at eleven years of age and 95% open at twelve years, but 94% closed at fifteen years. The concern regarding potential growth arrest resulting from a standard transphyseal procedure in children younger than twelve years of age is therefore justified. Various authors have stressed the importance of a number of technical considerations when a transphyseal technique is used in such children. The tibial tuberosity must be avoided to prevent genu recurvatum⁴². Damage to the growth plate can be minimized by drilling very slowly and in short bursts. The drill-holes should be in the center of the growth plate^42,43. Only a soft-tissue graft such as hamstrings should be used, and the graft should be fixed well away from the growth plate to avoid direct physeal damage^6,10,20,42. Treatment of damaged growth plates by placement of soft tissue across the defect was demonstrated by Langenskiöld and others^44-46. Transphyseal reconstruction performed in skeletally immature sheep was shown to result in no angular deformities or limb-length discrepancies when the defect was filled with a soft-tissue graft but to result in shortening and valgus angulation on the femoral side when the tunnels were left empty^29,30.

Three-dimensional studies based on CT and MRI scans have shown that a tunnel that is 8 mm in diameter (the mean in this series) affects <3% of the area of the growth plate⁴⁷. A 9-mm drill-hole also affects a smaller area than that required to cause arrest, which is 7% of the growth plate^42,47.

The effect of tethering of the growth plate due to the tension in the graft is also a concern. Edwards et al. demonstrated significant growth disturbance with excessive tensioning of a soft-tissue graft through a transphyseal tunnel in a canine model⁴⁸. Such growth disturbance, combined with the periosteal release required to place the tibial drill-hole, means that children treated with this technique could develop an angular deformity similar to that seen after a proximal tibial fracture⁴⁹. Such an angular deformity was observed in one child in our series. We believe strongly that the precautions listed above must be taken during transphyseal reconstruction. Almost all of the reported cases of growth plate damage were associated with placement of fixation devices across or too near the growth plates^5,25,50. In all of the patients in our series, the femoral tunnel was drilled through the tibial tunnel with use of an offset femoral guide. This creates a centrally located femoral physeal drill-hole and a relatively vertical femoral tunnel that may appear more vertical and elongated as the graft elongates within it (Fig. 3). We have not changed to drilling the femoral tunnel through the medial arthroscopy portal as described by many other authors. We are concerned that the drill-hole would not be as centrally located and would cross the growth plate more obliquely, affecting a larger cross-sectional area. The important point is the entry point of the femoral tunnel, and the results of our study show that it is possible to locate this close enough to the normal anatomical insertion of the ACL to produce a stable knee and a good result.

The final question is whether it is better for surgeons to use a technique with which they are familiar, such as the standard reconstruction technique with hamstrings that is commonly used in adults, or a physeal-sparing technique with which they are not familiar, such as that recommended by Kocher et al.¹⁰. We believe that it may be better to use a familiar technique, taking special care when using it in very young children.

We acknowledge that the strength of our results was diminished by the small size of the series resulting from the high exclusion rate. We wanted to test a specific null hypothesis—in this case, that “ACL reconstruction in the young, immature patient is safe”—that did not include adolescents. We therefore excluded patients according to strictly set criteria, as is evident in Table I, in order to be able to report only the results in those patients with substantial growth remaining. This study is also limited by the lack of a control group and the lack of randomization. However, the primary aim of the study was not to assess the advantage of early reconstruction compared with conservative treatment but to demonstrate the safety of this particular method.

Appendix

Introduction | Materials and Methods | Results | Discussion | Appendix

A table outlining the Tanner stages is available with the online version of this article as a data supplement at jbjs.org.

Angel KR; Hall DJ. The role of arthroscopy in children and adolescents. Arthroscopy. 1989;5( 3):192-6.[CrossRef][PubMed]

Shea KG; Pfeiffer R; Wang JH; Curtin M; Apel PJ. Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. J Pediatr Orthop. 2004 Nov-Dec;24( 6):623-8.[CrossRef]

Dorizas JA; Stanitski CL. Anterior cruciate ligament injury in the skeletally immature. Orthop Clin North Am. 2003 Jul;34( 3):355-63.[CrossRef]

McCarroll JR; Shelbourne KD; Porter DA; Rettig AC; Murray S. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med. 1994 Jul-Aug;22( 4):478-84.[CrossRef]

Lipscomb AB; Anderson AF. Tears of the anterior cruciate ligament in adolescents. J Bone Joint Surg Am. 1986 Jan;68( 1):19-28.

Gaulrapp HM; Haus J. Intraarticular stabilization after anterior cruciate ligament tear in children and adolescents: results 6 years after surgery. Knee Surg Sports Traumatol Arthrosc. 2006 May;14( 5):417-24. Epub 2006 Jan 10.[CrossRef]

Aichroth PM; Patel DV; Zorrilla P. The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review. J Bone Joint Surg Br. 2002 Jan;84( 1):38-41.[CrossRef]

Higuchi T; Hara K; Tsuji Y; Kubo T. Transepiphyseal reconstruction of the anterior cruciate ligament in skeletally immature athletes: an MRI evaluation for epiphyseal narrowing. J Pediatr Orthop B. 2009 Nov;18( 6):330-4.[CrossRef]

Liddle AD; Imbuldeniya AM; Hunt DM. Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children. J Bone Joint Surgery Br. 2008 Oct;90( 10):1317-22.[CrossRef]

Kocher MS; Smith JT; Zoric BJ; Lee B; Micheli LJ. Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007 Dec;89( 12):2632-9.[CrossRef]

Brief LP. Anterior cruciate ligament reconstruction without drill holes. Arthroscopy. 1991;7( 4):350-7.[CrossRef][PubMed]

Kocher MS; Garg S; Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005 Nov;87( 11):2371-9.[CrossRef]

Kim SH; Ha KI; Ahn JH; Chang DK. Anterior cruciate ligament reconstruction in the young patient without violation of the epiphyseal plate. Arthroscopy. 1999 Oct;15( 7):792-5.[CrossRef]

Anderson AF; Anderson CN. Hamstring anterior cruciate ligament reconstruction in the skeletally immature patient. Tech Orthop. 2005;20( 3):314-22.[CrossRef]

Beasley LS; Chudik SC. Anterior cruciate ligament injury in children: update of current treatment options. Curr Opin Pediatr. 2003 Feb;15( 1):45-52.[CrossRef]

McCarroll JR; Rettig AC; Shelbourne KD. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988 Jan-Feb;16( 1):44-7.[CrossRef]

Grudziak JS. Physeal sparring transepiphyseal anterior cruciate ligament reconstruction. Oper Tech Orthop. 2009;19( 1):44-51.[CrossRef]

Edwards PH; Grana WA. Anterior cruciate ligament reconstruction in the immature athlete: long-term results of intra-articular reconstruction. Am J Knee Surg. 2001 Fall;14( 4):232-7.[PubMed]

Fuchs R; Wheatley W; Uribe JW; Hechtman KS; Zvijac JE; Schurhoff MR. Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient. Arthroscopy. 2002 Oct;18( 8):824-8.[CrossRef]

Gebhard F; Ellermann A; Hoffmann F; Jaeger JH; Friederich NF. Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of four different techniques. Knee Surg Sports Traumatol Arthrosc. 2006 Sep;14( 9):797-803. Epub 2006 Apr 21.[CrossRef]

Mizuta H; Kubota K; Shiraishi M; Otsuka Y; Nagamoto N; Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995 Nov;77( 6):890-4.

Graf BK; Lange RH; Fujisaki CK; Landry GL; Saluja RK. Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment. Arthroscopy. 1992;8( 2):229-33.[CrossRef][PubMed]

Henry J; Chotel F; Chouteau J; Fessy MH; Bérard J; Moyen B. Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity?Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17( 7):748-55. Epub 2009 Feb 28.[CrossRef]

Engebretsen L; Svenningsen S; Benum P. Poor results of anterior cruciate ligament repair in adolescence. Acta Orthop Scand. 1988 Dec;59( 6):684-6.[CrossRef]

Kocher MS; Saxon HS; Hovis WD; Hawkins RJ. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002 Jul-Aug;22( 4):452-7.

Chudik S; Beasley L; Potter H; Wickiewicz T; Warren R; Rodeo S. The influence of femoral technique for graft placement on anterior cruciate ligament reconstruction using a skeletally immature canine model with a rapidly growing physis. Arthroscopy. 2007 Dec;23( 12):1309-1319. e1.[CrossRef]

Bonnard C; Fournier J; Babusiaux D; Planchenault M; Bergerault F; de Courtivron B. Physeal-sparing reconstruction of anterior cruciate ligament tears in children: results of 57 cases using patellar tendon. J Bone Joint Surg Br. 2011 Apr;93( 4):542-7.[CrossRef]

Guzzanti V; Falciglia F; Gigante A; Fabbriciani C. The effect of intra-articular ACL reconstruction on the growth plates of rabbits. J Bone Joint Surg Br. 1994 Nov;76( 6):960-3.

Seil R; Pape D; Kohn D. The risk of growth changes during transphyseal drilling in sheep with open physes. Arthroscopy. 2008 Jul;24( 7):824-33. Epub 2008 Apr 14.[CrossRef]

Meller R; Kendoff D; Hankemeier S; Jagodzinski M; Grotz M; Knobloch K; Krettek C. Hindlimb growth after a transphyseal reconstruction of the anterior cruciate ligament: a study in skeletally immature sheep with wide-open physes. Am J Sports Med. 2008 Dec;36( 12):2437-43. Epub 2008 Sep 24.[CrossRef]

Sasaki T; Ishibashi Y; Okamura Y; Toh S; Sasaki T. MRI evaluation of growth plate closure rate and pattern in the normal knee joint. J Knee Surg. 2002 Spring;15( 2):72-6.[PubMed]

Lysholm J; Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982 May-Jun;10( 3):150-4.[CrossRef]

Tegner Y; Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985 Sep;( 198):43-9.

Tanner JM; Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child. 1976 Mar;51( 3):170-9.[CrossRef]

Hefti F; Müller W; Jakob RP; Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1( 3-4):226-34.[CrossRef][PubMed]

Ganko A; Engebretsen L; Ozer H. The rolimeter: a new arthrometer compared with the KT-1000. Knee Surg Sports Traumatol Arthrosc. 2000;8( 1):36-9.[CrossRef][PubMed]

Pressman AE; Letts RM; Jarvis JG. Anterior cruciate ligament tears in children: an analysis of operative versus nonoperative treatment. J Pediatr Orthop. 1997 Jul-Aug;17( 4):505-11.

DeLee JC; Curtis R. Anterior cruciate ligament insufficiency in children. Clin Orthop Relat Res. 1983 Jan-Feb;( 172):112-8.

Bisson LJ; Wickiewicz T; Levinson M; Warren R. ACL reconstruction in children with open physes. Orthopedics. 1998 Jun;21( 6):659-63.

Howell SM; Clark JA; Farley TE. A rationale for predicting anterior cruciate graft impingement by the intercondylar roof. A magnetic resonance imaging study. Am J Sports Med. 1991 May-Jun;19( 3):276-82.[CrossRef]

Odensten M; Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am. 1985 Feb;67( 2):257-62.

Shea KG; Belzer J; Apel PJ; Nilsson K; Grimm NL; Pfeiffer RP. Volumetric injury of the physis during single-bundle anterior cruciate ligament reconstruction in children: a 3-dimensional study using magnetic resonance imaging. Arthroscopy. 2009 Dec;25( 12):1415-22. Epub 2009 Nov 7.[CrossRef]

Shea KG; Apel PJ; Pfeiffer RP; Traughber PD. The anatomy of the proximal tibia in pediatric and adolescent patients: implications for ACL reconstruction and prevention of physeal arrest. Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15( 4):320-7.[CrossRef]

Langenskiöld A. An operation for partial closure of an epiphysial plate in children, and its experimental basis. J Bone Joint Surg Br. 1975 Aug;57( 3):325-30.

Stadelmaier DM; Arnoczky SP; Dodds J; Ross H. The effect of drilling and soft tissue grafting across open growth plates. A histologic study. Am J Sports Med. 1995 Jul-Aug;23( 4):431-5.[CrossRef]

Nordentoft EL. Experimental epiphyseal injuries. Grading of traumas and attempts at treating traumatic epiphyseal arrest in animals. Acta Orthop Scand. 1969;40( 2):176-92.[CrossRef][PubMed]

Kercher J; Xerogeanes J; Tannenbaum A; Al-Hakim R; Black JC; Zhao J. Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions. J Pediatr Orthop. 2009 Mar;29( 2):124-9.[CrossRef]

Edwards TB; Greene CC; Baratta RV; Zieske A; Willis RB. The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis. J Bone Joint Surg Am. 2001 May;83-A( 5):725-34.

Ogden JA; Ogden DA; Pugh L; Raney EM; Guidera KJ. Tibia valga after proximal metaphyseal fractures in childhood: a normal biologic response. J Pediatr Orthop. 1995 Jul-Aug;15( 4):489-94.[CrossRef]

Koman JD; Sanders JO. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am. 1999 May;81( 5):711-5.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

tanner stages ; anterior cruciate ligament reconstruction

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Sujit Kumar, David Ahearne, David M. Hunt; Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally ImmatureFollow-up to a Minimum of Sixteen Years of Age. The Journal of Bone & Joint Surgery. 2013 Jan;95(1):e1 1-6.

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