ACL Reconstruction in the Skeletally Immature Athlete
Abstract & Commentary
Synopsis: The patient, family, and surgeon must balance the risks of further knee injury while delaying reconstruction vs. the risk of growth disturbance with transphyseal techniques vs. possibly inferior stability with physeal sparing or extra-articular techniques.
Source: Barber FA, et al. Anterior cruciate ligament reconstruction in the skeletally immature high-performance athlete: What to do and when to do it? Arthroscopy 2000;16:391-394.
This "point-counterpoint" article presents the controversy surrounding reconstructing the anterior cruciate ligament (ACL) in the skeletally and physiologically immature athlete (i.e., those in Tanner stages 1 and 2).
Sanders presents the arguments for delaying an ACL reconstruction in young athletes, stressing the need to use physiologic measures such as the Tanner scale to assess maturity rather than relying on chronologic age. He suggests that if the family of the ACL-injured youth insist on proceeding with an ACL reconstruction, even after the surgeon discusses with them the possibility of growth disturbance, one should consider using an intra-articular physeal sparing technique for ACL reconstruction such as that described by Micheli1 or Brief.2 However, his preference is to modify activity and wait for growth to become more complete.
Clark presents the argument that one must initially assess the amount of growth remaining in the injured athlete before selecting treatment options following ACL injury. He does not rely on bone age or Tanner staging, as he states "both systems appear to have a wide variance." He states that it is only necessary to assess if growth sites (physeal lines) are close to closing, in which case the youth with an ACL injury can be treated like an adult.
Clark feels that if growth centers are "wide open," he still prefers reconstruction of the ACL, as he argues that the risk of growth arrest following intra-articular ACL reconstruction is far less than the risk of reinjury secondary to an episode of slipping (27/38 patients in one series developed meniscal tears while "waiting" to become skeletally mature and have their ACL reconstructed).3 However, in this group of young athletes, Clark discourages the use of bone plugs and screws across the physes. He reminds us that clinical reports and animal studies indicate that physeal closure does not typically result from drilling across the physis or from a soft tissue graft. His preference is to use hamstring autograft through transphyseal bone tunnels with staple fixation on the tibia and cross-pin fixation in the femur placed away from the physes using fluoroscopic control.
Comment by Letha Y. Griffin, MD, PhD
As the number of young people participating in fast-moving sports requiring frequent cutting, jumping, and pivoting has increased, the number of ACL injuries in this population has also increased. Sanders and Clark agree that:
• Chronological age does not necessarily correlate with the amount of physeal growth remaining in the extremity.
• It is the amount of growth remaining that is important in selecting treatment for the young athlete with an ACL-deficient knee.
• Patients should be adequately counseled regarding the benefits, risks, and limitations of this procedure.
It is interesting that Clark was only able to locate two cases of ACL growth arrest in the literature. In our own community, I have heard of at least two cases of growth arrest following ACL reconstruction. Hence, it would appear that the occurrence of this complication may be underreported in the literature.
McCarroll et al,4 in their review of this topic, advise waiting to reconstruct the ACL until the athlete has reached Tanner stage 3 or 4, but also stress that compliance with a restricted activity program during this period is enhanced if the young athlete is given a specific date for reconstruction instead of merely being told that ACL reconstruction will occur when "growth is near completion."
In summary, children in Tanner stages 4 and 5 (and probably 3 also) can be treated like adults when considering ACL reconstructive procedures. Children in Tanner stages 1 and 2 have much growth remaining and therefore although some orthopedists would advise intra-articular reconstruction in this group of young athletes, others advise activity modification, exercises, and brace protection until sufficient growth has occurred to safely proceed with intra-articular ACL reconstruction. v
References
1. Micheli LJ, et al. Anterior cruciate reconstruction in patients who are prepubescent. Clin Orthop 1999; 364:40-47.
2. Brief LP. Anterior cruciate ligament reconstruction without drill holes. Arthroscopy 1991;7:350-357.
3. McCarroll JR, et al. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med 1994;22:478-484.
4. McCarroll JR, et al. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med 1988;16:44-47.
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