Summary

This study evaluated return to sports ability (RTS), rotational laxity and potential growth disturbances in skeletally immature patients (SIP) after transphyseal Anterior Cruciate Ligament (ACL) reconstruction with metaphyseal fixation technique.

Abstract

Purpose

This study evaluated return to sports ability (RTS), rotational laxity and potential growth disturbances in skeletally immature patients (SIP) after transphyseal Anterior Cruciate Ligament (ACL) reconstruction with metaphyseal fixation technique.

Methods

Ninety SIP underwent, between 2010 and 2017, reconstruction of the ACL with quadruple hamstring tendon graft performed with an arthroscopic technique; accessory anteromedial portal and intraoperative fluoroscopic imaging for precise tunnel placement were used. For patients in later Tanner stage III or IV, the procedure was transphyseal, standard ACL reconstruction procedure (suspensory femoral fixation with interference tibial screw) was used for Tanner stage V patients (boys > 16 y.o. and girls > 14 y.o.). MRI and long leg Xrays were mandatory preoperatively; clinical follow up at 6 weeks, 3, 9, 12 months and one and a half years postoperatively. We created an online survey to evaluate our patients (29 out of 90 responded) using IKDC forms; statistical analysis and correlations was performed using SPSS software.

Results

Female prevalence was 70% of our study group, mean age 16 y.o. (13 to 18); main sport responsible for injuries was handball (76%). Return to sports was 69% in this group; 58% at the same level. Recommended interval for RTS was 12 months; only 22% complied, more than 25% returned between 6 to 7 months.
The mean IKDC score was 95 points (range 85-99 points). Ligament laxity testing with a KT-1000 Arthrometer revealed a mean side-to-side difference of 1.5 +/- 1.5 mm. At follow up no leg length differences and axis modifications were found.
Female patients had more chondral associated lesions than males, trochlea 42.9% vs 29.6% (p<0.05); lateral compartment 14.3% vs 3.7 % (p<0,05). Meniscal lesions were more frequent in males (25.9% vs 23.8% on medial, 18.5% vs 4.4% on lateral); four cases had lesions in both menisci. Twelve patients had their medial meniscus repaired.
Early complications accounted for 5.5% of our cases: reactive synovitis in 4 patients and 1 septic arthritis. Cases with late complications were identified (8.8%): 3 graft failures, 2 medial meniscus lesions, one medial meniscal suture failure, one tibial tunnel widening, one cyst due to biocomposite screw complication. The re-injuries happened at a mean of 12 months postoperatively, while practicing competitive sports. All patients with complications were professional level athletes.

Conclusions

Transepiphyseal replacement of the anterior cruciate ligament is a technically demanding procedure with a small margin of error and it should be attempted only by skilled knee surgeons. Our study shows good results in skeletally immature patients undergoing ACL reconstruction using hamstring grafts and a metaphyseal fixation. Return to previous sport activity level is possible. Severe growth disturbances were not reported.
Different rehabilitation strategies for female young patients and later return to competitive sports as handball should be recommended. Focus intervention programs for education - on both patients and physical therapist with enhanced written recommandation protocols. Determine the best moment for surgical intervention surgery considering the competitional season.