This technique, first described in 2003, uses two incisions and creates outside-in bone tunnels completely within the tibial and femoral epiphysis (Fig. 14.1). The graft of choice is a quadruple hamstring autograft. Anteroposterior and lateral views using C-arm fluoroscopy are used to assess guide wire and tunnel placement in relation to the femoral and tibia physes. The graft is first secured at the femur using suspensory cortical fixation with an EndoButton. The tibial fixation is then performed tying sutures over a post in the tibial metaphysis. The reported mean International Knee Documentation Committee (IKDC) score is 97% with no growth disturbances at a mean follow-up of 4.1 years (patients followed to skeletal maturity) [14, 19].

This technique uses different fixation devices at both the lateral femoral epiphysis and the anterior tibial epiphysis (OrthoPediatrics implants, Warsaw, IN). Instead of the tibial screw used for fixation of the autograft, a novel suspensory ArmorLink™ is utilized. This device has been designed to keep the fixation at the level of the epiphysis and to avoid crossing the physis with the fixation. This method eliminates the theoretical risk of growth disturbances due to the tethering of the tibial post located in the metaphysis distal to the physeal plate. At the femoral side, the EndoButton is replaced with a ShieldLoc™ ring/screw system (Fig. 14.2).

Graft preparation, guide wire insertion, C-arm fluoroscopy visualization, tibial and femoral bone outside-in tunnel drilling, and arthroscopic evaluation are all performed in the manner as previously described in the classic Anderson technique [14]. However, the OrthoPediatrics set has all the tools necessary to perform the modified technique. After the bone tunnels have been drilled, a counterbore reamer is drilled into the lateral portion of the lateral femoral condyle tunnel to a depth of 8 mm. This creates an additional 2 mm increase in the diameter of the tunnel. An appropriately sized ShieldLoc™ sleeve is inserted laterally into the tunnel in the lateral femoral condyle using a ShieldLoc™ insertion device with light tapping. Then, the guide sutures attached to the graft are passed through the tibial tunnel followed by the femoral tunnel and finally out the lateral femoral condyle. The distal portion of the graft is suspended outside of the anterior tibial cortex by looping the graft around the ArmorLink device using a hemostat. The sutures on the free end of the graft are then gently pulled to create tension on the distal portion of graft so that the ArmorLink device sits on the tibial cortex. It is not necessary for the rotational orientation of the ArmorLink™ device to be in any particular position, as long as it is sitting flush with the anterior cortex. After the graft has been pulled through the ShieldLoc sleeve, the knee is placed in 20–30° flexion, and the graft is then tensioned with the graft tensioner. An interference screw is inserted to anchor the graft proximally.

Lykissas et al. [20] reported a technical modification to this technique. He described a split tibial tunnel within the epiphysis that functions as a low-profile fixation post (Fig. 14.3). Because half of the graft passes through each split tibial tunnel, the size of the tunnel is smaller, thereby increasing the safety margin.

In 2010, Lawrence and Ganley introduced an all-epiphyseal technique with retroscrews for ACL reconstruction in skeletally immature patients (Fig. 14.4) [15]. By avoiding any fixation, tunnels, or placing grafts through the open physes, this technique theoretically diminishes the risk of growth abnormalities that could result from disruption of the physes. In the original report, three prepubescent boys in Tanner stage I and II of bone development underwent ACL reconstruction with this technique. After a mean follow-up of 5.7 years after surgery, no angular or growth discrepancies were noted on radiographic examination [15].

Graft preparation, knee position, and arthroscopic evaluation are performed in the same manner as the previously described techniques. The remaining torn ACL is removed and any meniscal tears are addressed. The outside-in femoral guide, set at 95°, is inserted into the anteromedial portal made earlier for arthroscopic examination and set on the medial portion of the lateral femoral condyle within the intercondylar notch. A small incision is made over the lateral aspect of the lateral femoral condyle, and the tissue is dissected to the bone. The outside-in femoral guide is then used to insert a guide wire parallel to the distal femoral physis in the epiphysis until it reaches the intercondylar notch out of the ACL footprint on the femur. After the wire has been placed, a RetroDrill is used to create the all-epiphyseal tibial tunnel. The cannulated guide pin for the drill is used to prevent complete drilling through the anterior tibial cortex. The tibial tunnel should be approximately 17 mm in depth from the joint space. Using an O-arm, intraoperative CT scans are done to confirm that the positions of the femoral guide wire and tibial tunnel are at a safe distance from the physes. The femoral tunnel is created using a standard reamer in an outside-to-inside fashion from the lateral femoral condyle to the intercondylar notch. The femoral tunnel is examined arthroscopically to ensure that the distal femoral physis has not been damaged.

The quadrupled hamstring autograft is prepared in the same manner as described in previous techniques and should be approximately 20 mm in length. The prepared graft is wrapped in damp gauze and pretensioned to 15 pounds. For graft insertion, a FiberStick suture is passed up the guide pin used for the RetroDrill into the articular space and then out the femoral tunnel. The suture is then used to pass the graft and a nitinol wire through the femoral tunnel and to the tibial tunnel. The proximal end of the nitinol wire is then brought out of the anteromedial portal. The graft is tightly pulled through the tibial tunnel and is secured using a RetroScrew screwdriver passed over the nitinol wire while the graft is held under tension. The knee is cycled repeatedly through flexion and extension. Finally, the femoral portion of the graft is secured using an interference tenodesis screw while tension is applied with the graft tensioner. The incisions are closed using standard methods. A locked knee brace is used to keep the joint in maximum extension.

This technique is another example of an all-epiphyseal technique for ACL reconstruction [4, 21]. However, unlike the other techniques, both ends of the graft are fixed with buttons rather than tenodesis screws, and bone sockets are used instead of tunnels (Fig. 14.5). Through the use of buttons, the graft can be secured without placing screws in the softer non-cortical bone; hence the cortical bone is left intact on both the femoral and tibial locations. In addition to this feature, the use of buttons instead of tenodesis screws may potentially provide greater contact of the graft to the surrounding bone improving the environment for tissue incorporation [31]. The improved graft-to-bone healing potentially allows a shorter recovery from surgery and faster return to activity [22]. As with the other all-epiphyseal techniques for ACL reconstruction, the Cordasco-Green technique may be used in patients who are prepubescent. Twenty-three patients with a mean age of 12.6 years who underwent ACL reconstructive surgery were assessed for growth abnormalities after a mean follow-up of 18.5 months using hip-to-ankle anteroposterior radiographs and MRI [23]. No cases of growth arrest, angular deformities, or significant leg length discrepancies were observed. The 2-year clinical outcomes in this group of 23 athletes revealed that 91% return to sport and two athletes are required a second surgery. Cruz et al. [8] evaluated 103 patients, with a mean follow-up of 21 months, who underwent all-epiphyseal ACL reconstruction (either Ganley-Lawrence or Cordasco-Green reconstruction techniques). They reported an overall complication rate of 16.5%, where re-rupture accounted for 10.7%.