Dr. Steven Chudik explains the growth plate sparing ACL reconstruction surgery procedure he developed.
The anterior cruciate ligament (ACL) is one of the four major ligaments of the knee, particularly a ropelike structure in the center of the knee that helps maintain the normal stability. Unfortunately, a torn ACL does not heal and the knee will typically continue to be unstable (shifts or gives way) during sports that require pivoting, changing direction (cutting), jumping, or landing. Even with restriction of risky activities, living everyday life without reconstructing the ACL places abnormal stresses on the meniscus of the knee resulting in tears and accelerated degeneration of the cartilage and arthritis. The diagnosis of an ACL tear is usually made on physical examination, though an MRI can be helpful to demonstrate the tear as well as other injuries to the meniscus and cartilage. ACL tears are becoming increasingly more prevalent in young athletes.
During ACL surgery, the torn ligament is replaced (reconstructed) with a graft, because simple repair usually is not possible. Common grafts used to replace the torn ligament include the hamstring tendons, bone-patellar tendon-bone, quadriceps tendon, or allografts (from cadavers). Dr. Chudik prefers to use the patient’s own hamstring graft as this has shown better long-term results with a lesser risk for arthritis. The goals of the surgery are to reconstruct the torn ligament, repair any other damaged structures including the meniscus or cartilage, and restore function and stability to the knee. Normal ACL surgery requires the graft and hardware to cross over the growth plates in both the femur (thigh bone) and the tibia (shin bone).
In young patients with significant growth yet to occur, this can potentially cause growth abnormalities. Dr. Chudik has developed a special procedure to reconstruct the ACL without injuring physis (growth plate). This procedure does not cross the growth plates and therefore, minimizes the risk for affecting growth.
Dr. Chudik performs ACL surgery with the assistance of an arthroscope (small camera that lets him look inside the knee through small incisions). The torn ACL is replaced by a graft. During the surgery, the other ligaments, meniscus and cartilage of the knee are evaluated and treated appropriately. Arthroscopically, the torn remnants of the ACL are preserved, bone tunnels are created in the tibia (shinbone) and femur (thighbone), without crossing the growth plate, and the graft is placed anatomically where the injured ACL used to be. The graft is held in position with special fixation devices that usually do not need to be removed.
Anterior cruciate ligament (ACL) injury in the skeletally immature individual is being recognized with increasing frequency. Historically, nonoperative treatment of midsubstance ACL injuries in skeletally immature individuals has not been favorable. Despite many reports of successful ACL reconstruction, many orthopaedic surgeons still are reluctant to perform ACL reconstructive procedures in the skeletally immature individual because of clinical reports of subsequent growth abnormalities and a general lack of understanding regarding the physiologic consequences of ACL reconstruction in these patients.
Current clinical studies support the use of anatomic ACL reconstructive techniques via either paraphyseal, transphyseal, or epiphyseal graft positioning with either metaphyseal or epiphyseal graft fixation. Although there is a consensus that reconstructions via fixation devices or bone grafts that traverse the physis carry a high risk for growth abnormalities and are inappropriate, it is not known which technique of ACL reconstruction provides the least risk and best restores the anatomy and function of the ACL in the growing child.
From the results of our study, we cannot advocate any single femoral reconstructive technique. An epiphyseal femoral technique may reduce the risk of angular deformity and allow a more optimal femoral graft position after growth as opposed to transphyseal and over-the-top techniques. However, the epiphyseal technique may possess an increased risk for rotational deformity, physeal injury, and articular surface injury.
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