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Anterior Cruciate Ligament in Adolescents With Open Physes
Letters to the Editor
Anterior Cruciate Ligament in Adolescents With Open Physes
To the Editor: We read the article presented by Redler et al., “Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels,” in the November 2012 issue of Arthroscopy with great interest.1 It is a real challenge to deal with ACL tears in young patients who have open physes. Although the authors clearly explained the evaluation and treatment of the patients in the study, there are some points that seem to be dealt with inadequately. First, it has been shown that it is not possible to target the femoral tunnel in a clockwise fashion accurately using a transtibial technique.2 It seems that the authors might have missed targeting the desired position of the femoral tunnels in their patients. However, they reported that all knees were considered stable by manual Lachman and pivot-shift tests. Second, the authors report that 6 meniscal repairs had been performed concurrently during ACL reconstruction. It is confusing why weight bearing was not limited for at least 6 weeks in patients who had meniscal repairs. The outcome of the patients who had meniscal resection was not clearly outlined, even with KT-1000 (MEDmetric, San Diego, CA) tests. Third, it is seen in Fig 1B that the tibial tunnel is slightly vertical and the anterior border of the tibial tunnel is not behind the Blumensaat line. The effect of contraction of the quadriceps muscle, which translates the tibia over the femur anteriorly, must be remembered during tunnel preparation in the transtibial technique.3-6 Although this position is easily recognized on the radiographs reported in the study, the authors state that there were no restrictions in either flexion or extension. It has been reported that the vertical position of the tibial tunnels misses to catch proper femoral tunnels in transtibial techniques.4 In addition, it has been assumed by many researchers that vertically oriented ACLs are far from having rotational stability.3,7 Although the authors report that they had negative pivot-shift test results postoperatively in all of the patients, there might be inadequate interpretation of the manual tests. This is another significant point that the authors must try to explain, that is, how the rotational stability is achieved in their series if this technique is neither anatomic nor isometric as described by the authors. The transtibial technique gives the advantage of less damage to the femoral and tibial physes. Anderson8 reported an anatomometric technique that preserves the
femoral and tibial physes. However, it requires fluoroscopic imaging during tunnel placement. Overall, the authors have shown that there is no doubt about treating adolescent patients with open physes using hamstring grafts. However, we believe that they should try to discuss the findings in their series. Hamza Özer, M.D. Hakan Selek, M.D. Ankara, Turkey Note: The authors report that they have no conflicts of interest in the authorship and publication of this report. Ó 2013 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2013.01.004
References 1. Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate ligament reconstruction in skeletally immature patients with transphyseal tunnels. Arthroscopy 2012;28: 1710-1717. 2. Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral cruciate ligament insertion: A cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194-199. 3. Strobel MJ, Castillo RJ, Weiler A. Reflex extension loss after anterior cruciate ligament reconstruction due to femoral “high noon” graft placement. Arthroscopy 2001;17: 408-411. 4. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction. Am J Sports Med 2006;34:553-564. 5. Jaureguito JW, Paulos LE. Why grafts fail. Clin Orthop Relat Res 1996:25-41. 6. Yaru NC, Daniel DM, Penner D. The effect of tibial attachment site on graft impingement in an anterior cruciate ligament reconstruction. Am J Sports Med 1992;20: 217-220. 7. Lo IKY, Kirkley A, Fowler PJ, Miniaci A. The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child. Arthroscopy 1997;13:627-634. 8. Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am 2003;85:1255-1322.
Author’s Reply We thank Drs. Özer and Selek for taking the time to critically review our article and for raising important
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 4 (April), 2013: pp 611-612
611
Anterior Cruciate Ligament in Adolescents With Open Physes
To the Editor: We read the article presented by Redler et al., “Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels,” in the November 2012 issue of Arthroscopy with great interest.1 It is a real challenge to deal with ACL tears in young patients who have open physes. Although the authors clearly explained the evaluation and treatment of the patients in the study, there are some points that seem to be dealt with inadequately. First, it has been shown that it is not possible to target the femoral tunnel in a clockwise fashion accurately using a transtibial technique.2 It seems that the authors might have missed targeting the desired position of the femoral tunnels in their patients. However, they reported that all knees were considered stable by manual Lachman and pivot-shift tests. Second, the authors report that 6 meniscal repairs had been performed concurrently during ACL reconstruction. It is confusing why weight bearing was not limited for at least 6 weeks in patients who had meniscal repairs. The outcome of the patients who had meniscal resection was not clearly outlined, even with KT-1000 (MEDmetric, San Diego, CA) tests. Third, it is seen in Fig 1B that the tibial tunnel is slightly vertical and the anterior border of the tibial tunnel is not behind the Blumensaat line. The effect of contraction of the quadriceps muscle, which translates the tibia over the femur anteriorly, must be remembered during tunnel preparation in the transtibial technique.3-6 Although this position is easily recognized on the radiographs reported in the study, the authors state that there were no restrictions in either flexion or extension. It has been reported that the vertical position of the tibial tunnels misses to catch proper femoral tunnels in transtibial techniques.4 In addition, it has been assumed by many researchers that vertically oriented ACLs are far from having rotational stability.3,7 Although the authors report that they had negative pivot-shift test results postoperatively in all of the patients, there might be inadequate interpretation of the manual tests. This is another significant point that the authors must try to explain, that is, how the rotational stability is achieved in their series if this technique is neither anatomic nor isometric as described by the authors. The transtibial technique gives the advantage of less damage to the femoral and tibial physes. Anderson8 reported an anatomometric technique that preserves the
femoral and tibial physes. However, it requires fluoroscopic imaging during tunnel placement. Overall, the authors have shown that there is no doubt about treating adolescent patients with open physes using hamstring grafts. However, we believe that they should try to discuss the findings in their series. Hamza Özer, M.D. Hakan Selek, M.D. Ankara, Turkey Note: The authors report that they have no conflicts of interest in the authorship and publication of this report. Ó 2013 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2013.01.004
References 1. Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate ligament reconstruction in skeletally immature patients with transphyseal tunnels. Arthroscopy 2012;28: 1710-1717. 2. Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral cruciate ligament insertion: A cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194-199. 3. Strobel MJ, Castillo RJ, Weiler A. Reflex extension loss after anterior cruciate ligament reconstruction due to femoral “high noon” graft placement. Arthroscopy 2001;17: 408-411. 4. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction. Am J Sports Med 2006;34:553-564. 5. Jaureguito JW, Paulos LE. Why grafts fail. Clin Orthop Relat Res 1996:25-41. 6. Yaru NC, Daniel DM, Penner D. The effect of tibial attachment site on graft impingement in an anterior cruciate ligament reconstruction. Am J Sports Med 1992;20: 217-220. 7. Lo IKY, Kirkley A, Fowler PJ, Miniaci A. The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child. Arthroscopy 1997;13:627-634. 8. Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am 2003;85:1255-1322.
Author’s Reply We thank Drs. Özer and Selek for taking the time to critically review our article and for raising important
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 4 (April), 2013: pp 611-612
611