What Is the Best Treatment for Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals?

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Chapter 31 What Is the Best Treatment for Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals?

R. BAXTER. WILLIS, MD, FRCSC

Anterior cruciate ligament (ACL) injury in a growing child is being diagnosed with some degree of frequency, probably because of increased skill in diagnostic ability including specialized imaging studies such as magnetic resonance imaging.¹^–⁷ The true incidence of ACL injury in the skeletally immature athlete is unknown. In a series of 1000 consecutive ACL injuries treated at the Cleveland Clinic, 5 patients were younger than 12 years.⁸

From insurance claim data in the United States for youth soccer leagues, the overall incidence rate is about 0.01% with 550 claims for ACL injury out of 6 million children and youths who were insured during the time period.⁹ Girls have been noted to be 2 to 9 times more likely to sustain this injury than boys.¹⁰

NATURAL HISTORY OF ANTERIOR CRUCIATE LIGAMENT INJURY IN CHILDREN

In adults, chronic ACL insufficiency leads to intra-articular damage. Meniscal tears and chondral damage occur in individuals who continue to participate in sports and recreational activities without the benefit of a stable knee.¹¹^–¹³ What is the evidence? A number of Level II and III studies confirm the same dismal prognosis in children with open physes; namely, if the ACL is left untreated, the patient has a markedly increased risk for development of meniscal tears and chondral damage leading to eventual osteoarthritis.^4,^5,¹⁴^–¹⁸

Level III studies by Graf and colleagues,⁴ McCarroll and coworkers,⁵ and Angel and Hall¹ all report on the high incidence of meniscal tears and the inability to resume preinjury activity levels. Level II studies by Aichroth and investigators,¹⁴ Pressman and researchers,¹⁸ and Kannus and Jarvinen¹⁹ have confirmed the results of these earlier studies.

MAKING THE DIAGNOSIS

Since the early 1990s, the orthopedic literature has discussed in depth the possibility of an ACL disruption in the growing child. Before these detailed descriptions, it was generally believed that children did not tear the ACL with the exception of the pediatric equivalent, namely, the tibial eminence fracture.²⁰^–²³ With that background, it is important for the physician to have a high index of suspicion in a child presenting with a presumed hemarthrosis (swollen knee) after a knee injury.

In a number of series of knee injuries in the pediatric population, the incidence rate of ACL disruption has been reported to be as low as 10% and as high as 65% in series with the number of patients ranging from 35 to 138 patients.²⁴^–²⁸

A physical examination in this clinical setting should include a careful examination for ACL insufficiency. The examination should consist of a careful and gentle Lachman test for anteroposterior instability with the knee at 20 to 30 degrees of flexion, an anterior drawer test at 90 degrees if the patient’s pain and tense effusion will allow, and finally, a gentle examination for a positive pivot shift.

Again, a high index of suspicion is necessary. Except in the incidence of tibial or femoral bony avulsion, there is no need for urgent surgical reconstruction (Level of Evidence V). The patient can be instructed to ice the knee, start active range-of-motion exercises and strengthening, and be re-evaluated in 2 to 3 weeks when the physical examination will be more reliable and easier to perform because the patient will be more comfortable and the majority of the hemarthrosis will be resorbed.

DIAGNOSTIC IMAGING

All patients with a significant knee injury and presenting with an effusion (hemarthrosis) should have plain radiographs of the knee to rule out tibial eminence fracture or other bony avulsions and osteochondral fractures.

The decision to order magnetic resonance imaging still remains somewhat controversial. However, in 2007, it is recommended for patients with suspected ACL tears to be evaluated for meniscal tear and osteochondral lesions (such as a fracture or a “bone bruise”) (Fig. 31-1) (Level of Evidence V).

FIGURE 31-1 A, Magnetic resonance imaging (MRI) of a skeletally immature adolescent with disruption of anterior cruciate ligament (ACL) tear. Note disruption of anterior cruciate ligament (white arrows) and open physes. B, Same patient. Note peripheral separation of lateral meniscus, an injury commonly seen in patients with ACL disruption.

TREATMENT

Special Considerations in the Growing Child

Children with open growth plates may present challenges to the treating orthopedic surgeon familiar with reconstruction techniques used in adults. Most ACL reconstructions in adults use autograft tendon (hamstring or patellar tendon) to replace the torn ACL. The surgical technique involves a central drill hole in the proximal tibia and another in the distal femur to place the tendon graft to closely resemble the anatomic location of the normal ACL. Utilizing this surgical technique in a growing child may result in a growth arrest or altered growth in either the proximal tibia or the distal femur. Growth disturbances using conventional surgical techniques have been reported in both animal models ²⁹^–³¹ and clinical series of reconstructions in pediatric patients.³²^–³⁴

Is There a Place for Nonoperative Treatment?

A number of commercially available knee orthoses are available that theoretically prevent the knee instability seen in patients with chronic ACL insufficiency. Unfortunately, no evidence has been presented to show they prevent the dreaded consequences of further meniscal damage and chondral change despite the claims of rendering the knee more stable ¹⁶^–¹⁸ (Level of Evidence IV). Also, few growing children are willing to alter their active lifestyle and give up change-of-direction sports.

Operative Treatment

Given the unique anatomic aspects of the growing child, nontraditional surgical methods have been used in an attempt to prevent knee instability whereas at the same time preventing or reducing the risk for growth disturbance.

These surgical methods can be divided into the following categories:

1. Extra-articular surgical reconstructions

2. Physis-sparing surgical reconstructions including graft fixation in the epiphysis

3. Partial physeal-sparing reconstructions

4. Transphyseal reconstructions

Extra-articular Surgical Reconstruction.

Extra-articular surgical reconstruction was popular in adults in the 1970s. Unfortunately, the location of the graft in a nonanatomic location was unsuccessful in controlling anterior translation of the tibia on the femur. Nevertheless, these extra-articular reconstructions have been proposed as a “temporizing” procedure in the skeletally immature patient ^2,^{4, 5} (Level of Evidence IV). No evidence suggests that they will act any more efficiently than reported previously.

Physis-Sparing Reconstructions.

In an attempt to avoid crossing the physis with the graft, a number of grafts have been used with variations on a theme. The graft avoids the proximal tibial physis by using a drill hole in the proximal epiphysis only.³⁵^–³⁷ In addition, the distal femoral physis is avoided by placing the graft in an “over-the-top” position through the posterior capsule^35,³⁷ or by a drill hole into the epiphysis only³⁶ (Fig. 31-2). Only Level III and IV studies have documented the efficacy of these surgical treatments, with the longest follow-up being 5 years.^35,^36,³⁸^–⁴³

FIGURE 31-2 Physis-sparing technique of anterior cruciate ligament reconstruction utilizing autogenous patellar tendon as the graft. The graft remains attached distally to the tibia and is passed through a notch in the proximal tibial epiphysis beneath the intermeniscal ligament to an intra-articular position, and subsequently is passed through the posterior capsule to an “over-the-top” position on the distal femur above the distal femoral physis.

A variation of the combined intra-articular and extra-articular reconstruction popularized by McIntosh and Darby has been proposed by Kocher ³⁷ in prepubescent skeletally immature children and adolescents to provide knee stability whereas at the same time avoiding the dreaded iatrogenic complication of growth disturbance seen with drill holes through either the proximal tibial or the distal femoral physis, or both (Level of Evidence IV) (Fig. 31-3).

FIGURE 31-3 Physeal-sparing, combined intra-articular and extra-articular anterior cruciate ligament (ACL) reconstruction. A, Autogenous iliotibial band graft is harvested keeping it attached distally to Gerdy’s tubercle. B, The graft is brought to an “over-the-top” position and then into the joint through the posterior capsule. C, From the knee joint, the graft is brought under the intermeniscal ligament anteriorly. D, The graft is sutured to the periosteum using interrupted mattress sutures.

In their Level IV study, 44 skeletally immature children (Tanner stage I or II) underwent the combined intra-articular and extra-articular reconstruction using iliotibial band. The factors evaluated were functional outcome, graft survival, and radiographic outcome with special emphasis on any growth disturbance. Follow-up period ranged from 2.0 to 15.1 years with a mean of 5.3 years. No growth disturbances were noted after the surgery as measured clinically and radiographically. Functional outcome was excellent with subjective knee scores of 96.7 ± 6.7 (range, 74–100) using the Lysholm knee score. Examination for stability of the knee revealed normal Lachman test results in 23 patients and near-normal results in 18 patients, whereas pivot shift examination was normal in 31 patients and near normal in 11 patients. Four patients who had undergone concurrent meniscal repair at the time of the ligamentous reconstruction (out of a total of 24 patients) underwent repeat meniscal surgery, either repair or partial resection.

Partial Physeal-Sparing Techniques.

Partial physeal-sparing techniques use a small, central, and vertical drill hole through the proximal tibial physis and placement of the graft through the posterior capsule to an “over-the-top” position on the distal femur. Level IV studies indicate this technique renders the knee stable with little or no further meniscal damage, and no alteration of growth in either the distal femur or proximal tibia ^42,^{44, 45} (Fig. 31-4).

FIGURE 31-4 Partial physeal-sparing anterior cruciate ligament (ACL) reconstruction. Hamstring tendons (semitendinosus and gracilis) are harvested and fed through a 6- to 8-mm vertical drill hole in the proximal tibia, then out through the posterior capsule to an “over-the-top” position on the distal femur. The graft is fixed to the distal femur with staples or sutures.

Transphyseal Reconstructions.

Transphyseal reconstructions use a 6- to 8-mm drill hole in the proximal tibia and distal femur. The drill holes are placed in as vertical orientation as possible to minimize the cross-sectional damage to the physes. The graft is placed in the same anatomic location as the native ACL (Figs. 31-5 and 31-6). A number of authors have concluded that transphyseal reconstructions are safe with no disruption of longitudinal growth (Fig. 31-7).

FIGURE 31-5 Diagram of transphyseal anterior cruciate ligament (ACL) reconstruction used in older adolescents and adults. Free hamstring tendons are used, and the fixation devices should not encroach on either physis if the physis is still open.

FIGURE 31-6 A, Anteroposterior radiograph of skeletally immature child after transphyseal anterior cruciate ligament (ACL) reconstruction using autogenous hamstring tendons. Note vertical orientation of drill holes in proximal tibia and distal femur. B, Lateral radiograph of same patient.

FIGURE 31-7 A, Axial magnetic resonance image (MRI) of knee after transphyseal anterior cruciate ligament (ACL) reconstruction. Note small, centrally placed drill hole in proximal tibia (white arrow). B, Lateral MRI of same patient showing graft filling tibial tunnel. Note Park–Harris growth arrest lines (white arrows) on distal femur proximal to physis indicating continued growth.

However, there are reports of growth disturbance utilizing a transphyseal reconstruction in children with open physes.³⁴ Level II and III studies have documented that this reconstruction offers the benefits of long-term knee stability.^5,⁴⁶ In most cases, it should be reserved for the adolescent at or near the end of growth. Fig. 31-8 presents an algorithm for treatment of ACL tears in children.

FIGURE 31-8 Algorithm for treatment of anterior cruciate ligament tears in children.

POSTOPERATIVE REHABILITATION

Postoperative therapy is important to the success of the surgery and is recommended for all patients. Patients are kept toe touch weight bearing for up to 6 weeks in the prepubescent patients and up to 2 to 3 weeks in older adolescents.

Therapy consists of the use of a removable brace, although there is no evidence to suggest the outcome is any better, but it tends to restrict overzealous patients from too much activity (Level of Evidence V). The therapist works with the patient to decrease swelling, increase range of motion, and increase strength with closed chain exercises followed by proprioceptive training. At 3 months, jogging and sports-specific exercises are permitted with change of direction, cutting activities, and expected return to sports 6 months after the surgery.

RECOMMENDATIONS

Based on a number of Level III and IV studies, the following recommendations can be made. For the young child with an ACL disruption and 3 to 4 years or more of growth remaining, a trial of bracing and activity modification is warranted until the child is older or until such time as the treatment is deemed a failure.

In younger children with 3 or more years of growth remaining, there are 2 options. In prepubescent patients, a physeal-sparing technique should be used. Although not exactly replicating the anatomic location of the native ACL, studies suggest the efficacy of this treatment in controlling instability and preventing further intraarticular damage whereas at the same time not disrupting growth at either the distal femur or proximal tibia ³⁵^–⁴³ (grade C).

A strip of iliotibial band about 2 to 3 cm wide and 15 cm long is harvested, keeping the strip attached distally to Gerdy’s tubercle and detaching it proximally. Arthroscopy is performed, and the graft is passed in a retrograde fashion from an “over-the-top” position through the posterior capsule and intercondylar notch, underneath the intermeniscal ligament to a second incision on the proximal tibia. It is sutured to the periosteum distally to the proximal tibial physis after a small notch is placed in the proximal tibial epiphysis.³⁷ The graft is first fixed on the femoral side at the insertion of the lateral intermuscular septum to the lateral femoral condyle with the knee flexed 90 degrees. It is then fixed under tension to the periosteum of the proximal tibia with the knee flexed 20 degrees.

In adolescent patients with approximately 2 years of growth remaining, partial transphyseal reconstructions are recommended. A small (6–8-mm) drill hole is placed in the proximal tibia in a more vertical orientation than is performed in skeletally mature individuals. Hamstring tendons (semitendinosus and gracilis) are used and are passed through the tibial tunnel and through the intercondylar notch and posterior capsule of the knee joint to an “over-the-top” position on the distal femur. A number of different fixation techniques have been used including staples and screws and washers for the distal femur fixation.^42,^{44, 45}

The fixation devices should be used at a distance of 1.5 to 2.0 cm from the physis. The hamstring tendons can be left attached on the proximal tibia and fed up the tunnel or detached and fixed in the tibial tunnel with a bioabsorbable screw. The drill hole needs to be placed in a more vertical orientation than is used in adults to allow the insertion of the interference screw without damaging the proximal tibial physis.

In the adolescent near skeletal maturity, the transphyseal method of reconstruction is safe and provides a stable knee. If the adolescent has 1 year or less of growth remaining, it is recommended to perform a transphyseal reconstruction of the ACL using autograft hamstring tendon, autograft bone-patellar tendon-bone, or allograft tendon (Achilles).^5,⁴⁶ The recommendations are summarized in the algorithm in Fig. 31-8 and in Table 31-1.

TABLE 31-1 Levels of Evidence for Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals

STATEMENT	LEVEL OF EVIDENCE/GRADE OF RECOMMENDATION	REFERENCES
1. Untreated anterior cruciate ligament injuries in children lead to meniscal tears and chondral damage.

B 1, 4, 5 B 14, 18, 19

2. Knee braces do not alter the long-term natural history.

B 16, 18 B 1

3. Extra-articular anterior cruciate ligament reconstruction does not correct the clinical problem of knee instability.

B 2, 4, 5

4. Physis-sparing reconstructions can offer the advantage of stabilizing the knee without the risk for growth arrest at the proximal tibia or distal femur.

C 35–43

5. Partial physeal-sparing techniques appear to offer knee stability without the risk for growth arrest.

C 42, 44, 45

6. Transphyseal ligamentous reconstructions offer long-term stability but some risk for growth disturbance. They should be reserved for the adolescent near the end of growth.

B 5, 46 B 34

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