Femoral Physeal Sparing/Transphyseal Tibial (Hybrid) Technique for ACL Reconstruction in Skeletally Immature Athletes

2017 ◽  
pp. 147-155 ◽  
Author(s):  
Matthew D. Milewski ◽  
Carl W. Nissen
Keyword(s):  
Acl Reconstruction ◽  
Hybrid Technique ◽  
Skeletally Immature ◽  
Physeal Sparing

scholarly journals Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

2018 ◽  
Vol 6 (2) ◽  
pp. 232596711875533 ◽  
Author(s):  
Robert G. Willson ◽  
Regina O. Kostyun ◽  
Matthew D. Milewski ◽  
Carl W. Nissen
Keyword(s):  
Anterior Cruciate Ligament ◽  
Skeletal Maturity ◽  
Cruciate Ligament ◽  
Return To Play ◽  
Hybrid Technique ◽  
Skeletally Immature ◽  
Acl Injuries ◽  
Outcome Scores ◽  
Anterior Cruciate ◽  
Physeal Sparing

Background: Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood. Purpose: To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique. Study Design: Case series; Level of evidence, 4. Methods: Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed. Results: Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb. Conclusion: The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children

2018 ◽  
Vol 100 (13) ◽  
pp. 1087-1094 ◽  
Author(s):  
Mininder S. Kocher ◽  
Benton E. Heyworth ◽  
Peter D. Fabricant ◽  
Frances A. Tepolt ◽  
Lyle J. Micheli
Keyword(s):  
Acl Reconstruction ◽  
Iliotibial Band ◽  
Skeletally Immature ◽  
Physeal Sparing

scholarly journals VARIATION IN PREFERRED TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN THE SKELETALLY IMMATURE: WHERE DO WE STAND?

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0011
Author(s):  
Neeraj M. Patel ◽  
Nakul S. Talathi ◽  
Divya Talwar ◽  
Peter D. Fabricant ◽  
Mininder S. Kocher ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Fellowship Training ◽  
Reconstruction Technique ◽  
Hybrid Technique ◽  
Skeletally Immature ◽  
Anterior Cruciate ◽  
Age Range ◽  
The Impact

Purpose: Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear. The goal of this study was to identify preferred techniques in skeletally immature patients of various ages and analyze differences in operative strategy based on surgeon and practice demographics. Methods: An electronic survey was administered to members of the Pediatric Research in Sports Medicine society, a cohort of experienced surgeons who perform a high volume of pediatric ACL reconstructions. The survey presented a scenario of a patient who had a physical exam and imaging consistent with an acute, isolated ACL tear. The respondent was asked to select their preferred reconstruction technique for females and males at consecutive skeletal ages from 8 to 15 years. Surgeon and practice demographic information was recorded. Univariate analysis was followed by stepwise multinominal logistic regression to control for confounders. Results: Eighty-eight of 103 surgeons (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 in females and 11 to 14 in males. The modified MacIntosh was the most frequently utilized from ages 8 to 10. An all-epiphyseal technique was preferred over a broader age range in males than females, with peak utilization at age 11 in both. A partial trans-physeal (hybrid) technique was preferred in slightly older patients, with peak utilization at age 12 in females and 13 in males. The trans-physeal technique was most widely used at age 13 and up in females and 14 and up in males. The impact of fellowship training on technique preference was statistically significant for males ages 11-13 and females 11 and 12 (p<0.05 for all). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports training preferred the modified MacIntosh. Conclusions: The preferred ACL reconstruction technique for skeletally immature patients varied considerably, especially in the 11-13 year-old age range, highlighting a lack of consensus among orthopedic surgeons for the optimal ACL reconstruction strategy in skeletally immature patients. Surgeon’s fellowship training was significantly associated with their preferred surgical technique.

scholarly journals Hybrid ACL reconstruction in a 6-year-old female with fibular hemimelia

2019 ◽  
Vol 7 ◽  
pp. 2050313X1882347
Author(s):  
Patrick G Tate ◽  
Edward M Wojtys
Keyword(s):  
Posterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Lower Limb ◽  
Cruciate Ligament ◽  
Limb Lengthening ◽  
Hybrid Technique ◽  
Unique Case ◽  
Technical Aspects ◽  
Fibular Hemimelia ◽  
Physeal Sparing

Fibular hemimelia is a rare congenital malformation that is commonly associated with other lower limb abnormalities. This is a unique case of a bicruciate ligament, anterior cru ciate ligament/posterior cruciate ligament (ACL/PCL) deficiency in a 6-year-old female with fibular hemimelia in which we describe an ACL reconstruction using autograft–allograft hybrid technique. This case focuses on the technical aspects of an ACL reconstruction using a physeal-sparing technique with a hybrid ACL graft in a pediatric patient with fibular hemimelia. When evaluating patients with fibular hemimelia, it is important to consider implications of treatment in a stepwise manner as this condition commonly presents with other abnormalities that will most likely require multiple procedures, including limb lengthening.

scholarly journals OVER-THE-TOP VERSUS ALL-EPIPHYSEAL TECHNIQUE FOR PHYSEAL SPARING ACL RECONSTRUCTION

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0014
Author(s):  
Nirav K. Pandya ◽  
Brian Feeley ◽  
Stephanie Wong
Keyword(s):  
Acl Reconstruction ◽  
Skeletal Maturity ◽  
Angular Deformity ◽  
Skeletally Immature ◽  
Growth Disturbance ◽  
Patient Reported ◽  
Over The Top ◽  
Physeal Sparing ◽  
The Ideal

BACKGROUND A variety of techniques are utilized for physeal sparing ACL reconstruction, however, no clear consensus exists on the ideal surgical technique, the frequency of complications, and how to best avoid growth disturbance. The purpose of this systematic review is to compare outcomes and complications between over-the-top and all-epiphyseal ACL reconstruction techniques. METHODS The EMBASE and PubMed databases were queried for studies on ACL ruptures in the skeletally immature from 1985 to 2016. Full-text, English studies discussing operative intervention on skeletally immature patients with ACL tears were included (n = 160). Studies that reported re-rupture and/or complications after physeal sparing ACL reconstruction, specifically growth disturbance, were then included in a secondary analysis (n=10). Studies were separated into two groups: an all-epiphyseal group with femur and tibia fixation points within the epiphysis and a group that had over-the-top femur and tibia physeal-sparing reconstruction. Complications that were not specific to the pediatric population were excluded. Angular deformity greater than 3 degrees between the operative and non-operative extremities was used as the threshold. Patient demographics, evaluation of skeletal maturity and growth disturbance, graft type, surgical technique, follow up, growth disturbance, re-rupture, and patient reported outcome scores were collected. Data was analyzed in aggregate. RESULTS Ten studies were included with 280 knees in 279 patients. The average age was 11.8 years, 79% were male, and the mean post-operative follow up was 46.2 months. There were 178 patients who underwent all-epiphyseal reconstruction and 102 patients who underwent ACL reconstruction with the femoral graft placed in an over-the-top position. The overall re-rupture rate was 8.2% (23 of 280). There were 16 re-ruptures in the all-epiphyseal group (9%), and 7 re-ruptures in the over-the-top group (6.9%). Of those studies that specified treatment for re-rupture, 80% of patients required revision ACL reconstruction. Two studies did not conduct objective assessment of skeletal maturity. The majority of studies (50%) did not assess for baseline limb length inequality or angular deformity. 30% of studies performed routine hips-to-ankles bilateral lower extremity radiographs. 20% of studies assessed baseline LLD/angular deformity using clinical examination. Post-operatively, 50% of studies obtained routine hips-to-ankles lower extremity radiographs. 30% of studies obtained post-operative alignment imaging only if there was clinical suspicion of growth disturbance. There were ten total growth disturbances (3 required corrective surgery, or 30%). Seven knees developed limb overgrowth (six in the all-epiphyseal group (mean 1.8 cm) and one in the over-the-top group, 1.5 cm). Two of the patients with overgrowth from the all epiphyseal group required epiphysiodesis (28.6%). Five patients were observed. There were two angular deformities (one with 4 degrees of valgus, and another with 4 degrees varus), both in the over-the-top group which were treated with observation. There were no knees which developed angular deformity in the all epiphyseal group. One patient from the over-the-top group developed a multi-planar flexion-valgus deformity and required distal femoral osteotomy for correction. Five studies reported excellent Lysholm scores of 96.4. Six studies reported IKDC scores (range 88.5-100, 93% grade A or B). CONCLUSIONS / SIGNIFICANCE Growth disturbance after physeal sparing ACL reconstruction was overall uncommon and mild. The phenomenon of overgrowth was common likely due to younger patients receiving physeal sparing procedures. Overgrowth was more common in the all-epiphyseal group and angular deformity in the over-the-top group. Re-rupture rates were similar between the two groups. Evaluation of pre-operative skeletal maturity and comparison of baseline to post-operative growth disturbance was limited by lack of routine imaging assessment. We recommend routine PA hand radiographs, and pre- and post-operative hips-to-ankles alignment radiographs in all skeletally immature patients prior to undergoing ACL reconstruction. Further multi-center study with patient reported outcomes and long-term follow-up are necessary to determine the ideal reconstructive technique in the young, skeletally immature population.

Preoperative 3-D MRI planning of tunnel placement in ACL reconstruction for a skeletally immature patient: A case report

2019 ◽  
Vol 24 (6) ◽  
pp. 1144-1148 ◽  
Author(s):  
Kanji Osaki ◽  
Satoshi Hamai ◽  
Ken Okazaki ◽  
Yasutaka Tashiro ◽  
Yukihide Iwamoto
Keyword(s):  
Case Report ◽  
Acl Reconstruction ◽  
Skeletally Immature ◽  
Tunnel Placement ◽  
Skeletally Immature Patient

Anatomic Physeal-sparing ACL Reconstruction

2012 ◽  
Vol 11 (4) ◽  
pp. 210-213
Author(s):  
Dave Lee Yee Han ◽  
Akbar Nawab
Keyword(s):  
Acl Reconstruction ◽  
Physeal Sparing
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