- Arthroscopy Techniques

All-Epiphyseal, All-Inside Anterior Cruciate Ligament
Reconstruction Technique for Skeletally Immature Patients
Moira M. McCarthy, M.D., Jessica Graziano, P.T., D.P.T., Daniel W. Green, M.D., and
Frank A. Cordasco, M.D.
Abstract: Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the
juvenile population. Unfortunately, outcomes with conservative treatment are extremely poor. Adult
reconstruction techniques are inappropriate to treat skeletally immature patients because of the risk
of physeal complications, including limb-length discrepancy and angular deformities. “Physealsparing” reconstruction techniques exist, but their ability to restore knee stability is not well
understood. We describe an all-epiphyseal ACL reconstruction for use in skeletally immature
patients. This is an all-inside technique with the femoral tunnel drilled retrograde and the tibial tunnel
drilled retrograde; both tunnels are entirely within the epiphysis. Fixation of the hamstring autograft
is achieved with soft-tissue buttons on both the femur and tibia. We present case examples for 2
patients who underwent the all-inside, all-epiphyseal reconstruction and our postoperative rehabilitation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients.
A
nterior cruciate ligament (ACL) injuries are common in active, young patients and are increasingly being treated in skeletally immature patients.
The increase in the incidence of these injuries in
children and adolescents results in part from Title IX,
which has doubled the denominator by including female persons in athletics; in addition, there has been a
proliferation of competitive sports at younger ages, as
well as a surge in the level of competition within these
age groups, and improved recognition of these injuries
by athletic trainers and orthopaedic surgeons. The
surgical treatment of ACL injuries in this age group
has risen because of the increased injury rate and as a
From the Hospital for Special Surgery, New York, New York,
U.S.A.
The authors report the following potential conflict of interest or
source of funding in relation to this article: Arthrex, Naples, FL.
Received May 12, 2012; accepted August 27, 2012.
Address correspondence to Moira M. McCarthy, M.D., Hospital
for Special Surgery, 535 E 71st St, New York, NY 10021, U.S.A.
E-mail: mccarthymo@hss.edu
© 2012 by the Arthroscopy Association of North America
2212-6287/12322/$36.00
http://dx.doi.org/10.1016/j.eats.2012.08.005
result of literature documenting the poor natural history of nonoperative treatment.1-7
The true incidence of midsubstance ACL rupture in
children is unknown, but ACL injury has been reported in 10% to 65% of pediatric knees with acute
hemarthrosis.8-11 Shea et al.12 found that ACL injuries
accounted for 6.7% of total injuries and 30.8% of all
knee injuries in soccer players aged 5 to 18 years in
the United States. Bony ACL avulsions are more
likely to occur in preadolescents, whereas adolescents
are more prone to ACL substance tears.13,14 Historically, ACL reconstruction in skeletally immature patients was not recommended because of potential iatrogenic physeal injury resulting in growth arrest,
limb-length discrepancies, and angular deformities.15-21 Left untreated, chronic ACL deficiency can
lead to instability, meniscal damage, chondral damage, osteoarthritis, and decreased activity levels. Previous data have shown that between 21% and 100% of
pediatric patients have a concomitant meniscal injury
at the time of the ACL injury.22-28
The increased recognition of these injuries and the
need for treatment acutely rather than delaying treatment until skeletal maturity have led to the emergence
Arthroscopy Techniques, Vol 1, No 2 (December), 2012: pp e231-e239
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M. M. MCCARTHY ET AL.
of a variety of surgical procedures for ACL reconstruction.29 “Physeal-sparing” alternative techniques
have been developed, including over-the-top reconstructions of the femur and tibia, transtibial over-thetop femur reconstructions, and iliotibial band reconstructions.23,24,30-36 These reconstructions, however,
distort the intra-articular anatomy. A recently described all-epiphyseal reconstruction aims to restore
the intra-articular anatomy while minimizing the risk
of physeal injury.37,38 There is no consensus yet on the
optimal surgical technique to best re-create the biomechanics of the native ACL.39-41 Kocher et al.4 reported that 78% of surgeons surveyed had performed
an ACL reconstruction in a skeletally immature patient but that no single technique predominated.
We describe a novel all-inside, all-epiphyseal technique for ACL reconstruction. This technique restores
the intra-articular anatomy better than the other physealsparing techniques and minimizes the risk of physeal
injury by placing both the femoral and tibial sockets,
as well as fixation, exclusively within the epiphysis.
SURGICAL TECHNIQUE
Our reconstruction technique is demonstrated in
Video 1. The autologous hamstring graft is prepared
first. The semitendinosus is harvested by the standard
technique with a 2-cm vertical incision over the distal
insertion of the hamstring tendon. The knee is positioned at 60° of flexion with the hip externally rotated.
To achieve a quadrupled graft of the appropriate
length and diameter, the semitendinosus alone is most
commonly harvested while the gracilis is maintained.
If the diameter of the graft is determined to be insufficient (⬍7 mm), the gracilis is then harvested as well.
The graft is prepared by the GraftLink technique (Arthrex, Naples, FL) with 2 TightRope RT suture buttons (Arthrex) for fixation on the tibia and femur (Fig
1). The graft length is between 50 and 55 mm. The
goal graft diameter is 7 to 8 mm. The graft is sized,
pretensioned to 20 lb for 5 minutes, and then wrapped
in damp gauze and stored in a sterile sealed plastic bag
on the back table.
Standard diagnostic knee arthroscopy is performed
through the anteromedial and anterolateral portals. All
chondral and meniscal pathology is addressed appropriately. The intrasubstance ACL tear is identified,
confirmed, and debrided to show the tibial and femoral insertional footprints. A 70° arthroscope is routinely used to better view the femoral footprint from
the anterolateral portal. One can use a 30° arthroscope
from the anteromedial portal as an alternative.
FIGURE 1. The graft is a quadrupled semitendinosus autograft
secured with 2 TightRope RT devices in the GraftLink technique.
Graft length is between 50 and 55 mm, with a diameter between 7
and 8 mm. The graft is tensioned at 20 lb for 5 minutes.
The femoral socket is addressed first (Fig 2). The
surgeon places an outside-in femoral ACL guide (Arthrex), set at approximately 95°, onto the center of the
femoral footprint, approximately 2 to 3 mm from the
back wall, through the anterolateral portal, while
viewing with a 30° arthroscope from the anteromedial
portal. A 1-cm incision is made followed by dissection
and seating of the guide just anterior to the lateral
epicondyle. The appropriate size FlipCutter (Arthrex)
is then used to drill from the lateral cortex to the
guide on the footprint. The positioning distal to the
physis is verified by fluoroscopy. Once the position
is confirmed, the drill sleeve is malleted through the
cortex; this ensures a bone bridge of at least 7 mm
between the end of the tunnel and the lateral cortex.
The FlipCutter is then deployed and used to drill the
femoral socket retrograde to approximately 20 to 25
mm. The FlipCutter is advanced into the joint,
closed, and removed through the lateral cortex. A
FiberStick (Arthrex) is advanced through the guide,
delivered out the anteromedial portal, and tagged
for later graft passage.
The tibial socket is then addressed (Fig 3). The
tibial ACL guide, set at approximately 50°, is
placed through the medial portal. The guide is
placed approximately 1.5 cm medial to the tibial
tubercle. The appropriate size FlipCutter is then
drilled through the guide. Again, positioning is verified by fluoroscopy to avoid physeal damage. The
FlipCutter is drilled retrograde within the tibial
epiphysis to establish a socket of approximately 15
to 20 mm, again with a bone bridge of at least 7
mm. A FiberStick is then advanced through the
socket, retrieved through the anterolateral portal (to
ACL RECONSTRUCTION IN YOUNG PATIENTS
e233
FIGURE 2. (A) The femoral footprint is debrided while the surgeon is viewing with arthroscopes using both 70° and 30° lenses from the
anterolateral portal. This is a view using the 70° lens. The tunnel is planned for the center of the femoral footprint, approximately 2 to 3 mm
from the back wall. (B) The tunnel is drilled by first placing the outside-in femoral guide through the anterolateral portal. Once the appropriate
position is verified by fluoroscopy, the FlipCutter is opened and the tunnel is drilled retrograde while the surgeon is viewing with either a
30° or 70° arthroscope from the anteromedial portal. (C) The tunnel, viewed from the anterolateral portal, with a bone bridge to the lateral
cortex of at least 7 mm, is tagged with a FiberStick for later graft passage.
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M. M. MCCARTHY ET AL.
FIGURE 3. (A) The tibial footprint, as viewed through the anterolateral portal with a 70° arthroscope, is debrided. The tunnel is planned for
the center of the tibial footprint. Again, the FlipCutter is drilled from outside in completely within the epiphysis. Once appropriate position
is confirmed by fluoroscopy on the anteroposterior and lateral views, the FlipCutter is opened and the tunnel is drilled antegrade. (B) Views
of the tibial tunnel from the anterolateral portal using a 70° arthroscope. The guide is malleted through the cortex to ensure a bone bridge
of at least 7 mm between the graft and the suture button.
avoid complication with the femoral FiberStick),
and tagged for later graft passage.
The 2 blind sockets are then evaluated arthroscopically to ensure appropriate position and the absence of
physeal damage. The graft is passed retrograde through
the anteromedial portal. By use of the previously passed
FiberStick, the femoral side is passed first. The button is
engaged on the lateral cortex and deployed to dock at
least 1 cm of the graft inside the femoral socket. The
tibial-side FiberStick is then shuttled from the anterolateral portal to the anteromedial portal, and the tibial side
of the graft is docked into the tibial socket. The suture
button is engaged on the cortex and deployed to dock the
graft in the tunnel. Viewing the graft arthroscopically
ACL RECONSTRUCTION IN YOUNG PATIENTS
FIGURE 4.
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Views of intra-articular portion of all-epiphyseal ACL reconstruction from anterolateral portal.
(Fig 4) and with the knee placed in extension, the femoral and tibial TightRope RT devices are both tensioned
until tight (Fig 5). The incisions are irrigated thoroughly
and closed according to standard protocol. The knee is
dressed with sterile dressings and placed in a hinged
knee brace locked in maximal extension. Patients in this
age group are generally admitted to the hospital for 1
night and undergo cryotherapy in the postanesthesia care
unit. Physical therapy is begun on postoperative day 1,
FIGURE 5. Radiographs of all-epiphyseal ACL
reconstruction and fixation with GraftLink RT.
and patients are weight bearing as tolerated unless meniscal repair or treatment of articular cartilage injury
dictates otherwise.
CASE REPORTS
Two case examples are presented. Both patients and
their parents gave consent to having their cases presented.
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M. M. MCCARTHY ET AL.
Patient 1 is a healthy 11-year-old boy who sustained
an acute noncontact twisting injury of the left knee 10
days before presentation. His physical examination
was notable for a 1⫹ effusion, a grade 2B Lachman
test, a 2⫹ pivot-shift test, and range of motion (ROM)
lacking 5° of extension. A magnetic resonance imaging (MRI) study confirmed the presence of an acute,
complete rupture of the ACL with characteristic lateralcompartment transchondral fractures. Knee radiographs showed open physes, and a hand radiograph
showed a bone age of 12 years 6 months.42 The patient
completed a short course of physical therapy focusing
on regaining full ROM. He underwent an all-inside,
all-epiphyseal ACL reconstruction with hamstring autograft as described earlier. At 6 months postoperatively, he has full knee ROM and negative Lachman
and pivot-shift examinations. He is on target with the
rehabilitation protocol described earlier.
Patient 2 is a healthy 10-year-old boy who sustained
a contact injury of the right knee while ski racing 4
months before presentation. His physical examination
was notable for no effusion, a grade 2B Lachman test,
a 2⫹ pivot-shift test, and full ROM. Knee radiographs
showed open physes. An MRI study showed a complete ACL intrasubstance tear with no bone edema but
with anterior tibial translation. The patient underwent
an all-inside, all-epiphyseal ACL reconstruction with
hamstring autograft as described earlier. At 6 months
postoperatively, he has full knee ROM and negative
Lachman and pivot-shift examinations. He is ahead of
schedule with the rehabilitation protocol and is already progressing to agility and side-to-side training.
DISCUSSION
Because of the fear of physeal injury in skeletally
immature patients presenting with complete ACL ruptures, several techniques for physeal-sparing ACL reconstruction have been developed and described. One
of the first techniques was reported by Micheli et al.43
and Kocher et al.,34,44 and it is a nonanatomic, extraarticular reconstruction that involves harvesting a strip
of iliotibial band. The strip is left attached to the
Gerdy tubercle; passed around the lateral femoral condyle, through the notch, and secured in the over-thetop position on the femur; and then passed under the
transverse meniscal ligament and sutured to the periosteum of the anterior tibial plateau distal to the physis. This is an anatomy-distorting procedure and is
technically demanding. Kocher et al.34 reported on 44
skeletally immature patients with a mean follow-up of
5.3 years. There were 2 failures, normal Lachman exam-
inations in 23 patients, nearly normal Lachman examinations in 18 patients, normal pivot-shift examinations in
31 patients, and nearly normal pivot-shift examinations
in 11 patients. There were no angular deformities or
clinically apparent growth disturbances. Recent biomechanical reports suggest that this extra-articular reconstruction technique may overconstrain the knee, especially with regard to rotational stability,39 which is
concerning in this very young age group.
Another physeal-sparing technique, described by
Guzzanti et al.,32 involves a small, centrally located
and vertical femoral tunnel combined with an allepiphyseal but eccentric proximal tibial tunnel. The
autograft hamstrings are left attached distally, brought
into the tibial tunnel and through the femoral tunnel.
With the knee in 30° of flexion, the graft is fixed to the
femur proximal to the physis. Among 14 patients, 10
were asymptomatic and fully active in sports at skeletal maturity with no significant leg-length or angular
deformities. Another physeal-sparing technique, described by Anderson,30,45 involves all-epiphyseal tunnels on both the femur and tibia. The tibial tunnel is
eccentric. Fixation on the femur is achieved with a
washer and an EndoButton (Smith & Nephew Endoscopy, Andover, MA), whereas fixation on the tibia is
achieved with a post and suture distal to the physis.
There were no failures among 12 patients with a mean
follow-up of 4.1 years.
The most recently described technique, reported by
Lawrence et al.,38 involves all-epiphyseal tunnels in
both the femur and tibia. The femoral tunnel is parallel
to the epiphysis and fixed with an interference screw.
The tibial tunnel is drilled with a RetroDrill (Arthrex),
which places it in a more anatomic location than the
eccentric tunnels advocated in the techniques described earlier. The RetroDrill requires placement of a
3-mm guide pin across the tibial physis. Fixation on
the tibial side is with a RetroScrew (Arthrex); however, the tibial tunnel length must be at least 20 mm to
accommodate the RetroScrew, thereby excluding
smaller knees. There is cause for concern regarding
the use of a RetroScrew in this setting. First, placement of a RetroScrew may cause damage to the autograft, especially the intra-articular portion, during
placement. In addition, the use of biologically active
screws that are intended to provide strong initial fixation may cause physeal growth disturbance if they
are placed too close to the physis or across the physis.
Moreover, the proper placement of tunnels in this
technique requires the use of an intraoperative computed tomography scan, as advocated by Lawrence et
ACL RECONSTRUCTION IN YOUNG PATIENTS
al. This increases the radiation exposure as well as the
operative time in these young patients.
The technique described in this report is novel in
several ways. The graft is a hamstring autograft but
requires only harvesting of the semitendinosus with
maintenance of the gracilis in some cases. This may
improve the postoperative lower extremity knee flexor
and internal rotator strength as compared with harvesting both the semitendinosus and gracilis tendons,
which can be deficient even at 2 years postoperatively.46-58 This technique is less anatomy distorting
than the iliotibial band reconstruction technique, with
lower postoperative morbidity. The sockets used with
this technique are all epiphyseal and blind ended
with a cortical bone bridge of at least 7 mm. Although
research into tendon-to-bone healing is ongoing and,
to our knowledge, has not evaluated these particular
sockets, these blind sockets may provide a better biological environment for predictable tendon-to-bone
healing by excluding the extraosseous environment
and not allowing an opening for release of growth
factors. Unlike the transtibial tunnels or the tunnels
drilled with the RetroDrill, there is no violation of
either the tibial or femoral physes. This minimizes risk
to the growth plates and does not require intraoperative computed tomography or anything more than
several mini C-arm fluoroscopy images. In a recently
described study evaluating the clinically identifiable
intraoperative landmarks of the popliteus tendon and
the center of the femoral footprint, MRI allowed reproducible epiphyseal socket placement and length.59
In addition, the fixation method described with this
technique is entirely within the physis. Other methods
including those that cross the physes are at risk for
growth disturbance due to tethering of the physes
by the fixation methods.60 As a result of this concern,
these fixation devices are often removed at 6 months
to 1 year, necessitating additional surgery to avoid this
type of complication.
Currently, there are sparse descriptions of rehabilitation programs regarding skeletally immature individuals in the literature. The descriptions that do exist
limit early weight bearing and ROM.44,61,62 It is not
recommended to follow adult ACL reconstruction
guidelines for patients who have received physealsparing ACL reconstruction because of differing fixation technique as well as patient maturity level. Isometric graft placement allows for immediate motion
without adverse loads. However, current surgical techniques for epiphyseal ACL reconstruction make it
difficult to restore native ACL attachments while
keeping graft fixation entirely in the epiphysis.38
e237
Therefore the reported guidelines limit ROM to 90°
and maintain partial weight bearing postoperatively
with a hinged knee brace locked in extension for 4
weeks. If the patient is apprehensive regarding weight
bearing, an underwater treadmill is a great modality to
unload the extremity. Walking in waist deep water has
demonstrated a 40 to 50% reduction in weight bearing.63
Early and appropriate management postoperatively
is critical for successful recovery. The reported guidelines progress through criteria-based functional progression and stress the importance of education and
the home exercise program (HEP). Frequent reassessment is critical to ensure performance of the HEP as
well as improvement of ROM and strength. If the
patient is apprehensive and ROM plateaus, the clinician should ensure proper performance of the HEP. A
home continuous passive motion unit may be used to
prevent arthrofibrosis. Brace education is performed
with both the patient and caregiver and is crucial for
both graft protection and prevention of ambulation on
a bent knee. The clinician should encourage frequent
brace checks throughout the day because the brace
tends to loosen and slide distally, which may cause
knee extension loss. Activity modification and frequent cryotherapy should be emphasized.
The patient’s age and maturity level need to be
considered for appropriate management. Compliance
tends to be problematic with pediatric athletes. Both
patient and caregiver should be involved throughout
the rehabilitation process to ensure adherence to precautions, activity modifications, and proper brace use,
as well as compliance with the HEP. The clinician
should administer 1-on-1 care to ensure safety, proper
technique with therapeutic exercises, and performance
of the appropriate number of repetitions and sets. The
child’s relationship with the clinician is critical in
enhancing the child’s confidence with progression
through the rehabilitation program. The clinician
should be creative and find what motivates the child,
create clear tangible goals that the patient can understand, and gain the patient’s trust.
Neuromuscular control is of particular importance,
because athletes who return to sports after ACL reconstruction are at increased risk of subsequent ACL
injury (either reinjury or injury to the contralateral
extremity).64-66 The risk of subsequent ACL injury is
significantly higher compared with the risk of initial
ACL injury, especially in young, active individuals.64-66 It is highly recommended that the pediatric
athlete participate in an ACL injury prevention program to address neuromuscular control deficits and
train for at least 1 year before returning to sports.
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M. M. MCCARTHY ET AL.
Constant communication among the physician, physical therapist, and caregiver is crucial for the success
of the surgery and safe return to sports.
Overall, our novel technique for all-epiphyseal
ACL reconstruction provides a successful treatment
for primary ACL ruptures in skeletally immature patients with minimal risk of physeal disturbance and a
protocol for return to sports that takes into account the
unique pediatric population.
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