The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents"
by Mininder S. Kocher, MD, MPH, et al.

Commentary & Perspective by
Frank R. Noyes, MD*,
Cincinnati Sports Medicine, Cincinnati, Ohio

The treatment of complete ruptures to the anterior cruciate ligament in skeletally immature patients is a difficult problem. Kocher et al. provide an operative approach and an encouraging outcome in such patients. Forty-four of fifty children and adolescents (age range, 3.6 to 14.0 years) who underwent physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft were followed from two to fifteen years postoperatively. The time from the injury to the operation ranged from three to forty months. I was not able to determine how many of the patients were managed with conservative treatment or how many patients sustained repeat full giving-way injuries before the operative procedure. In addition, while the authors listed a repairable meniscus tear as an indication for surgery, I was unable to detect how many patients were in this category. Further detail regarding the conservative management program would be helpful in future publications, including rehabilitation exercises performed, braces worn, and the amount of time the patients were involved in a supervised program.

At least twenty-seven (61%) of the patients sustained meniscal injuries, and, fortunately, the authors repaired these tears in twenty-three patients. The repairs were successful in all but four patients. I have long advocated meniscal repair for tears located both in the periphery and extending into the central avascular region and have reported the results of this technique in patients as young as nine years of age¹. Although the authors did not describe their meniscal repair technique or the type and location of the meniscal tears, I have found that vertical divergent sutures placed every 4 mm along the tear site provides reliable results, even for tears that extend into the central avascular region.

The most noteworthy data provided in this report are the results of the anterior cruciate ligament reconstruction in prepubescent patients. The study population was comprised of three patients who were between three and six years old and twenty-four patients who were between seven and ten years old. The remaining seventeen patients were between eleven and fourteen years of age. There have been many papers on the results of operative procedures with regard to the latter group, but few, if any, concerning patients who were ten years of age or younger. Any risk at all of interruption of growth or an angular deformity in these younger patients is not only serious but involves the necessity for subsequent major surgical procedures to address the problem. Thus, the authors are to be congratulated for their good-to-excellent clinical results in subjective, objective, and functional categories in a sufficient number of patients without one instance of a growth or angular deformity. The mean growth in total height (trunk and lower extremity) from the time of surgery to the final follow-up examination was 21.5 cm (range 9.5 cm to 118.5 cm). Granted, the number of patients precludes definitive conclusions; however, this still represents a unique set of patients in which limited clinical data exist for decision-making regarding the type of operative procedure to be selected.

The authors correctly admit that the iliotibial band graft is nonanatomic, and the over-the-top femoral position would be expected to result in a higher number of patients with increased laxity compared with that of the opposite, normal knee. Indeed, the results may point to this situation regarding the subjective grading of the Lachman and pivot-shift tests, in which the results were normal for twenty-three patients and thirty-one patients, respectively, and nearly normal (3 to 5 mm increase in anterior tibial translation, trace pivot-shift) for eighteen patients and eleven patients, respectively. This does represent a mild increase in residual anterior translation, which did not achieve functional significance in these patients but is still a higher number than that reported in studies in which anatomic anterior cruciate ligament reconstruction was performed. One patient had abnormal results on the Lachman examination, and the grafts failed in two other patients following a reinjury. The overall failure rate (judged by revision or abnormal results of examination) was only 7% (three of forty-four knees).

One of the missing data sets which would have strengthened the results of the stability tests is objective tibial translation values as measured by a KT-2000 or other measurement system. All surgeons are aware of the subjectivity of Lachman and pivot-shift tests, even among skilled examiners. In my opinion, reviewers and editors should insist on the inclusion of these important data in anterior cruciate ligament reconstruction studies. In addition, there is a subset of patients in this study in the two to four-year duration of follow-up, and it will be important for the authors to report a longer follow-up to determine if the nonanatomic graft provides function five to seven years postoperatively.

Kocher et al. appeared to use the main portion of the iliotibial band, but they did not state whether a repair of the iliotibial band defect was performed. Patients with such a defect may complain of pain, and the cosmetic aspects of a bulging vastus lateralis may be avoided by a direct repair. There are also theoretical advantages to restoring the iliotibial band function.

I congratulate the authors for the use of immediate knee motion from 0° to 90° and a progressive rehabilitation program to avoid arthrofibrosis and other postoperative complications. The authors used continuous passive motion from 0° to 90° for the first two postoperative weeks to "initiate motion and overcome the anxiety associated with postoperative movement in these young children." I am confident that these authors had a diligent physical therapy team to provide a zero incidence of motion complications. As an advocate of immediate knee motion following anterior cruciate ligament reconstruction for patients of all ages, I believe that the institution of early flexion and extension exercises, along with patellar mobilization and quadriceps strengthening, are essential for a favorable outcome. The rehabilitation of children requires even more scrupulous supervision than that of older patients. Frequent physical therapy visits are recommended to closely monitor knee motion, joint effusion, muscle, and gait characteristics.

My current recommendations with regard to prepubescent patients who sustain a complete anterior cruciate ligament rupture are conservative treatment, rehabilitation, bracing, and activity modification. However, if nonoperative treatment fails, it is encouraging that a physeal sparing technique can be used successfully to stabilize the knee and avoid further meniscal or chondral damage. I agree with the authors that this method may be subject to failure in the future and warn the parents and patients of this potential risk. What is unique and important about this study is the provision of data showing the safety of this approach and ability to achieve good functional results, particularly in patients younger than ten years of age. In this young group of patients, surgeons have little information on stabilization techniques, and it is possible that future techniques may emerge that are safe and worthy of consideration. Until these data become available, it would appear that Kocher and associates have performed a real service to their orthopaedic colleagues by presenting this operative approach.

*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.

Reference

1. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears extending into the avascular zone in patients younger than twenty years of age. Am J Sports Med. 2002;30:589-600.