Fear of iatrogenic growth disturbance has prevented the routine use, in
children, of anatomic methods of anterior cruciate ligament replacement that
have proven successful in adults. To minimize the risk of growth disturbance,
extra-articular or modified physeal sparing procedures have been performed to
stabilize the knee, but these procedures do not provide isometry. This study
was performed to evaluate the results of a transepiphyseal replacement of the
anterior cruciate ligament in skeletally immature athletes.
From 1993 to 1999, twelve patients with a mean age (and standard deviation)
of 13.3 ± 1.4 years underwent replacement of the anterior cruciate
ligament with a quadruple hamstring tendon graft performed with an
arthroscopic technique and intraoperative fluoroscopic imaging for precise
tunnel placement. The femoral and tibial tunnels went through the epiphyses
but avoided the physes. Eight of the twelve patients also had a meniscal
repair. All patients returned for follow-up, at a mean of 4.1 ± 1.9
years (range, two to 8.2 years) after surgery.
The mean amount of growth from the time of surgery to the time of follow-up
was 16.5 ± 10.0 cm (range, 8 to 38 cm). The difference between the
lengths of the lower limbs, as measured on orthoradiographs, was not
clinically relevant. The mean score on the International Knee Documentation
Committee (IKDC) subjective knee form was 96.5 ± 4.4 points (range, 86
to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a
mean side-to-side difference of 1.5 ± 1.1 mm. The rating according to
the criteria of the objective 2001 IKDC knee form was normal for seven
patients and nearly normal for five.
Transepiphyseal replacement of the anterior cruciate ligament, a
technically demanding procedure with a small margin of error, should be
attempted only by accomplished knee surgeons. The preliminary results in this
small series, however, demonstrate that this surgical technique can be
performed in prepubescent patients with efficacy and relative safety.