Case Report Tanner II Immature Skeletal ACL Reconstruction in Immature Skeleton.

Authors:

Luis Fernando Rodríguez M.D.,
Orthopedic Surgeon. Knee Surgery CECIMIN-UNISANITAS, Bogotá.
Ernesto Martínez M.D.,
Orthopedic Surgeon. Knee Surgery CECIMIN-UNISANITAS, Bogotá.
José Andrés Ruiz M.D*.
Resident of Orthopedics. Fundación Universitaria Sanitas, Bogotá.

*Corresponding author  E-mail address: ja.ruizpe@unisanitas.edu.co

All the authors declare no conflict of interest.

INTRODUCTION

Anterior cruciate ligament (ACL) injuries in children and adolescents generate a high impact, from psychosocial, academic development, performance and sports participation to economic impact⁽¹⁾. The incidence of ACL injury is 51 per 100,000 children, however this figure increases in the female adolescent population, especially in those who practice multiple disciplines ⁽²⁾. Additionally, the incidence of ACL rupture in children and adolescents is increasing at around 2 - 3% per year, which is related to a greater intensity and specialization of sports participation at an early age⁽¹⁾. 

Historically, ACL injuries in children were managed conservatively or with reconstruction after skeletal maturity, due to the risk of physiological injury with conventional reconstruction techniques. However, in recent years, several studies, starting with that of Ramski and collaborators, have reported that 75% of patients with conservative management present pathological laxity versus 14% with surgical management ⁽³⁾. Multiple techniques for surgical management have been described, however there is no evidence to support the superiority of any of them, especially in patients with open physis and growth expectations, Tanner II or lower. In this work we report the case of a patient managed surgically in our institution with adequate evolution in his follow-up at 1 year. The patient and his parents gave signed consent for the publication of the case.

This case study presents the case of JDJ, a 7-year-old boy who sustained valgus trauma to the left knee during a soccer activity, resulting in subsequent pain and effusion. Despite initial management with physiotherapy, there was no improvement. Consequently, he was admitted to our institution, where MRI results revealed a complete rupture of the ACL in its medial portion, associated with an AP instability that was observed with tests. A clinical and radiological evaluation was performed to determine the patient's bone age, resulting in a Tanner II classification. Consequently, the ACL reconstruction procedure was performed with an autologous iliotibial band graft (ITB), as described by Micheli ⁽⁴⁾, with the author's own variations (using hamstring tendons). 

DESCRIPTION OF THE TECHNIQUE

Patient in supine decubitus under general anesthesia, with pneumatic tourniquet 100mmHg above systolic tension. Stability maneuvers are performed with the patient under anesthesia, checking AP instability, asepsis and antisepsis and placement of surgical fields commonly used for arthroscopy.  

Surgical Technique Steps:

1. Approach of the tibial insertion of the hamstrings with a 4 cm longitudinal incision medial to the Anterior Tibial Tuberosity (ATT), dissection by planes until identifying the semitendinosus (SMT) and gracilis (G) tendons, performing tibial disinsertion of these. In the free ends, we performed a continuous crossed suture of Krackow type with Vicryl 0.
2. The arthroscopic procedure is started by conventional anteromedial and anterolateral portals, diagnostic arthroscopy is performed to rule out possible additional pathologies to the ACL.
3. Under arthroscopic vision with anteromedial and anterolateral portals, visualization of the Anterior Intermeniscal Ligament (AIL).
4. Debridement is performed with shaver and radiofrequency of anterior fat.
5. From the proximal tibia, the free ends of the SMT and G tendons are taken below the LIA and with a Kelly curve is advanced through the medial portal into the intercondylar groove, using arthroscopic guidance, forceps are advanced through the intercondylar groove to the posterolateral portion at the head of the lateral gastrocnemius.
6. The forceps are advanced posterolaterally until reaching the site of approach to take the graft and the forceps are opened to open the capsule in that portion. Subsequently, the graft is advanced with another Kelly forceps and introduced into the open ends of the first one. The sutures are recovered by approach and the graft is advanced to the “over the top” position.
7. Traction is performed for femoral fixation of the ACL with Knotless screw. Fixation is performed with knee between 75 - 90 of flexion and neutral rotation, maintaining the tension (This fixation is done by confirming this supraphysial point with X-Ray).
8. The SMT and G tendons are passed subfacially towards the epiphyseal point corresponding to Gerdy's tubercle, fixation with Knotless screw is made at this point resembling anterolateral reconstruction. Control with Rx of epiphyseal location.
9. The Lachman maneuver is performed to verify adequate stability, followed by arthroscopic verification.
10. The wounds are washed and closed with vicryl 2.0 stitches and skin with prolene. Cover with sterile dressings and immobilization with bulky bandage.

RESULTS

For the management of ACL ruptures there are multiple treatments described starting with conservative, which is considered successful in the absence of recurrent instability and subsequent meniscal or chondral injury. However, as previously mentioned, instability is more frequent in patients with conservative management, and it has even been found that for each week of delay in repair, the risk of medial meniscal tears increases by 2% ⁽⁵⁾. On the other hand, deferred surgery has also been shown to increase the risk of chondral lesions in all compartments and the return to sporting activity is notably greater ⁽¹⁾.

Among the surgical treatment options, the main techniques described are over the iliotibial band reconstruction (ITBR), all-epiphyseal reconstruction (AE), hybrid fixations and transepiphysial reconstructions. Although at the moment there are no clinical practice guidelines for the management of these injuries, principles for treatment have been defined, such as those made by the Olympic Committee, among which are included: 1) restoration of stability and functionality of the knee; 2) reduction of the incidence of meniscal and chondral lesions; and 3) decrease in the alterations in growth and associated with deformity in the lower limbs ⁽⁶⁾. 

Currently the most widely used technique is the ITBR, which has shown superior results compared to other techniques in Tanner I and II patients. According to the study conducted by the Society of Sports Medicine, the ITBR technique is the most performed in the skeletally immature and is the most predictable in Tanner I and II patients (under 10 years of age)⁽⁷⁾. Kocher and collaborators additionally report in their study that the incidence of graft rupture with ITBR compared to EC techniques is lower, being 6.6% and 11-17% respectively ⁽⁸⁾.

In the articular mechanics it has been suggested that the ITBR technique does not restore the anatomy of the knee, which could generate alterations in the gait pattern, however in several biomechanical studies they have demonstrated good restoration of the articular biomechanics ^(9)(10). On the other hand, Turati and collaborators in their study of 2023 where they propose a management algorithm for ACL injuries in children Tanner I and II consider that the injuries that are in the medial portion of the ligament should be treated with ITBR since it is the most predictable technique and with less risk for the growth cartilage and the injuries that are more proximal towards the femoral insertion could be managed with reinsertion given the healing potential of children under 10 years of age ⁽¹¹⁾.  

Within the ITBR techniques the best known is the one described by MacIntosh, however there are multiple variations within the same, within what is described in the literature, our experience and taking into account the main complication of these procedures, which is the lesion of the growth cartilage, in our center a modification of the technique described by Micheli (4) is performed, where instead of performing a fixation in the periosteum at the level of the anterior tuberosity of the tibia and the lateral femoral condyle, a fixation is performed with anchors in the lateral femoral condyle and the lateral epiphysis of the tibia avoiding the physis.

Within the 1-year follow-up of the patient, full ranges of mobility in the knee, symmetrical quadriceps trophism, adequate clinical stability of the knee, no length discrepancy or angular deformities have been evidenced. Radiographs with implant footprint in adequate position, no asymmetric angular deformities and MRI showing graft with adequate tension and fixed in femoral and tibial portion, considering an adequate postoperative result, follow-up will continue as recommended in the literature with Ortho-radiographies every 6 months. 

REFERENCES

1. Bixby EC, Heyworth BE. Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients. Curr Rev Musculoskelet Med. 2024 Jul:17(7):258-72.
2. Bram JT, Magee LC, Mehta NN, Patel NM, Ganley TJ. Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes: A Systematic Review and Meta-analysis. Am J Sports Med. 2021 Jun;49(7):1962-72.
3. Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior Cruciate Ligament Tears in Children and Adolescents: A Meta-analysis of Nonoperative Versus Operative Treatment. Am J Sports Med. 2014 Nov;42(11):2769-76.
4. Micheli LJ, Rask B, Gerberg L. Anterior Cruciate Ligament Reconstruction in Patients Who Are Prepubescent: Clin Orthop.1999 Jul;364;40-7.
5. Kolin DA, Dawkins B, Park J, Fabricant PD, Gilmore A, Seeley M, et al. ACL. Reconstruction Delay in Pediatric and Adolescent Patients is Associated with a Progressive Increased Risk of Medial Meniscal Tears. J Bone Jt Surg. 2021 Aug 4;103(15):1368-73
6. Ardem CL, Ekås G, Grindem H, Mosknes H, Anderson A, Chotel F, et al. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Knee Surg Sports Traumatol Arthrosc. 2018 Apr;26(4):989-1010.
7. Patel NM, Talathi NS, Talwar D, Fabricant PD, Kocher MS, Ganley TJ, et al. Factors Affecting the Preferred Surgical Tecnique in Pediatric Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2018 Sep;6(9):232596711879617.
8. Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ. Ourcomes of physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. J Bone Jt. Surg. 2018 Jul 5;100(13:1087-94.
9. Sena M. Chen J, Dellamaggioria R, Coughlin DG, Lotz JC, Feeley BT. Dynamic Evaluation of Pivot-Shift Kinematics in Physeal-Sparing Pediatric Anterior Cruciate Ligament Reconstruction Techniques. AM J Sports Med. 2013 Apr;41(4):826-34.
10. Kennedy A. Coughlin DG, Metzger MF, Tang R, Pearle AD, Lotz JC, et al. Biomechanical Evaluation of Pediatric Anterior Cruciate Ligament Reconstruction Tecniques. Am J Sports Med. 2011 May;39(5):964-71.
11. Turati M, RigamontiL, Giulivi A, Gaddi D, Accadbled F, Zanchi N, et al. Management of Anterior Cruciate Ligament Tears in Tanner Stage 1 and 2 children: a Narrative Review and Treatment Algorithm Guided by ACL Tear Location. J Sports Med Phys Fitness (Internet). 2023 Oct (cited 2024 Jul2);63(11). Available from: https;//www.minervamedica.it/index2.php?show=R40Y2023N11A1218

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