Summary
Over-the-top techniques for ACL reconstruction in patients with open physes represents a safe and effective options for all ages
Abstract
Introduction
Patients with open physes with ACL rupture represents a challenghing population to treat, due to the risk of phyesal damage during ACL reconstruction and also to the high risk of second ACL injuries. To date, no consensus exisits on the type of surgical technique, graft and lateral extra-articular procedures. Over-the-top with hamstrings represents viable option, but evidences are limited.
Methods
All patients with either femural and\or tibial open physis that underwent ACL reconstruction between April 2022 and April 2025 by a single surgeon at Rizzoli Orthopaedic Institute (Bologna) were prospectively enrolled. All patients underwent physeal sparing ACL reconstruction plus lateral tenodesis using hamstrings with 1 of 3 Over-the-top technique variants: Extraphyseal over-the-top (no tunnels) for males <12 years and females <10 years; supraphyseasl tibial tunnel and femoral over-the-top for males 12-15 years and females 10-13 years; transphyseal tibial tunnel and femoral over the top for males >15 years and females >13 years. Skeletal age was determined by Knee MRI bone age atlas by Pennock.
Patients were prospecitvaley assessed evaluating complications and reoperations. Return to sport rate, clinical limb lenght discrepancies, reconstruction failure and contralateral injury were assessed only in patients with at least 2 years of follow-up.
Results
A total of 85 patients (78% males, 22% females) with a mean skeletal age of 14.3 ± 1.9 years were included. A total of 11 patients (13%) underwent extra-physeal technique (mean age 11.7 ± 1.3 years), 40 patients (47%) underwent supra-physeal technique (mean age 14.0 ± 0.8 years) and 34 patients (40%) underwent trans-physeal technque (mean age 15.7 ± 0.9 years). Minor post-operative complication were reported in 14 patients (16.5%). Seven patients (8.2%) had transitory post operative fever and swelling, which resolved within 3 weeks; 1 of them (1.2%) underwent joint lavage (no infection). Three patients (3.5%) experinced transitory loss of extension and 2 patients (2.3%) experienced transitory loss of flexion; all 5 recovered full ROM within 3 months. Three patients (3.5%) had delayed wound healing and 1 of them underwent wound debridement and closure.
A total of 25 patients reached the 2 years follow-up: 2 patients (8%) had a new knee sprain but did not underwent ACL revision, while 3 patients (12%) underwent contralateral ACL reconstruction. One patient (4%) underwent medial meniscectomy after suture failure, and 1 patient (4%) underwent staple removal.
Conclusions
Over-the-top techniques for ACL reconstruction in patients with open physes represents a safe and effective options for all ages, however, the second injury rate remains high in this population. Long-term studies are needed to confirm the outcomes.