Children and adolescents continue to sustain disruptions of the ACL prior to physeal closure, which poses different challenges for reconstruction than for patients with closed physes. We discuss current options for the treatment of an ACL tear in a population with open growth plates.
The literature shows that delaying ACL reconstruction in adolescents and prepubescent patients increases the risk of further chondral or meniscal damage to the knee, which puts the child at even more risk for premature osteoarthritis after ACL disruption. Most experts agree that ACL reconstruction should be undertaken as soon as feasible to allow for a stable knee and prevent further injury.
Figure 1. Examples of different techniques of ACL reconstruction in patients with open physes are shown. A physeal-sparing technique with IT band over the top and under the transverse meniscal ligament is shown (A). Epiphyseal drilling of both femoral and tibial tunnels with different types of fixation for femur and tibia are shown (B through D).
Male patients approximately 14 years to 16 years of age and female patients approximately 12 years to 14 years of age with Tanner stage 3 or higher may safely undergo transphyseal tunnel placement and soft tissue grafts without great concern about physeal arrest. Care must be taken so that fixation does not cross the physis and the tibial tunnel should be more vertical if possible. Also, it is recommended to utilize a soft tissue autograft so the bone plugs will not cross the physis. Most physeal arrests have been associated with fixation that spans the physis or bone blocks crossing the physis, and not from drilling across the physis or a soft tissue graft crossing the physis. A combination technique of all epiphyseal on the femoral side with drilling more vertically across the physis on the tibial side can also be used safely. This avoids drilling across the femoral physis, which has higher risk of developing physeal arrest than drilling across the tibia.
For patients with Tanner stage 1 or stage 2, physeal sparing methods should be considered. These would include both femoral and tibial tunnels being drilled in a manner so that the tunnels are both all epiphyseal and avoid the physis. The other option would be a physeal-sparing procedure that utilizes a strip of iliotibial band that uses the over-the-top position on the femur and then passage of the graft through the notch and under the transverse meniscal ligament. No drilling of tunnels is required. The graft can then be sutured to the periosteum or fixed with a post to secure it distally.
This case shows an 11-year-old patient with open physis treated with a physeal-sparing technique as described above. Drilling is not required, but the reconstruction is not anatomic.
Figure 2. The IT band has been tubularized and is passed around the over-the-top position of the lateral femoral condyle.
Darren L. Johnson, MD,
Figure 4. Fixation of the IT band graft to the tibia after placing it under the transverse meniscal ligament is shown.
is professor and chairman of the Department of Orthopaedic Surgery and director of Sports Medicine at the University of Kentucky School of Medicine in Lexington, Ky. Kosmas J. Kayes, MD,
is an orthopedic sports medicine fellow at the University of Kentucky Sports Medicine Program.
Disclosures: Johnson and Kayes report no financial disclosures.