Simultaneous anterior cruciate ligament reconstruction and implant-mediated guided growth to correct genu valgum in skeletally immature patients

Anterior Tibial Hemiepiphysiodesis to Correct Increased Tibial Slope in Pediatric ACL Rupture: Report of Two Cases

CASE

A 13-year-old adolescent boy and a 12-year-old girl, with torn anterior cruciate ligament (ACL) and increased posterior tibial slopes (PTS) of 17° and 19°, underwent transphyseal anterior tibial hemiepiphysiodesis and ACL reconstruction using a quadriceps autograft. Epiphysiodesis plates were removed after epiphyseal closure in the girl and after 12 months in the boy. Follow-up at 12 and 15 months showed Tegner and Lysholm scores of 4 and 100, with PTS reduced to 8° and 9°. Both resumed sports without further instability.

CONCLUSION

Anterior tibial hemiepiphysiodesis effectively reduced the increased PTS to physiological levels in both cases.

Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients

PURPOSE OF REVIEW

Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered.

RECENT FINDINGS

Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.