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The Journal of Bone and Joint Surgery (American). 2004;86:201-209
© 2004 The Journal of Bone and Joint Surgery, Inc.

Transepiphyseal Replacement of the Anterior Cruciate Ligament Using Quadruple Hamstring Grafts in Skeletally Immature Patients

Allen F. Anderson, MD1

1 Tennessee Orthopaedic Alliance/The Lipscomb Clinic, 4230 Harding Road, Suite 1000, Nashville, TN 37205. E-mail address: andersonaf{at}tnortho.com

Investigation performed at the Tennessee Orthopaedic Alliance/The Lipscomb Clinic, Nashville, Tennessee

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 85-A, pp. 1255-1263, July 2003

The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart{at}haderermuller.com).

BACKGROUND:

Fear of iatrogenic growth disturbance has prevented the routine use, in children, of anatomic methods of anterior cruciate ligament replacement that have proven successful in adults. To minimize the risk of growth disturbance, extra-articular or modified physeal sparing procedures have been performed to stabilize the knee, but these procedures do not provide isometry. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature athletes.

METHODS:

From 1993 to 1999, twelve patients with a mean age (and standard deviation) of 13.3 ± 1.4 years underwent replacement of the anterior cruciate ligament with a quadruple hamstring tendon graft performed with an arthroscopic technique and intraoperative fluoroscopic imaging for precise tunnel placement. The femoral and tibial tunnels went through the epiphyses but avoided the physes. Eight of the twelve patients also had a meniscal repair. All patients returned for follow-up, at a mean of 4.1 ± 1.9 years (range, two to 8.2 years) after surgery.

RESULTS:

The mean amount of growth from the time of surgery to the time of follow-up was 16.5 ± 10.0 cm (range, 8 to 38 cm). The difference between the lengths of the lower limbs, as measured on orthoradiographs, was not clinically relevant. The mean score on the International Knee Documentation Committee (IKDC) subjective knee form was 96.5 ± 4.4 points (range, 86 to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a mean side-to-side difference of 1.5 ± 1.1 mm. The rating according to the criteria of the objective 2001 IKDC knee form was normal for seven patients and nearly normal for five.

CONCLUSIONS:

Transepiphyseal replacement of the anterior cruciate ligament, a technically demanding procedure with a small margin of error, should be attempted only by accomplished knee surgeons. The preliminary results in this small series, however, demonstrate that this surgical technique can be performed in prepubescent patients with efficacy and relative safety.


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Related articles in JBJS:

Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients: A Preliminary Report
Allen F. Anderson
JBJS 2003 85: 1255-1263. [Abstract] [Full Text]  



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