by
Frank Cordasco, MD, MS, and Daniel Green, MD, MS, FAAP, FACS
![FrankCordasco]()
![DanielGreen]()
Anterior cruciate ligament (ACL) injuries in skeletally
immature athletes are increasing secondary to multiple factors that include
increased participation and level of competition within sports, sports specialization
and societal factors. Conservative treatment of these injuries has a poor
natural history due to recurrent instability with meniscal and articular cartilage
damage (1,2,3).
All Inside, all-epiphyseal ACL reconstruction in children appears to be a safe and effective treatment (2,5-9). The availability of pediatric guides provides surgeons an opportunity to apply All-Inside ACL reconstruction techniques just as they would in adults without significant risk to the physis (2,4,6). We have evaluated this technique in our biomechanics laboratory and have found the kinematic and contact stress properties to be favorable compared to the ACL deficient state and other ACL reconstruction procedures (5,8). One of the main advantages of this technique is that there is no fixation device distal to the proximal tibial physis or proximal to the distal femoral physis nor do the sockets cross the growth plate (2,3,4). In addition the GraftLink hamstring technique provides a graft that is often 9 to 11 mm in diameter, which is preferred as grafts less than 8.5 mm in diameter have been shown to have a higher failure rate.
Historically, the skeletally immature athlete with a complete ACL tear was either treated with benign neglect or some combination of extraarticular and intraarticular reconstruction (to avoid injury to the physis), often necessitating arthrotomy with the associated morbidity and local soft tissue trauma. These were often non-anatomic reconstructions that would not be performed in the adult population.
The all-epiphyseal ACL reconstruction is a modification of the original epiphyseal ACL reconstruction described by Anderson (transepiphyseal ACL reconstruction) (2,3). The All-Inside, all-epiphyseal technique allows for a minimally invasive anatomic reconstruction using hamstring autograft. Our initial two-year follow up with this procedure demonstrates good functional results and physeal safety (6,7,9).
![Biomechanical GraftLink]()
The “All-Inside”
technique creates epiphyseal sockets
with a cortical bone bridge rather than tunnels with openings at both ends,
which uses an “Outside-In” technique. We believe these sockets allow for
improved biologic healing of soft tissue grafts to bone (10). The All-Inside
technique has been performed in adults and based upon our experience with this
procedure and instrumentation
in the adult population, we developed this technique for use in the pediatric
and young adolescent populations. We are performing ACL reconstructions in the
skeletally immature athlete utilizing these principles, essentially performing
an “adult type of reconstruction” in the skeletally immature - now with the
ability to do so without compromising the physis.
Finally, this instrumentation allows for versatility in treating the young athlete with either an all-inside, partial transephyseal (Hybrid) or complete transphyseal reconstruction, based upon the athlete’s skeletal age and the potential for further growth in a safe and effective manner.
In our experience, an All-Inside, all-epiphyseal ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. There was a 4% graft failure rate and a 9% incidence of second surgery in this cohort (9). The ‘Return to Play’ assessment is an important tool to guide the young athlete and his or her family regarding resumption of competitive sports. Young athletes were on average released for full return to sport after one year from ACL reconstruction (9).
References:
1. Cordasco FA. CORR Insights® on meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? Clin Orthop Relat Res. 2014; 472(3):998-1000.
2. McCarthy MM, Graziano J, Green DW, Cordasco FA. All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients. Arthrosc Tech. 2012;1(2):e231-e239.
3. Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al. Reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a review of current concepts: AAOS exhibit selection [erratum, J Bone Joint Surg Am. 2013;95(16):e117]. J Bone Joint Surg. 2013;95(5):e28.
4. Fabricant PD, McCarthy MM, Cordasco FA, Green DW. All-inside, all-epiphyseal autograft reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a surgical technique. JBJS Essent Surg Tec. 2013;3(2):e9.
5. McCarthy MM, Tucker S, Nguyen J, Green DW, Imhauser CW, Cordasco FA. Contact stress and kinematic analysis of all-epiphyseal and over-the-top pediatric reconstruction techniques for the anterior cruciate ligament. Am J Sports Med. 2013. 41(6):1330-1339.
6. Nawabi DH, Jones KJ, Lurie B, Potter HG, Green DW, Cordasco FA. All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis. Am J Sports Med. 2014. pii: 0363546514552994.
7. Nawabi D, McCarthy M, Graziano J, et al. Return to play and clinical outcomes after all-inside, anterior cruciate ligament reconstruction in skeletally immature athletes. Paper presented at: 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine; July 10-13, 2014; Seattle, WA.
8. McCarthy MM, Imhauser C, Fabricant P, Green DW, Cordasco FA. Kinematics and contact stress comparison of all-epiphyseal and complete transphyseal reconstructions. Presenting at: 2014 Specialty Day of the American Orthopaedic Society for Sports Medicine; March 28, 2015; Las Vegas, NV.
9. Cordasco FA, Graziano J, DeMille P, et al.All-inside, all-epiphyseal ACL reconstruction in skeletally immature athletes: return to play, incidence of second surgery and two-year clinical outcomes. Presenting at AANA, ISAKOS, AOSSM 2015.
10. Smith P, Cook JL, Stannard J, Pfeiffer F, Kuroki K. Suspensory versus interference screw fixation for arthroscopic ACL reconstruction in a novel canine model. 2014 ACL Study group meeting; February 4, 2014; Cape Town, South Africa.
Frank Cordasco, MD, MS, and Daniel Green, MD, MS, FAAP, FACS, are surgeons at Hospital for Special Surgery and are consultants to Arthrex Inc.
Anterior cruciate ligament (ACL) injuries in skeletally
immature athletes are increasing secondary to multiple factors that include
increased participation and level of competition within sports, sports specialization
and societal factors. Conservative treatment of these injuries has a poor
natural history due to recurrent instability with meniscal and articular cartilage
damage (1,2,3). All Inside, all-epiphyseal ACL reconstruction in children appears to be a safe and effective treatment (2,5-9). The availability of pediatric guides provides surgeons an opportunity to apply All-Inside ACL reconstruction techniques just as they would in adults without significant risk to the physis (2,4,6). We have evaluated this technique in our biomechanics laboratory and have found the kinematic and contact stress properties to be favorable compared to the ACL deficient state and other ACL reconstruction procedures (5,8). One of the main advantages of this technique is that there is no fixation device distal to the proximal tibial physis or proximal to the distal femoral physis nor do the sockets cross the growth plate (2,3,4). In addition the GraftLink hamstring technique provides a graft that is often 9 to 11 mm in diameter, which is preferred as grafts less than 8.5 mm in diameter have been shown to have a higher failure rate.
Historically, the skeletally immature athlete with a complete ACL tear was either treated with benign neglect or some combination of extraarticular and intraarticular reconstruction (to avoid injury to the physis), often necessitating arthrotomy with the associated morbidity and local soft tissue trauma. These were often non-anatomic reconstructions that would not be performed in the adult population.
The all-epiphyseal ACL reconstruction is a modification of the original epiphyseal ACL reconstruction described by Anderson (transepiphyseal ACL reconstruction) (2,3). The All-Inside, all-epiphyseal technique allows for a minimally invasive anatomic reconstruction using hamstring autograft. Our initial two-year follow up with this procedure demonstrates good functional results and physeal safety (6,7,9).
The “All-Inside”
technique creates epiphyseal sockets
with a cortical bone bridge rather than tunnels with openings at both ends,
which uses an “Outside-In” technique. We believe these sockets allow for
improved biologic healing of soft tissue grafts to bone (10). The All-Inside
technique has been performed in adults and based upon our experience with this
procedure and instrumentation
in the adult population, we developed this technique for use in the pediatric
and young adolescent populations. We are performing ACL reconstructions in the
skeletally immature athlete utilizing these principles, essentially performing
an “adult type of reconstruction” in the skeletally immature - now with the
ability to do so without compromising the physis.Finally, this instrumentation allows for versatility in treating the young athlete with either an all-inside, partial transephyseal (Hybrid) or complete transphyseal reconstruction, based upon the athlete’s skeletal age and the potential for further growth in a safe and effective manner.
In our experience, an All-Inside, all-epiphyseal ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. There was a 4% graft failure rate and a 9% incidence of second surgery in this cohort (9). The ‘Return to Play’ assessment is an important tool to guide the young athlete and his or her family regarding resumption of competitive sports. Young athletes were on average released for full return to sport after one year from ACL reconstruction (9).
References:
1. Cordasco FA. CORR Insights® on meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? Clin Orthop Relat Res. 2014; 472(3):998-1000.
2. McCarthy MM, Graziano J, Green DW, Cordasco FA. All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients. Arthrosc Tech. 2012;1(2):e231-e239.
3. Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al. Reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a review of current concepts: AAOS exhibit selection [erratum, J Bone Joint Surg Am. 2013;95(16):e117]. J Bone Joint Surg. 2013;95(5):e28.
4. Fabricant PD, McCarthy MM, Cordasco FA, Green DW. All-inside, all-epiphyseal autograft reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a surgical technique. JBJS Essent Surg Tec. 2013;3(2):e9.
5. McCarthy MM, Tucker S, Nguyen J, Green DW, Imhauser CW, Cordasco FA. Contact stress and kinematic analysis of all-epiphyseal and over-the-top pediatric reconstruction techniques for the anterior cruciate ligament. Am J Sports Med. 2013. 41(6):1330-1339.
6. Nawabi DH, Jones KJ, Lurie B, Potter HG, Green DW, Cordasco FA. All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis. Am J Sports Med. 2014. pii: 0363546514552994.
7. Nawabi D, McCarthy M, Graziano J, et al. Return to play and clinical outcomes after all-inside, anterior cruciate ligament reconstruction in skeletally immature athletes. Paper presented at: 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine; July 10-13, 2014; Seattle, WA.
8. McCarthy MM, Imhauser C, Fabricant P, Green DW, Cordasco FA. Kinematics and contact stress comparison of all-epiphyseal and complete transphyseal reconstructions. Presenting at: 2014 Specialty Day of the American Orthopaedic Society for Sports Medicine; March 28, 2015; Las Vegas, NV.
9. Cordasco FA, Graziano J, DeMille P, et al.All-inside, all-epiphyseal ACL reconstruction in skeletally immature athletes: return to play, incidence of second surgery and two-year clinical outcomes. Presenting at AANA, ISAKOS, AOSSM 2015.
10. Smith P, Cook JL, Stannard J, Pfeiffer F, Kuroki K. Suspensory versus interference screw fixation for arthroscopic ACL reconstruction in a novel canine model. 2014 ACL Study group meeting; February 4, 2014; Cape Town, South Africa.
Frank Cordasco, MD, MS, and Daniel Green, MD, MS, FAAP, FACS, are surgeons at Hospital for Special Surgery and are consultants to Arthrex Inc.