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Nonanatomic Anterior Cruciate Ligament Reconstruction With Double-Stranded Semitendinosus

Grafts in Children With Open Physes: Minimum 15-Year Follow-up
Marco Kawamura Demange and Gilberto Luis Camanho
Am J Sports Med 2014 42: 2926 originally published online October 1, 2014
DOI: 10.1177/0363546514550981

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Nonanatomic Anterior Cruciate Ligament
Reconstruction With Double-Stranded
Semitendinosus Grafts in Children
With Open Physes
Minimum 15-Year Follow-up
Marco Kawamura Demange,*y MD, PhD, and Gilberto Luis Camanho,y MD, PhD
Investigation performed at the Hospital das Clı´nicas, Faculty of Medicine,
University of São Paulo, São Paulo, Brazil

Background: Nonanatomic anterior cruciate ligament (ACL) reconstruction (ACLR) with double-stranded semitendinosus grafts
in children with open physes has been described as a successful surgical technique in short-term follow-up clinical reports.
Purpose: To evaluate the clinical outcomes of nonanatomic ACLR in children with open physes and a minimum of 15 years’
follow-up.
Study Design: Case series; Level of evidence, 4.
Methods: Twelve patients with an average age of 10.7 years (range, 8.3-12.4 years) underwent ACLR between 1991 and 1998. All
patients were classified as Tanner development stage 2 or lower. The surgical technique involved transphyseal tibial tunnel drilling
and over-the-top (OTT) femoral fixation using a double-stranded graft for all patients. Clinical outcomes were evaluated in terms
of the manual Lachman test, pivot-shift test, return to sports activity, and International Knee Documentation Committee (IKDC)
score at the end of growth and at a minimum 15-year follow-up (range, 15-22 years).
Results: No clinically significant growth disturbance was observed. Ten patients had a grade A IKDC score, and 2 patients had
a grade B IKDC score at the end of growth. There was no progression of laxity or modification of knee stability with growth. Three
patients (25%) had ACL reruptures during sports activities after growth plate closure. All patients with reruptured ACLs underwent
additional reconstructive surgery.
Conclusion: Anterior cruciate ligament reconstruction using the OTT technique in the femur and the transphyseal technique in the
tibia produces good results with regard to growth plate closure but a high failure rate in adulthood.
Keywords: anterior cruciate ligament; open physes; children; knee instability

Although an anterior cruciate ligament (ACL) rupture in movement patterns associated with an injury risk during
skeletally immature children occurs less frequently than sports, such as landing or cutting.3
in adults, this injury has become more common, as chil- Nonoperative treatment has been unsuccessful in pre-
dren as young as 10 years old more regularly engage in venting instability or additional meniscal damage and car-
tilage degeneration.14,25 There is concern about the risk of
leg-length discrepancy and angular deformity after ACL
*Address correspondence to Marco Kawamura Demange, MD, PhD, reconstruction (ACLR) in patients with open physes. To
Hospital das Clı́nicas, Faculty of Medicine, University of São Paulo, Rua avoid this theoretical risk and to promote a more anatomic
Dr Ovı́dio Pires de Campos 333, Cerqueira Cesar, São Paulo 05403-01,
reconstruction, some surgeons have proposed using
Brazil (e-mail: [email protected]).
y
Hospital das Clı́nicas, Faculty of Medicine, University of São Paulo, physeal-sparing intra-articular reconstruction techni-
São Paulo, Brazil. ques.16 This surgical modification is more technically
The authors declared that they have no conflicts of interest in the demanding, as tunnels are drilled through the distal femo-
authorship and publication of this contribution. ral and proximal tibial epiphyses. However, there have
been reports of transphyseal ACLR performed without
The American Journal of Sports Medicine, Vol. 42, No. 12
DOI: 10.1177/0363546514550981 compromising leg length; most of these results have been
Ó 2014 The Author(s) reported in patients above Tanner stage 3.12,21,30,31

2926
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Vol. 42, No. 12, 2014 Nonanatomic ACL Surgery in Children 2927

Figure 1. Magnetic resonance imaging scans of (A) an ante-

rior cruciate ligament rupture and (B) a medial meniscal tear. Figure 2. A schema of anterior cruciate ligament reconstruc-
tion using the over-the-top technique in the femur and the
transphyseal tunnel in the tibia.
We describe the long-term outcomes of partial transphy-
seal ACLR combining transphyseal tibial drilling and the
over-the-top (OTT) femoral technique in skeletally imma- this series, with none lost to follow-up. Sexual development
ture patients with a sexual development stage below was Tanner stage 1 in 4 patients and Tanner stage 2 in 8
Tanner 2. Transphyseal tibial drilling and the OTT femo- patients.
ral technique were recommended as a surgical option for
young children in the mid-1990s and provided good
Surgical Technique
short-term knee stability until growth plate closure. The
purpose of this study was to determine whether very young The surgical technique used was the same for all patients,
children with ACL tears surgically treated with nonana- and the senior author performed all surgical procedures.
tomic ACLR with double-stranded semitendinosus grafts We used a single semitendinosus tendon graft prepared
have stable knees in the long term. in a double-arm pattern for single-bundle ACLR. The
double-stranded semitendinosus graft was harvested using
the standard technique.5
MATERIALS AND METHODS A diagnostic arthroscopic procedure was performed first
using anterolateral and anteromedial portals. Transphyseal
We prospectively followed 12 consecutive skeletally imma- drilling in the tibia was performed with a 5 mm–diameter
ture patients who underwent ACLR by a single surgeon drill, followed by tunnel enlargement to a diameter of
(the senior author, G.L.C.) between 1991 and 1998. All 6 mm when necessary. The tunnels were drilled slowly to
patients experienced a complete ACL rupture during minimize thermal damage to the growth plate. The tibial
sports activities; the ruptures were confirmed by magnetic tunnel was drilled to emerge in the ACL footprint, with
resonance imaging (MRI) (Figure 1). the tunnel crossing the tibial physis as perpendicularly as
There were 5 female (41.7%) and 7 male (58.3%) patients, possible. A physeal-sparing OTT technique was performed
with an average age of 10.7 years (range, 8.3-12.4 years). at the femoral site (Figure 2). A lateral incision was made
The average age was 10.7 years (range, 8.3-12.2 years) for over the distal femur, and the OTT position was palpated
female patients and 10.6 years (range, 9.0-12.4 years) for (Figure 3A). A posterior capsular opening was made, and
male patients. The left side (nondominant) was affected in the graft was passed at the OTT position using a curved,
7 patients (58.3%). inside-out graft-passing device. No osseous notchplasty
Skeletal and sexual maturity levels were assessed using was performed. Graft fixation was performed using a post
the Tanner scale (see the Appendix, available online at with a screw and washer in the tibia that was placed trans-
http://ajsm.sagepub.com/supplemental) after the patient versely across the tibia and distal to the growth plate. Fem-
had been anesthetized for surgery. All patients with oral fixation was also performed with a screw proximal to
Tanner stage 1 and 2 during this period were included in the growth plate (Figure 3B). During surgery, stable

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2928 Demange and Camanho The American Journal of Sports Medicine

was performed on 3 patients to evaluate graft healing

and growth plate aspects.
The 2001 International Knee Documentation Commit-
tee (IKDC) knee ligament form was used for evaluations
at the end of growth. Patients who did not have an appoint-
ment the year before this report were called back for a final
follow-up evaluation.
Ligament stability was measured by the Lachman and
pivot-shift tests. The return to sports activities, sports
activity level, and patient satisfaction were recorded dur-
ing the follow-up, which included the time of growth plate
closure and adulthood. The following Lachman grades
were used: 0 (\3 mm of laxity), 1 (3-5 mm of laxity), or 2
(.5 mm of laxity); the pivot-shift test was graded as 0 (neg-
ative), 1 (glide), 2 (clunk), or 3 (gross). The sports activity
level was assessed according to IKDC levels A through D,
which correspond to strenuous (competitive soccer or bas-
ketball), moderate (tennis, recreational sports), light (jog-
ging), and sedentary activities, respectively.

RESULTS
Twelve patients with Tanner stage 1 and 2 with open
growth plates underwent ACLR with transphyseal drilling
in the tibia and the OTT technique in the femur, with
a minimum 15-year follow-up (average, 18.3 years; range,
15-22 years). All patients had open physes documented
on radiographs at the time of surgery.
We identified 2 medial meniscal tears at the time of sur-
gery: 1 stable and 1 unstable. The unstable tear was trea-
ted with meniscal sutures using the inside-out technique,
Figure 3. (A) A lateral incision was made over the distal and the stable meniscal tear was left untreated.
femur, and the over-the-top position was palpated. (B) Ante- There were no superficial or deep infections, deep vein
roposterior (left) and lateral (right) radiographic images of thrombosis, nerve injuries, arthrofibrosis, or other peri-
graft fixation using a post with a screw and washer in the tibia operative complications. During the follow-up, there were
that was placed transversely across the tibia and distal to the no leg-length discrepancies or radiographic premature clo-
growth plate. Femoral fixation was also performed with sure of growth plates. The average age at the time of
a screw proximal to the growth plate. growth plate closure was 15.8 years (range, 14.3-17.0
years), and the average interval between surgery and
growth plate closure was 5.2 years (range, 2.5-8.0 years).
meniscal tears were not treated. Unstable meniscal tears In the female patients, the average age at the time of
were sutured using an inside-out technique. Full extension growth plate closure was 15.1 years (range, 14.3-15.7
and stable Lachman and anterior drawer test results were years), and the average interval between surgery and
achieved in all patients. growth plate closure was 4.4 years (range, 2.5-6.5 years).
During the postoperative period, the patients were In the male patients, the average age at the time of growth
oriented to partial weightbearing in the first week and pro- plate closure was 16.3 years (range, 15.7-17.0 years), and
gressed to full weightbearing as tolerated as well as imme- the average interval between surgery and growth plate clo-
diate knee motion without knee braces. sure was 5.7 years (range, 4.0-8.0 years) (Table 1).
Magnetic resonance imaging was performed on 3
Clinical and Radiological Evaluation patients at the end of growth to analyze the neoligament
and physes. We observed a good morphological aspect
The leg-length evaluation was performed by clinical and signal intensity of the neoligament. The physes were
assessment with tape measurements from the anterior closed in all patients, but the tibial tunnel and graft were
superior iliac spine to the lateral malleolus and with serial intact through the bone (Figure 4).
radiographic scanograms until the growth plate was Ten patients had grade A IKDC scores, and 2 patients
closed. The radiologists who performed the examinations had grade B IKDC scores at the evaluation of growth plate
evaluated the scanograms, and the senior author con- closure. Ten patients showed stable knees on the manual
firmed the measurements. Magnetic resonance imaging Lachman test, and 2 patients demonstrated mild laxity

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Vol. 42, No. 12, 2014 Nonanatomic ACL Surgery in Children 2929

TABLE 1
Study Results

Age at Tanner Age at Growth Time Between Surgery IKDC Graft Age at Graft
Patient No. Surgery, y Stage Sex Plate Closure, y and Growth Plate Closure, y Gradea Failureb Rupture, y

1 11.0 2 Female 15.5 4.5 A No —

2 11.5 2 Male 16.0 4.5 A No —
3 10.1 1 Male 16.6 6.5 B No —
4 11.8 2 Female 14.3 2.5 A No —
5 10.2 2 Male 15.7 4.5 A Yes 16.3
6 10.3 2 Female 15.3 5.0 B No —
7 12.2 2 Female 15.7 3.5 A Yes 16.9
8 8.3 1 Female 14.8 6.5 A No —
9 9.0 1 Male 17.0 8.0 A No —
10 9.5 1 Male 17.0 7.5 A Yes 18.5
11 12.4 2 Male 16.4 4.0 A No —
12 11.7 2 Male 15.7 4.0 A No —

a
International Knee Documentation Committee (IKDC) evaluation at growth plate closure.
b
Neoligament anterior cruciate ligament graft rupture after growth plate closure.

disarrangement of the knee at the time of the second sur-

gery. During the arthroscopic evaluation, all ruptured
ACL grafts showed good vascularity.
At the long-term evaluation, there was no progression of
ACL stability (Lachman manual test and pivot-shift test)
or decrease in the IKDC score compared with the evalua-
tion at the time of growth plate closure for the remaining
9 patients (excluding the 3 patients with reruptures). At
adulthood, 5 patients (4 male, 1 female) performed compet-
itive-level sports (3 soccer players and 2 basketball play-
ers), 5 patients performed recreational sports only, and 2
patients did not perform any sports activity.

DISCUSSION
To our knowledge, this report is the first to describe a long-
term, minimum 15-year follow-up series of ACLR with
transphyseal tibial tunnel drilling and the femoral
physeal-sparing OTT technique in children below Tanner
stage 2. Some authors believe that the risk of leg-length
discrepancy is higher closer to skeletal maturity as the
growth process slows down.2,8 Growth plates have the
potential to generate high distraction forces, which are
Figure 4. Magnetic resonance imaging of anterior cruciate able to break small bony bars crossing the physes in young
ligament (ACL) reconstruction at 5-year follow-up. Note the children.6 We did not observe any leg-length discrepancy
ACL graft in the tibial tunnel. or angular deformity in our series, as we have already
stated.7 Radiographic scanogram assessments of measure-
ment variance in limb-length discrepancy are considered
(same patients with grade B IKDC scores). The patient reliable methods with low interobserver and intraobserver
who received meniscal sutures presented with a grade B variability34 (Figure 5).
IKDC score. The distal femoral physis contributes 70% of the total
After growth plate closure, 3 patients (2 male, 1 female) femoral length and 37% of the total limb length at an aver-
presented with sports-related ruptures of their ACL grafts; age rate of 10 mm per year over the course of skeletal
none of the patients had meniscal tears at the time of their development. The OTT technique was initially introduced
initial ACL surgeries, and all patients presented with by MacIntosh in the 1970s for adult treatment as a repro-
grade A IKDC scores at the time of growth plate closure. ducible technique that allows consistent positioning of the
The 3 patients were treated with new arthroscopic graft close to an isometric position.1 In children, the tech-
single-bundle ACLR. None of them had any other intrinsic nique avoids drilling through the femoral growth plate by

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2930 Demange and Camanho The American Journal of Sports Medicine

disturbances are supported by large animal studies28 and

clinical studies. To minimize the risk of disturbing the
growth plate, we drilled the holes through the central
aspect of the plate using the smallest possible drill hole
and displacing the smallest possible volume of the growth
plate.15 Stadelmaier et al33 have demonstrated that a soft
tissue graft, filling drill holes through the growth plate,
prevents closure of the physes. We performed MRI to eval-
uate the growth plates and graft aspects at the end of
growth in 3 patients; we observed that the graft was still
visible through the growth plate scar. Animal studies
have shown that there is transient hypertrophy of the
physis tissue at the passing site of the graft, but the growth
plate recovers well from the trauma of drilling and the
placement of a soft tissue graft. The solid integration of
the graft into bone with the early development of
Figure 5. (A) Radiograph and (B) scanogram examination of Sharpey-like fibers has been described.29
a patient who underwent revision anterior cruciate ligament We used a double-stranded semitendinosus graft as our
surgery after graft failure. graft of choice in young patients (Tanner stage 2 or less)
to minimize the volume of growth plate disruptions.7 Differ-
ent graft options have been described for ACLR in children.
passing the graft over the angle between the posterior We favor using a hamstring graft, as this leads to lower
bulge of the lateral femoral condyle and the femoral shaft. complication rates. Bone-tendon-bone grafts may induce
Using this technique, the femoral attachment of the graft local growth arrest if they are placed across the physis. Dis-
is placed close to the native insertion of the anteromedial ruption of the anterior proximal tibial physis during har-
bundle of the ACL. It has been reported that the distance vesting of patellar tendon bone grafts may cause a tibial
between the femoral physis and the femoral origin of the recurvatum deformity. Fuchs et al13 described no limb-
ACL remains unchanged from gestation through skeletal length discrepancy or early physeal arrest in 10 skeletally
maturity and averages approximately 3 mm.4 Because of immature athletes who underwent transphyseal intra-artic-
this particularly short distance, it is difficult to avoid dis- ular ACLR using patellar tendon allografts. Hui et al18
rupting the growth plate when drilling a femoral tunnel described using live-donor, family-related hamstring allog-
in the proper anatomic femoral position. Additionally, rafts to avoid harvest-related problems. We did not observe
there is concern about disturbing the perichondral ring any donor site morbidity or early graft failure in our series.
in the cortical exit of the tunnel when using an anterome- We observed 2 medial meniscal tears (16%) in our
dial portal technique. In a report by Hui et al,18 15 patients series. Csintalan et al10 have reported that patients with
with Tanner stage 1 and 2 were treated with transphyseal ACL injuries with open physes are less likely to be women
anatomic ACLR and showed no growth disturbances at an and had fewer medial meniscal injuries compared with
average follow-up of 25 months; however, the authors patients with closed physes. Samora et al32 have reported
reported 10 patients with open physes, 4 patients with that lateral meniscal tears are more common than medial
closing physes, and 1 patient with closed physes at the meniscal tears. The posterior horn is injured in most
time of the follow-up. patients and is usually in a repairable configuration and
Techniques involving all-epiphyseal ACLR have been vascular zone. Cohen et al9 reported that 65.3% of the
reported,19 but these techniques are technically challenging patients in their series had meniscal tears. McIntosh
and may lead to acute graft angles or require the use of et al27 described 11 meniscal tears among 16 patients,
intraoperative fluoroscopy. Some authors advise that to with 7 patients treated with meniscal repair; 3 primary
safely perform femoral tunnel drilling in the distal femur, meniscal repairs failed and required further partial
the drill must be oriented from the ACL footprint to the pop- meniscectomies.
liteus tendon insertion,37 which may lead to a drilling orien- In children, we believe that there is less risk with the
tation that results in a horizontal tunnel with an acute surgical treatment for ACL tears compared with the com-
angle between the graft and the femoral tunnel opening. plications of a nonfavorable outcome resulting from nonop-
Biomechanical cadaveric studies have demonstrated that erative treatment. Nonoperative treatment may lead to
the OTT femoral technique has adequate graft fixation,23 chronic instability, meniscal tears, and cartilage degenera-
provides anterior and rotational stability, and decreases tion14,25; early surgical intervention provides better out-
posterior joint contact stresses in the ACL-deficient knee comes, particularly in preventing further meniscal
compared with the all-epiphyseal technique.26 injuries.17,22,30 However, for very young children, we
The proximal tibial physis contributes approximately believe that there are flaws in ACLR using the OTT tech-
55% of the total tibial length and 25% of the total limb nique in the femur and transtibial techniques in the tibia.
length over the course of skeletal development at a rate Although we achieved good knee stability, and there were
of 6.4 mm per year. The possibility and safety of drilling no graft ruptures until the end of growth, we observed 3
through the tibial growth plate without creating growth ACL graft ruptures (25%) during sports-related activities

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Vol. 42, No. 12, 2014 Nonanatomic ACL Surgery in Children 2931

after closure of the growth plates in our long-term series. 3. Andrish JT. Anterior cruciate ligament injuries in the skeletally imma-
McIntosh et al27 reported a traumatic graft disruption ture patient. Am J Orthop. 2001;30(2):103-110.
4. Behr CT, Potter HG, Paletta GA Jr. The relationship of the femoral ori-
rate of 12.5% (2 patients) before 2-year follow-up (4 and
gin of the anterior cruciate ligament and the distal femoral physeal
24 months). Most studies on open-physis ACLR report plate in the skeletally immature knee: an anatomic study. Am J Sports
data only up to the growth plate closure, which may under- Med. 2001;29(6):781-787.
estimate the graft failure rate by missing graft ruptures 5. Brahmabhatt V, Smolinski R, McGlowan J, Dmochowski J, Ziv I.
during adulthood. Koizumi et al20 have reported that the Double-stranded hamstring tendons for anterior cruciate ligament
rerupture rates in adults and in adolescents with open reconstruction. Am J Knee Surg. 1999;12(3):141-145.
physes with an average age of 14 years are similar using 6. Bylski-Austrow DI, Wall EJ, Rupert MP, Roy DR, Crawford AH.
Growth plate forces in the adolescent human knee: a radiographic
double-bundle physeal-sparing ACLR in adolescents and and mechanical study of epiphyseal staples. J Pediatr Orthop.
anatomic double-bundle ACLR in adults. The increased 2001;21(6):817-823.
failure rate observed in our study may also be explained 7. Camanho GL, Olivi R, Camanho LF, Torres MR, Ribeiro Filho JEG.
by the smaller hamstring grafts that the young children Anterior cruciate ligament lesion of the knee in patients with immature
had compared with the adults. Some authors24 have dem- skeleton. Acta Ortop Bras. 1999;7:152-158.
onstrated that hamstring grafts with a diameter of 8. Chotel F, Henry J, Seil R, Chouteau J, Moyen B, Berard J. Growth
disturbances without growth arrest after ACL reconstruction in chil-
7 mm correlated with higher ACL graft failure rates. At
dren. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1496-1500.
the time that our surgeries were performed, the data dem- 9. Cohen M, Ferretti M, Quarteiro M, et al. Transphyseal anterior cruci-
onstrating that double-stranded hamstring grafts have ate ligament reconstruction in patients with open physes. Arthros-
a higher failure rate than quadruple-stranded grafts copy. 2009;25(8):831-838.
were weak. Also, we could argue that the high failure 10. Csintalan RP, Inacio MC, Desmond JL, Funahashi TT. Anterior cruci-
rate in this series may be related to young age. There are ate ligament reconstruction in patients with open physes: early out-
comes. J Knee Surg. 2013;26(4):225-232.
reports showing higher failure rates among young ath-
11. Domzalski M, Grzelak P, Gabos P. Risk factors for anterior cruciate
letes.36 The lack of studies describing long-term follow-up ligament injury in skeletally immature patients: analysis of intercondy-
after ACLR in skeletally immature patients limits this lar notch width using magnetic resonance imaging. Int Orthop.
analysis. Kumar et al21 treated 32 patients with Tanner 2010;34(5):703-707.
stage 1 or 2 with transphyseal ACLR, with an average 12. Fabricant PD, Jones KJ, Delos D, et al. Reconstruction of the anterior
hamstring graft diameter of 8 mm (range, 7-9 mm) and cruciate ligament in the skeletally immature athlete: a review of cur-
a minimum 16 years’ follow-up. In their series, there was rent concepts. AAOS exhibit selection. J Bone Joint Surg Am.
2013;95(5):e28.
only 1 failure of the graft in a patient with Ehlers-Danlos 13. Fuchs R, Wheatley W, Uribe JW, Hechtman KS, Zvijac JE, Schurhoff
syndrome who had undergone surgery at the age of 10.5 MR. Intra-articular anterior cruciate ligament reconstruction using
years. We do believe that the high failure rate among our patellar tendon allograft in the skeletally immature patient. Arthros-
group of patients is related to the combination of a nonideal copy. 2002;18(8):824-828.
surgical technique, graft diameter, and young age. 14. Graf BK, Lange RH, Fujisaki CK, Landry GL, Saluja RK. Anterior cru-
This study had some limitations. We did not evaluate ciate ligament tears in skeletally immature patients: meniscal pathol-
ogy at presentation and after attempted conservative treatment.
the other risk factors that may be associated with ACL
Arthroscopy. 1992;8(2):229-233.
injuries in young athletes and children, such as hormonal 15. Guarino J, Tennyson S, Barrios Y, Shea K, Pfeiffer R, Sabick M. Mod-
risk factors, muscle imbalance, intercondylar notch width, eling the growth plates in the pediatric knee: implications for anterior
posterior tibial slope, quadriceps angle, anterior pelvic tilt, cruciate ligament reconstruction. Comput Med Imaging Graph.
or femoral anteversion.11,35 In addition, our series was lim- 2004;28(7):419-424.
ited to 12 patients, but it is one of the largest series with 16. Guzzanti V, Falciglia F, Stanitski CL. Physeal-sparing intraarticular
anterior cruciate ligament reconstruction in preadolescents. Am J
a long-term follow-up of patients with Tanner stage 1 or 2.
Sports Med. 2003;31(6):949-953.
Treating ACL tears in very young children is still a chal- 17. Henry J, Chotel F, Chouteau J, Fessy MH, Berard J, Moyen B. Rup-
lenging and unresolved orthopaedic problem. Many differ- ture of the anterior cruciate ligament in children: early reconstruction
ent techniques have been described, but there is no ideal with open physes or delayed reconstruction to skeletal maturity?
surgical solution. We strongly recommend further studies Knee Surg Sports Traumatol Arthrosc. 2009;17(7):748-755.
to report long-term follow-up beyond the growth plate clo- 18. Hui C, Roe J, Ferguson D, Waller A, Salmon L, Pinczewski L. Out-
sure, as there may be a high failure rate after adulthood come of anatomic transphyseal anterior cruciate ligament recon-
struction in Tanner stage 1 and 2 patients with open physes. Am J
despite good short-term clinical follow-up outcomes. Ide- Sports Med. 2012;40(5):1093-1098.
ally, ACLR in children should provide long-term knee sta- 19. Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the
bility, prevent further knee injuries, and allow highly anterior cruciate ligament in skeletally immature prepubescent chil-
demanding sports activities. dren and adolescents: surgical technique. J Bone Joint Surg Am.
2006;88 Suppl 1(Pt 2):283-293.
20. Koizumi H, Kimura M, Kamimura T, Hagiwara K, Takagishi K. The
outcomes after anterior cruciate ligament reconstruction in adoles-
REFERENCES cents with open physes. Knee Surg Sports Traumatol Arthrosc.
2013;21(4):950-956.
1. Amirault JD, Cameron JC, MacIntosh DL, Marks P. Chronic anterior 21. Kumar S, Ahearne D, Hunt DM. Transphyseal anterior cruciate liga-
cruciate ligament deficiency: long-term results of MacIntosh’s lateral ment reconstruction in the skeletally immature: follow-up to a mini-
substitution reconstruction. J Bone Joint Surg Br. 1988;70(4):622-624. mum of sixteen years of age. J Bone Joint Surg Am. 2013;95(1):e1.
2. Anderson M, Green WT, Messner MB. Growth and predictions of 22. Lawrence JT, Argawal N, Ganley TJ. Degeneration of the knee joint in
growth in the lower extremities. J Bone Joint Surg Am. 1963;45:1-14. skeletally immature patients with a diagnosis of an anterior cruciate

Downloaded from ajs.sagepub.com at UNIVERSITE LAVAL on December 2, 2014

2932 Demange and Camanho The American Journal of Sports Medicine

ligament tear: is there harm in delay of treatment? Am J Sports Med. 30. Milewski MD, Beck NA, Lawrence JT, Ganley TJ. Anterior cruciate
2011;39(12):2582-2587. ligament reconstruction in the young athlete: a treatment algorithm
23. Lertwanich P, Kato Y, Martins CA, et al. A biomechanical comparison for the skeletally immature. Clin Sports Med. 2011;30(4):801-810.
of 2 femoral fixation techniques for anterior cruciate ligament recon- 31. Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate
struction in skeletally immature patients: over-the-top fixation versus ligament reconstruction in skeletally immature patients with trans-
transphyseal technique. Arthroscopy. 2011;27(5):672-680. physeal tunnels. Arthroscopy. 2012;28(11):1710-1717.
24. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of ham- 32. Samora WP 3rd, Palmer R, Klingele KE. Meniscal pathology associ-
string autograft size on patient-reported outcomes and risk of revi- ated with acute anterior cruciate ligament tears in patients with open
sion after anterior cruciate ligament reconstruction: a Multicenter physes. J Pediatr Orthop. 2011;31(3):272-276.
Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy. 33. Stadelmaier DM, Arnoczky SP, Dodds J, Ross H. The effect of drilling
2013;29(12):1948-1953. and soft tissue grafting across open growth plates: a histologic
25. McCarroll JR, Rettig AC, Shelbourne KD. Anterior cruciate ligament study. Am J Sports Med. 1995;23(4):431-435.
injuries in the young athlete with open physes. Am J Sports Med. 34. Terry MA, Winell JJ, Green DW, et al. Measurement variance in limb
1988;16(1):44-47. length discrepancy: clinical and radiographic assessment of interob-
26. McCarthy MM, Tucker S, Nguyen JT, Green DW, Imhauser CW, server and intraobserver variability. J Pediatr Orthop. 2005;25(2):
Cordasco FA. Contact stress and kinematic analysis of all-epiphyseal 197-201.
and over-the-top pediatric reconstruction techniques for the anterior 35. Vyas S, van Eck CF, Vyas N, Fu FH, Otsuka NY. Increased medial tib-
cruciate ligament. Am J Sports Med. 2013;41(6):1330-1339. ial slope in teenage pediatric population with open physes and ante-
27. McIntosh AL, Dahm DL, Stuart MJ. Anterior cruciate ligament recon- rior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc.
struction in the skeletally immature patient. Arthroscopy. 2006; 2011;19(3):372-377.
22(12):1325-1330. 36. Webster KE, Feller JA, Leigh WB, Richmond AK. Younger patients
28. Meller R, Kendoff D, Hankemeier S, et al. Hindlimb growth after are at increased risk for graft rupture and contralateral injury after
a transphyseal reconstruction of the anterior cruciate ligament: anterior cruciate ligament reconstruction. Am J Sports Med. 2014;
a study in skeletally immature sheep with wide-open physes. Am J 42(3):641-647.
Sports Med. 2008;36(12):2437-2443. 37. Xerogeanes JW, Hammond KE, Todd DC. Anatomic landmarks uti-
29. Meller R, Willbold E, Hesse E, et al. Histologic and biomechanical lized for physeal-sparing, anatomic anterior cruciate ligament recon-
analysis of anterior cruciate ligament graft to bone healing in skele- struction: an MRI-based study. J Bone Joint Surg Am. 2012;94(3):
tally immature sheep. Arthroscopy. 2008;24(11):1221-1231. 268-276.

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