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Physeal-Sparing ACL Reconstruction Using Hamstring Autograft

February 01, 2014

Contributors: Mathew Hamula, BA, BS; Dylan Lowe, MD; Theodore S. Wolfson, BS; Eric Jason Strauss, MD, FAAOS; David S. Feldman, MD; Laith M Jazrawi, MD, FAAOS; Deepan Patel, MD; Deepan Patel, MD

Intrasubstance tears of the anterior cruciate ligament (ACL) once were considered rare in skeletally immature athletes, but today are seen with increasing frequency. The recent surge in pediatric ACL injuries likely is related to the growing emphasis on year-round competition, single-sport specialization, and intense training at a younger age. Management of ACL tears in the skeletally immature population is challenging. Early surgical treatment is recommended to restore knee stability and prevent progressive meniscal and cartilage damage. However, concerns over iatrogenic growth disturbances resulting from transepiphyseal reconstructions have been raised. In an effort to avoid violating the growth plate, various physeal-sparing techniques have been developed. These techniques vary considerably regarding tunnel placement, graft choice, and fixation method. To date, no technique has emerged as the clear standard for pediatric ACL reconstruction. This video presents a physeal-sparing technique using hamstring autograft for ACL reconstruction in a skeletally immature athlete.

Methods: Those performing reconstruction of the ACL in skeletally immature patients must take into account clinical stability, associated intra-articular pathology, skeletal age, and activity level. To address these considerations, various techniques have been described, including transphyseal reconstruction, extraphyseal reconstruction, and all-epiphyseal reconstruction. The current all-epiphyseal technique offers several advantages. Intraoperative fluoroscopy is employed to confirm guidewire placement and prevent violation of the physis. Anatomically placed bone sockets are preferred to bone tunnels to preserve bone and restore the native ACL footprint. Quadrupled hamstring autograft with cortical button fixation confers strength and stability. This physeal-sparing procedure is performed through a minimally-invasive, all-inside approach.

Results: This video presents an all-epiphyseal, all-inside, physeal-sparing ACL reconstruction with hamstring autograft for the treatment of symptomatic ACL rupture in a skeletally immature athlete. Special considerations in this unique population are reviewed, and available treatment options are discussed. Key steps and pearls to keep in mind while performing this procedure are highlighted.

Conclusion: Risk for progressive intra-articular injury with nonsurgical treatment undermines its utility in the young, active population. However, fear of physeal injury and growth delay limit widespread adoption of surgical management. The all-epiphyseal technique demonstrated in this video spares the physis and offers a safe, effective, and reliable solution for symptomatic ACL rupture in skeletally-immature athletes. As children participate in competitive sports at a younger age with increased intensity, the rate of pediatric ACL ruptures will continues to rise. To address this mounting burden and return young athletes to the playing field, it is essential to develop and refine new techniques for ACL reconstruction.

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