ACL Reconstruction in the Skeletally Immature Patient

Peter D. Fabricant

Mininder S. Kocher

Sterile Instrument/Equipment

• All cases

• Tourniquet

• Knee arthroscopy equipment

• Preadolescents: modified MacIntosh procedure, combined extra- and intra-articular anterior cruciate ligament (ACL) reconstruction using iliotibial (IT) band autograft (Fig. 43-1)

• Cobb elevator

• Burr

Figure 43-1 | Modified MacIntosh procedure: combined extra- and intra-articular ACL reconstruction using iliotibial (IT) band autograft.

• Periosteal elevator

• Meniscotomes (left, right, and end cutting) (Fig. 43-2A)

• Large curved hemostat/clamp (Fig. 43-2B)

• “Rat-tail” rasp (Fig. 43-2C)

• Heavy nonabsorbable suture

Figure 43-2 | Equipment for the modified MacIntosh procedure. Meniscotomes (A), large curved hemostat/clamp (B), and rattail rasp (C).

• Adolescents: transphyseal hamstring ACL reconstruction (Fig. 43-3)

• Graft preparation board

• Suspensory fixation button (femoral fixation)

• Nonmetal interference screw (tibial fixation)

• ACL drill guides based on surgeon preference

• Open- or closed-ended tendon harvester based on surgeon preference

Positioning

• The patient is placed supine.

• Bumps can be placed under the hip and at the foot of the table to help with knee flexion.

• A nonsterile pneumatic tourniquet is placed on the proximal thigh.

• A lateral post is used based on surgeon preference.

Surgical Technique Considerations

• Minimal (<1 cm in each limb segment) growth remains around the knee after age 12-13 in girls (ie, 1 year after menarche) and 14 in boys.¹

• Before this time, reconstruction strategies must respect growing physes.

• Posteroanterior left hand radiograph can be obtained to measure skeletal age for surgical decision-making.

Figure 43-3 | Transphyseal ACL reconstruction using hamstring autograft. (From Fabricant PD, Kocher MS. Management of ACL injuries in children and adolescents. J Bone Joint Surg. 2017;99(7):600-612, Ref.2, with permission.)

Preadolescents: Modified MacIntosh Procedure, Combined Extra- and Intra-articular ACL Reconstruction Using IT Band Autograft^3,4

• Indicated for children who are Tanner stage 1 or 2; skeletal age ≤11 in females, ≤12 in males.

• The thigh tourniquet is inflated based upon surgeon preference.

• IT band graft harvest

• An 8- to 10-cm longitudinal oblique incision is centered over the mid-portion of the IT band just proximal to the lateral joint line.

• The central portion of the IT band is harvested proximally and left attached to Gerdy tubercle distally.

• A Cobb elevator is used to elevate the subcutaneous tissue off the superficial surface of the IT band a minimum of 15 cm up the thigh.

• The IT band is incised with a no. 15 scalpel near the border of the fascia of the vastus lateralis anteriorly and the posterior intermuscular septum posteriorly.

▪ A few millimeters of intact IT band are left anteriorly and posteriorly.

• Left and right meniscotomes are used to dissect the IT band proximally in line with its fibers (Fig. 43-4A).

• A curved meniscotome or an open-ended tendon harvester is used to truncate the graft proximally.

▪ If similar instruments are unavailable, a counterincision can be made proximally to detach the graft.

• The graft is further freed from the lateral joint capsule with a knife or dissecting scissors but is left attached to Gerdy tubercle distally (Fig. 43-4B).

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