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. “Physeal-
sparing” 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 rehabili-
tation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL recon-
struction in skeletally immature patients.

A nterior cruciate ligament (ACL) injuries are com-

mon in active, young patients and are increas-
ingly being treated in skeletally immature patients.
result of literature documenting the poor natural his-
tory of nonoperative treatment.1-7
The true incidence of midsubstance ACL rupture in
The increase in the incidence of these injuries in children is unknown, but ACL injury has been re-
children and adolescents results in part from Title IX, ported in 10% to 65% of pediatric knees with acute
which has doubled the denominator by including fe- hemarthrosis.8-11 Shea et al.12 found that ACL injuries
male persons in athletics; in addition, there has been a accounted for 6.7% of total injuries and 30.8% of all
proliferation of competitive sports at younger ages, as knee injuries in soccer players aged 5 to 18 years in
well as a surge in the level of competition within these the United States. Bony ACL avulsions are more
age groups, and improved recognition of these injuries likely to occur in preadolescents, whereas adolescents
by athletic trainers and orthopaedic surgeons. The are more prone to ACL substance tears.13,14 Histori-
surgical treatment of ACL injuries in this age group cally, ACL reconstruction in skeletally immature pa-
has risen because of the increased injury rate and as a tients was not recommended because of potential iat-
rogenic physeal injury resulting in growth arrest,
limb-length discrepancies, and angular deformi-
ties.15-21 Left untreated, chronic ACL deficiency can
From the Hospital for Special Surgery, New York, New York, lead to instability, meniscal damage, chondral dam-
U.S.A.
The authors report the following potential conflict of interest or age, osteoarthritis, and decreased activity levels. Pre-
source of funding in relation to this article: Arthrex, Naples, FL. vious data have shown that between 21% and 100% of
Received May 12, 2012; accepted August 27, 2012.
Address correspondence to Moira M. McCarthy, M.D., Hospital
pediatric patients have a concomitant meniscal injury
for Special Surgery, 535 E 71st St, New York, NY 10021, U.S.A. at the time of the ACL injury.22-28
E-mail: [email protected] The increased recognition of these injuries and the
© 2012 by the Arthroscopy Association of North America
2212-6287/12322/$36.00 need for treatment acutely rather than delaying treat-
http://dx.doi.org/10.1016/j.eats.2012.08.005 ment until skeletal maturity have led to the emergence

Arthroscopy Techniques, Vol 1, No 2 (December), 2012: pp e231-e239 e231

e232 M. M. MCCARTHY ET AL.

of a variety of surgical procedures for ACL recon-

struction.29 “Physeal-sparing” alternative techniques
have been developed, including over-the-top recon-
structions of the femur and tibia, transtibial over-the-
top femur reconstructions, and iliotibial band recon-
structions.23,24,30-36 These reconstructions, however,
distort the intra-articular anatomy. A recently de-
scribed 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 bio-
mechanics of the native ACL.39-41 Kocher et al.4 re-
ported that 78% of surgeons surveyed had performed FIGURE 1. The graft is a quadrupled semitendinosus autograft
an ACL reconstruction in a skeletally immature pa- secured with 2 TightRope RT devices in the GraftLink technique.
Graft length is between 50 and 55 mm, with a diameter between 7
tient but that no single technique predominated. and 8 mm. The graft is tensioned at 20 lb for 5 minutes.
We describe a novel all-inside, all-epiphyseal tech-
nique for ACL reconstruction. This technique restores
the intra-articular anatomy better than the other physeal-
sparing techniques and minimizes the risk of physeal The femoral socket is addressed first (Fig 2). The
injury by placing both the femoral and tibial sockets, surgeon places an outside-in femoral ACL guide (Ar-
as well as fixation, exclusively within the epiphysis. threx), 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
SURGICAL TECHNIQUE
viewing with a 30° arthroscope from the anteromedial
Our reconstruction technique is demonstrated in portal. A 1-cm incision is made followed by dissection
Video 1. The autologous hamstring graft is prepared and seating of the guide just anterior to the lateral
first. The semitendinosus is harvested by the standard epicondyle. The appropriate size FlipCutter (Arthrex)
technique with a 2-cm vertical incision over the distal is then used to drill from the lateral cortex to the
insertion of the hamstring tendon. The knee is posi- guide on the footprint. The positioning distal to the
tioned at 60° of flexion with the hip externally rotated. physis is verified by fluoroscopy. Once the position
To achieve a quadrupled graft of the appropriate is confirmed, the drill sleeve is malleted through the
length and diameter, the semitendinosus alone is most cortex; this ensures a bone bridge of at least 7 mm
commonly harvested while the gracilis is maintained. between the end of the tunnel and the lateral cortex.
If the diameter of the graft is determined to be insuf- The FlipCutter is then deployed and used to drill the
ficient (⬍7 mm), the gracilis is then harvested as well. femoral socket retrograde to approximately 20 to 25
The graft is prepared by the GraftLink technique (Ar- mm. The FlipCutter is advanced into the joint,
threx, Naples, FL) with 2 TightRope RT suture but- closed, and removed through the lateral cortex. A
tons (Arthrex) for fixation on the tibia and femur (Fig FiberStick (Arthrex) is advanced through the guide,
1). The graft length is between 50 and 55 mm. The delivered out the anteromedial portal, and tagged
goal graft diameter is 7 to 8 mm. The graft is sized, for later graft passage.
pretensioned to 20 lb for 5 minutes, and then wrapped The tibial socket is then addressed (Fig 3). The
in damp gauze and stored in a sterile sealed plastic bag tibial ACL guide, set at approximately 50°, is
on the back table. placed through the medial portal. The guide is
Standard diagnostic knee arthroscopy is performed placed approximately 1.5 cm medial to the tibial
through the anteromedial and anterolateral portals. All tubercle. The appropriate size FlipCutter is then
chondral and meniscal pathology is addressed appro- drilled through the guide. Again, positioning is ver-
priately. The intrasubstance ACL tear is identified, ified by fluoroscopy to avoid physeal damage. The
confirmed, and debrided to show the tibial and femo- FlipCutter is drilled retrograde within the tibial
ral insertional footprints. A 70° arthroscope is rou- epiphysis to establish a socket of approximately 15
tinely used to better view the femoral footprint from to 20 mm, again with a bone bridge of at least 7
the anterolateral portal. One can use a 30° arthroscope mm. A FiberStick is then advanced through the
from the anteromedial portal as an alternative. 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.
e234 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), engaged on the lateral cortex and deployed to dock at
and tagged for later graft passage. least 1 cm of the graft inside the femoral socket. The
The 2 blind sockets are then evaluated arthroscopi- tibial-side FiberStick is then shuttled from the anterolat-
cally to ensure appropriate position and the absence of eral portal to the anteromedial portal, and the tibial side
physeal damage. The graft is passed retrograde through of the graft is docked into the tibial socket. The suture
the anteromedial portal. By use of the previously passed button is engaged on the cortex and deployed to dock the
FiberStick, the femoral side is passed first. The button is graft in the tunnel. Viewing the graft arthroscopically
 ACL RECONSTRUCTION IN YOUNG PATIENTS e235

FIGURE 4. Views of intra-articular portion of all-epiphyseal ACL reconstruction from anterolateral portal.

(Fig 4) and with the knee placed in extension, the fem- and patients are weight bearing as tolerated unless me-
oral and tibial TightRope RT devices are both tensioned niscal repair or treatment of articular cartilage injury
until tight (Fig 5). The incisions are irrigated thoroughly dictates otherwise.
and closed according to standard protocol. The knee is
dressed with sterile dressings and placed in a hinged CASE REPORTS
knee brace locked in maximal extension. Patients in this
age group are generally admitted to the hospital for 1 Two case examples are presented. Both patients and
night and undergo cryotherapy in the postanesthesia care their parents gave consent to having their cases pre-
unit. Physical therapy is begun on postoperative day 1, sented.

FIGURE 5. Radiographs of all-epiphyseal ACL

reconstruction and fixation with GraftLink RT.
e236 M. M. MCCARTHY ET AL.

Patient 1 is a healthy 11-year-old boy who sustained inations in 23 patients, nearly normal Lachman exami-
an acute noncontact twisting injury of the left knee 10 nations in 18 patients, normal pivot-shift examinations in
days before presentation. His physical examination 31 patients, and nearly normal pivot-shift examinations
was notable for a 1⫹ effusion, a grade 2B Lachman in 11 patients. There were no angular deformities or
test, a 2⫹ pivot-shift test, and range of motion (ROM) clinically apparent growth disturbances. Recent biome-
lacking 5° of extension. A magnetic resonance imag- chanical reports suggest that this extra-articular recon-
ing (MRI) study confirmed the presence of an acute, struction technique may overconstrain the knee, espe-
complete rupture of the ACL with characteristic lateral- cially with regard to rotational stability,39 which is
compartment transchondral fractures. Knee radio- concerning in this very young age group.
graphs showed open physes, and a hand radiograph Another physeal-sparing technique, described by
showed a bone age of 12 years 6 months.42 The patient Guzzanti et al.,32 involves a small, centrally located
completed a short course of physical therapy focusing and vertical femoral tunnel combined with an all-
on regaining full ROM. He underwent an all-inside, epiphyseal but eccentric proximal tibial tunnel. The
all-epiphyseal ACL reconstruction with hamstring au- autograft hamstrings are left attached distally, brought
tograft as described earlier. At 6 months postopera- into the tibial tunnel and through the femoral tunnel.
tively, he has full knee ROM and negative Lachman With the knee in 30° of flexion, the graft is fixed to the
and pivot-shift examinations. He is on target with the femur proximal to the physis. Among 14 patients, 10
rehabilitation protocol described earlier. were asymptomatic and fully active in sports at skel-
Patient 2 is a healthy 10-year-old boy who sustained etal maturity with no significant leg-length or angular
a contact injury of the right knee while ski racing 4 deformities. Another physeal-sparing technique, de-
months before presentation. His physical examination scribed by Anderson,30,45 involves all-epiphyseal tun-
was notable for no effusion, a grade 2B Lachman test, nels on both the femur and tibia. The tibial tunnel is
a 2⫹ pivot-shift test, and full ROM. Knee radiographs
eccentric. Fixation on the femur is achieved with a
showed open physes. An MRI study showed a com-
washer and an EndoButton (Smith & Nephew Endos-
plete ACL intrasubstance tear with no bone edema but
copy, Andover, MA), whereas fixation on the tibia is
with anterior tibial translation. The patient underwent
achieved with a post and suture distal to the physis.
an all-inside, all-epiphyseal ACL reconstruction with
There were no failures among 12 patients with a mean
hamstring autograft as described earlier. At 6 months
follow-up of 4.1 years.
postoperatively, he has full knee ROM and negative
Lachman and pivot-shift examinations. He is ahead of The most recently described technique, reported by
schedule with the rehabilitation protocol and is al- Lawrence et al.,38 involves all-epiphyseal tunnels in
ready progressing to agility and side-to-side training. 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),
DISCUSSION which places it in a more anatomic location than the
Because of the fear of physeal injury in skeletally eccentric tunnels advocated in the techniques de-
immature patients presenting with complete ACL rup- scribed earlier. The RetroDrill requires placement of a
tures, several techniques for physeal-sparing ACL re- 3-mm guide pin across the tibial physis. Fixation on
construction have been developed and described. One the tibial side is with a RetroScrew (Arthrex); how-
of the first techniques was reported by Micheli et al.43 ever, the tibial tunnel length must be at least 20 mm to
and Kocher et al.,34,44 and it is a nonanatomic, extra- accommodate the RetroScrew, thereby excluding
articular reconstruction that involves harvesting a strip smaller knees. There is cause for concern regarding
of iliotibial band. The strip is left attached to the the use of a RetroScrew in this setting. First, place-
Gerdy tubercle; passed around the lateral femoral con- ment of a RetroScrew may cause damage to the au-
dyle, through the notch, and secured in the over-the- tograft, especially the intra-articular portion, during
top position on the femur; and then passed under the placement. In addition, the use of biologically active
transverse meniscal ligament and sutured to the peri- screws that are intended to provide strong initial fix-
osteum of the anterior tibial plateau distal to the phy- ation may cause physeal growth disturbance if they
sis. This is an anatomy-distorting procedure and is are placed too close to the physis or across the physis.
technically demanding. Kocher et al.34 reported on 44 Moreover, the proper placement of tunnels in this
skeletally immature patients with a mean follow-up of technique requires the use of an intraoperative com-
5.3 years. There were 2 failures, normal Lachman exam- puted tomography scan, as advocated by Lawrence et
 ACL RECONSTRUCTION IN YOUNG PATIENTS e237

al. This increases the radiation exposure as well as the Therefore the reported guidelines limit ROM to 90°
operative time in these young patients. and maintain partial weight bearing postoperatively
The technique described in this report is novel in with a hinged knee brace locked in extension for 4
several ways. The graft is a hamstring autograft but weeks. If the patient is apprehensive regarding weight
requires only harvesting of the semitendinosus with bearing, an underwater treadmill is a great modality to
maintenance of the gracilis in some cases. This may unload the extremity. Walking in waist deep water has
improve the postoperative lower extremity knee flexor demonstrated a 40 to 50% reduction in weight bearing.63
and internal rotator strength as compared with harvest- Early and appropriate management postoperatively
ing both the semitendinosus and gracilis tendons, is critical for successful recovery. The reported guide-
which can be deficient even at 2 years postopera- lines progress through criteria-based functional pro-
tively.46-58 This technique is less anatomy distorting gression and stress the importance of education and
than the iliotibial band reconstruction technique, with the home exercise program (HEP). Frequent reassess-
lower postoperative morbidity. The sockets used with ment is critical to ensure performance of the HEP as
this technique are all epiphyseal and blind ended well as improvement of ROM and strength. If the
with a cortical bone bridge of at least 7 mm. Although patient is apprehensive and ROM plateaus, the clini-
research into tendon-to-bone healing is ongoing and, cian should ensure proper performance of the HEP. A
to our knowledge, has not evaluated these particular home continuous passive motion unit may be used to
sockets, these blind sockets may provide a better bi- prevent arthrofibrosis. Brace education is performed
ological environment for predictable tendon-to-bone with both the patient and caregiver and is crucial for
healing by excluding the extraosseous environment both graft protection and prevention of ambulation on
and not allowing an opening for release of growth a bent knee. The clinician should encourage frequent
factors. Unlike the transtibial tunnels or the tunnels brace checks throughout the day because the brace
drilled with the RetroDrill, there is no violation of tends to loosen and slide distally, which may cause
either the tibial or femoral physes. This minimizes risk knee extension loss. Activity modification and fre-
to the growth plates and does not require intraopera- quent cryotherapy should be emphasized.
tive computed tomography or anything more than The patient’s age and maturity level need to be
several mini C-arm fluoroscopy images. In a recently considered for appropriate management. Compliance
described study evaluating the clinically identifiable tends to be problematic with pediatric athletes. Both
intraoperative landmarks of the popliteus tendon and patient and caregiver should be involved throughout
the center of the femoral footprint, MRI allowed re- the rehabilitation process to ensure adherence to pre-
producible epiphyseal socket placement and length.59 cautions, activity modifications, and proper brace use,
In addition, the fixation method described with this as well as compliance with the HEP. The clinician
technique is entirely within the physis. Other methods should administer 1-on-1 care to ensure safety, proper
including those that cross the physes are at risk for technique with therapeutic exercises, and performance
growth disturbance due to tethering of the physes of the appropriate number of repetitions and sets. The
by the fixation methods.60 As a result of this concern, child’s relationship with the clinician is critical in
these fixation devices are often removed at 6 months enhancing the child’s confidence with progression
to 1 year, necessitating additional surgery to avoid this through the rehabilitation program. The clinician
type of complication. should be creative and find what motivates the child,
Currently, there are sparse descriptions of rehabili- create clear tangible goals that the patient can under-
tation programs regarding skeletally immature indi- stand, and gain the patient’s trust.
viduals in the literature. The descriptions that do exist Neuromuscular control is of particular importance,
limit early weight bearing and ROM.44,61,62 It is not because athletes who return to sports after ACL re-
recommended to follow adult ACL reconstruction construction are at increased risk of subsequent ACL
guidelines for patients who have received physeal- injury (either reinjury or injury to the contralateral
sparing ACL reconstruction because of differing fix- extremity).64-66 The risk of subsequent ACL injury is
ation technique as well as patient maturity level. Iso- significantly higher compared with the risk of initial
metric graft placement allows for immediate motion ACL injury, especially in young, active individu-
without adverse loads. However, current surgical tech- als.64-66 It is highly recommended that the pediatric
niques for epiphyseal ACL reconstruction make it athlete participate in an ACL injury prevention pro-
difficult to restore native ACL attachments while gram to address neuromuscular control deficits and
keeping graft fixation entirely in the epiphysis.38 train for at least 1 year before returning to sports.
e238 M. M. MCCARTHY ET AL.

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