title: All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients.
abstract: BACKGROUND
  Treating ACL injuries in prepubescent patients requires balancing the risk of chondral and meniscal injuries associated with delaying treatment against the risk of growth disturbance from early surgical reconstruction. Multiple physeal respecting techniques have been described to address this vulnerable population; however, none restore the native ACL attachments while keeping the graft and fixation entirely in the epiphysis.
  
  
  METHODS
  We describe a technique of all-epiphyseal ACL reconstruction for use in prepubescent skeletally immature patients. Intraoperative CT scanning with three-dimensional (3-D) reconstruction was used to confirm the precise localization of the all-epiphyseal femoral and tibial tunnels. The femoral tunnel is drilled entirely in the epiphysis of the lateral femoral condyle. The tibial tunnel is drilled from inside-out to the level of the tibial physis using a retrograde drill. Fixation of the soft tissue graft is achieved with a retrograde interference screw in the tibia and an interference screw in the femur.
  
  
  METHODS
  Case examples are presented for three boys aged 10-12, Tanner Stage 1 development, with a minimum followup of 1 year.
  
  
  RESULTS
  All three patients had stable knees based on Lachman and KT-1000 testing and no evidence of growth disturbance. All had full ROM and symmetric strength for knee flexion and extension. All patients returned to their sports activities using a custom ACL brace.
  
  
  CONCLUSIONS
  Although longer-term followup will be necessary, this technique provides for an anatomic all-epiphyseal-based ACL reconstruction using intraoperative 3-D imaging to minimize the risk of growth disturbance.
  
  
  METHODS
  Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Wood Building, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA.
authors.forename: J Todd R
authors.initials: JT
authors.lastname: Lawrence
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Bowers
authors.forename: Jonathan
authors.initials: J
authors.lastname: Belding
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Cody
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Ganley
mesh_terms: D000367:Age Factors; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D002648:Child; D004838:Epiphyses / Q000601:surgery*; D005269:Femur / Q000601:surgery; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods; D007718:Knee Injuries / Q000601:surgery*; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods*; D019651:Plastic Surgery Procedures; D016896:Treatment Outcome