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Nonanatomic Anterior Cruciate Ligament Reconstruction With Double-Stranded Semitendinosus

Grafts in Children With Open Physes: Minimum 15-Year Follow-up
Marco Kawamura Demange and Gilberto Luis Camanho
Am J Sports Med 2014 42: 2926 originally published online October 1, 2014
DOI: 10.1177/0363546514550981

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Nonanatomic Anterior Cruciate Ligament
Reconstruction With Double-Stranded
Semitendinosus Grafts in Children
With Open Physes
Minimum 15-Year Follow-up
Marco Kawamura Demange,*y MD, PhD, and Gilberto Luis Camanho,y MD, PhD
Investigation performed at the Hospital das Clı´nicas, Faculty of Medicine,
University of São Paulo, São Paulo, Brazil

Background: Nonanatomic anterior cruciate ligament (ACL) reconstruction (ACLR) with double-stranded semitendinosus grafts
in children with open physes has been described as a successful surgical technique in short-term follow-up clinical reports.
Purpose: To evaluate the clinical outcomes of nonanatomic ACLR in children with open physes and a minimum of 15 years’
follow-up.
Study Design: Case series; Level of evidence, 4.
Methods: Twelve patients with an average age of 10.7 years (range, 8.3-12.4 years) underwent ACLR between 1991 and 1998. All
patients were classified as Tanner development stage 2 or lower. The surgical technique involved transphyseal tibial tunnel drilling
and over-the-top (OTT) femoral fixation using a double-stranded graft for all patients. Clinical outcomes were evaluated in terms
of the manual Lachman test, pivot-shift test, return to sports activity, and International Knee Documentation Committee (IKDC)
score at the end of growth and at a minimum 15-year follow-up (range, 15-22 years).
Results: No clinically significant growth disturbance was observed. Ten patients had a grade A IKDC score, and 2 patients had
a grade B IKDC score at the end of growth. There was no progression of laxity or modification of knee stability with growth. Three
patients (25%) had ACL reruptures during sports activities after growth plate closure. All patients with reruptured ACLs underwent
additional reconstructive surgery.
Conclusion: Anterior cruciate ligament reconstruction using the OTT technique in the femur and the transphyseal technique in the
tibia produces good results with regard to growth plate closure but a high failure rate in adulthood.
Keywords: anterior cruciate ligament; open physes; children; knee instability

Although an anterior cruciate ligament (ACL) rupture in
skeletally immature children occurs less frequently than
in adults, this injury has become more common, as chil-
dren as young as 10 years old more regularly engage in
*Address correspondence to Marco Kawamura Demange, MD, PhD,
Hospital das Clı́nicas, Faculty of Medicine, University of São Paulo, Rua
Dr Ovı́dio Pires de Campos 333, Cerqueira Cesar, São Paulo 05403-01,
Brazil (e-mail: demange@usp.br).
y
Hospital das Clı́nicas, Faculty of Medicine, University of São Paulo,
São Paulo, Brazil.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 42, No. 12
DOI: 10.1177/0363546514550981
Ó 2014 The Author(s)
movement patterns associated with an injury risk during
sports, such as landing or cutting.3
Nonoperative treatment has been unsuccessful in pre-
venting instability or additional meniscal damage and car-
tilage degeneration.14,25 There is concern about the risk of
leg-length discrepancy and angular deformity after ACL
reconstruction (ACLR) in patients with open physes. To
avoid this theoretical risk and to promote a more anatomic
reconstruction, some surgeons have proposed using
physeal-sparing intra-articular reconstruction techni-
ques.16 This surgical modification is more technically
demanding, as tunnels are drilled through the distal femo-
ral and proximal tibial epiphyses. However, there have
been reports of transphyseal ACLR performed without
compromising leg length; most of these results have been
reported in patients above Tanner stage 3.12,21,30,31

2926
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Vol. 42, No. 12, 2014
Figure 1. Magnetic resonance imaging scans of (A) an ante-
rior cruciate ligament rupture and (B) a medial meniscal tear.
We describe the long-term outcomes of partial transphy-
seal ACLR combining transphyseal tibial drilling and the
over-the-top (OTT) femoral technique in skeletally imma-
ture patients with a sexual development stage below
Tanner 2. Transphyseal tibial drilling and the OTT femo-
ral technique were recommended as a surgical option for
young children in the mid-1990s and provided good
short-term knee stability until growth plate closure. The
purpose of this study was to determine whether very young
children with ACL tears surgically treated with nonana-
tomic ACLR with double-stranded semitendinosus grafts
have stable knees in the long term.
MATERIALS AND METHODS
We prospectively followed 12 consecutive skeletally imma-
ture patients who underwent ACLR by a single surgeon
(the senior author, G.L.C.) between 1991 and 1998. All
patients experienced a complete ACL rupture during
sports activities; the ruptures were confirmed by magnetic
resonance imaging (MRI) (Figure 1).
There were 5 female (41.7%) and 7 male (58.3%) patients,
with an average age of 10.7 years (range, 8.3-12.4 years).
The average age was 10.7 years (range, 8.3-12.2 years) for
female patients and 10.6 years (range, 9.0-12.4 years) for
male patients. The left side (nondominant) was affected in
7 patients (58.3%).
Skeletal and sexual maturity levels were assessed using
the Tanner scale (see the Appendix, available online at
http://ajsm.sagepub.com/supplemental) after the patient
had been anesthetized for surgery. All patients with
Tanner stage 1 and 2 during this period were included in
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Nonanatomic ACL Surgery in Children 2927
Figure 2. A schema of anterior cruciate ligament reconstruc-
tion using the over-the-top technique in the femur and the
transphyseal tunnel in the tibia.
this series, with none lost to follow-up. Sexual development
was Tanner stage 1 in 4 patients and Tanner stage 2 in 8
patients.
Surgical Technique
The surgical technique used was the same for all patients,
and the senior author performed all surgical procedures.
We used a single semitendinosus tendon graft prepared
in a double-arm pattern for single-bundle ACLR. The
double-stranded semitendinosus graft was harvested using
the standard technique.5
A diagnostic arthroscopic procedure was performed first
using anterolateral and anteromedial portals. Transphyseal
drilling in the tibia was performed with a 5 mm–diameter
drill, followed by tunnel enlargement to a diameter of
6 mm when necessary. The tunnels were drilled slowly to
minimize thermal damage to the growth plate. The tibial
tunnel was drilled to emerge in the ACL footprint, with
the tunnel crossing the tibial physis as perpendicularly as
possible. A physeal-sparing OTT technique was performed
at the femoral site (Figure 2). A lateral incision was made
over the distal femur, and the OTT position was palpated
(Figure 3A). A posterior capsular opening was made, and
the graft was passed at the OTT position using a curved,
inside-out graft-passing device. No osseous notchplasty
was performed. Graft fixation was performed using a post
with a screw and washer in the tibia that was placed trans-
versely across the tibia and distal to the growth plate. Fem-
oral fixation was also performed with a screw proximal to
the growth plate (Figure 3B). During surgery, stable
2928 Demange and Camanho
Figure 3. (A) A lateral incision was made over the distal
femur, and the over-the-top position was palpated. (B) Ante-
roposterior (left) and lateral (right) radiographic images of
graft fixation using a post with a screw and washer in the tibia
that was placed transversely across the tibia and distal to the
growth plate. Femoral fixation was also performed with
a screw proximal to the growth plate.
meniscal tears were not treated. Unstable meniscal tears
were sutured using an inside-out technique. Full extension
and stable Lachman and anterior drawer test results were
achieved in all patients.
During the postoperative period, the patients were
oriented to partial weightbearing in the first week and pro-
gressed to full weightbearing as tolerated as well as imme-
diate knee motion without knee braces.
Clinical and Radiological Evaluation
The leg-length evaluation was performed by clinical
assessment with tape measurements from the anterior
superior iliac spine to the lateral malleolus and with serial
radiographic scanograms until the growth plate was
closed. The radiologists who performed the examinations
evaluated the scanograms, and the senior author con-
firmed the measurements. Magnetic resonance imaging
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The American Journal of Sports Medicine
was performed on 3 patients to evaluate graft healing
and growth plate aspects.
The 2001 International Knee Documentation Commit-
tee (IKDC) knee ligament form was used for evaluations
at the end of growth. Patients who did not have an appoint-
ment the year before this report were called back for a final
follow-up evaluation.
Ligament stability was measured by the Lachman and
pivot-shift tests. The return to sports activities, sports
activity level, and patient satisfaction were recorded dur-
ing the follow-up, which included the time of growth plate
closure and adulthood. The following Lachman grades
were used: 0 (\3 mm of laxity), 1 (3-5 mm of laxity), or 2
(.5 mm of laxity); the pivot-shift test was graded as 0 (neg-
ative), 1 (glide), 2 (clunk), or 3 (gross). The sports activity
level was assessed according to IKDC levels A through D,
which correspond to strenuous (competitive soccer or bas-
ketball), moderate (tennis, recreational sports), light (jog-
ging), and sedentary activities, respectively.
RESULTS
Twelve patients with Tanner stage 1 and 2 with open
growth plates underwent ACLR with transphyseal drilling
in the tibia and the OTT technique in the femur, with
a minimum 15-year follow-up (average, 18.3 years; range,
15-22 years). All patients had open physes documented
on radiographs at the time of surgery.
We identified 2 medial meniscal tears at the time of sur-
gery: 1 stable and 1 unstable. The unstable tear was trea-
ted with meniscal sutures using the inside-out technique,
and the stable meniscal tear was left untreated.
There were no superficial or deep infections, deep vein
thrombosis, nerve injuries, arthrofibrosis, or other peri-
operative complications. During the follow-up, there were
no leg-length discrepancies or radiographic premature clo-
sure of growth plates. The average age at the time of
growth plate closure was 15.8 years (range, 14.3-17.0
years), and the average interval between surgery and
growth plate closure was 5.2 years (range, 2.5-8.0 years).
In the female patients, the average age at the time of
growth plate closure was 15.1 years (range, 14.3-15.7
years), and the average interval between surgery and
growth plate closure was 4.4 years (range, 2.5-6.5 years).
In the male patients, the average age at the time of growth
plate closure was 16.3 years (range, 15.7-17.0 years), and
the average interval between surgery and growth plate clo-
sure was 5.7 years (range, 4.0-8.0 years) (Table 1).
Magnetic resonance imaging was performed on 3
patients at the end of growth to analyze the neoligament
and physes. We observed a good morphological aspect
and signal intensity of the neoligament. The physes were
closed in all patients, but the tibial tunnel and graft were
intact through the bone (Figure 4).
Ten patients had grade A IKDC scores, and 2 patients
had grade B IKDC scores at the evaluation of growth plate
closure. Ten patients showed stable knees on the manual
Lachman test, and 2 patients demonstrated mild laxity
Vol. 42, No. 12, 2014 Nonanatomic ACL Surgery in Children 2929

TABLE 1
Study Results

Age at Tanner Age at Growth Time Between Surgery IKDC Graft Age at Graft
Patient No. Surgery, y Stage Sex Plate Closure, y and Growth Plate Closure, y Gradea Failureb Rupture, y

1 11.0 2 Female 15.5 4.5 A No —

2 11.5 2 Male 16.0 4.5 A No —
3 10.1 1 Male 16.6 6.5 B No —
4 11.8 2 Female 14.3 2.5 A No —
5 10.2 2 Male 15.7 4.5 A Yes 16.3
6 10.3 2 Female 15.3 5.0 B No —
7 12.2 2 Female 15.7 3.5 A Yes 16.9
8 8.3 1 Female 14.8 6.5 A No —
9 9.0 1 Male 17.0 8.0 A No —
10 9.5 1 Male 17.0 7.5 A Yes 18.5
11 12.4 2 Male 16.4 4.0 A No —
12 11.7 2 Male 15.7 4.0 A No —

a
International Knee Documentation Committee (IKDC) evaluation at growth plate closure.
b
Neoligament anterior cruciate ligament graft rupture after growth plate closure.

disarrangement of the knee at the time of the second sur-

gery. During the arthroscopic evaluation, all ruptured
ACL grafts showed good vascularity.
At the long-term evaluation, there was no progression of
ACL stability (Lachman manual test and pivot-shift test)
or decrease in the IKDC score compared with the evalua-
tion at the time of growth plate closure for the remaining
9 patients (excluding the 3 patients with reruptures). At
adulthood, 5 patients (4 male, 1 female) performed compet-
itive-level sports (3 soccer players and 2 basketball play-
ers), 5 patients performed recreational sports only, and 2
patients did not perform any sports activity.

Figure 4. Magnetic resonance imaging of anterior cruciate
ligament (ACL) reconstruction at 5-year follow-up. Note the
ACL graft in the tibial tunnel.
(same patients with grade B IKDC scores). The patient
who received meniscal sutures presented with a grade B
IKDC score.
After growth plate closure, 3 patients (2 male, 1 female)
presented with sports-related ruptures of their ACL grafts;
none of the patients had meniscal tears at the time of their
initial ACL surgeries, and all patients presented with
grade A IKDC scores at the time of growth plate closure.
The 3 patients were treated with new arthroscopic
single-bundle ACLR. None of them had any other intrinsic
DISCUSSION
To our knowledge, this report is the first to describe a long-
term, minimum 15-year follow-up series of ACLR with
transphyseal tibial tunnel drilling and the femoral
physeal-sparing OTT technique in children below Tanner
stage 2. Some authors believe that the risk of leg-length
discrepancy is higher closer to skeletal maturity as the
growth process slows down.2,8 Growth plates have the
potential to generate high distraction forces, which are
able to break small bony bars crossing the physes in young
children.6 We did not observe any leg-length discrepancy
or angular deformity in our series, as we have already
stated.7 Radiographic scanogram assessments of measure-
ment variance in limb-length discrepancy are considered
reliable methods with low interobserver and intraobserver
variability34 (Figure 5).
The distal femoral physis contributes 70% of the total
femoral length and 37% of the total limb length at an aver-
age rate of 10 mm per year over the course of skeletal
development. The OTT technique was initially introduced
by MacIntosh in the 1970s for adult treatment as a repro-
ducible technique that allows consistent positioning of the
graft close to an isometric position.1 In children, the tech-
nique avoids drilling through the femoral growth plate by

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2930 Demange and Camanho
Figure 5. (A) Radiograph and (B) scanogram examination of
a patient who underwent revision anterior cruciate ligament
surgery after graft failure.
passing the graft over the angle between the posterior
bulge of the lateral femoral condyle and the femoral shaft.
Using this technique, the femoral attachment of the graft
is placed close to the native insertion of the anteromedial
bundle of the ACL. It has been reported that the distance
between the femoral physis and the femoral origin of the
ACL remains unchanged from gestation through skeletal
maturity and averages approximately 3 mm.4 Because of
this particularly short distance, it is difficult to avoid dis-
rupting the growth plate when drilling a femoral tunnel
in the proper anatomic femoral position. Additionally,
there is concern about disturbing the perichondral ring
in the cortical exit of the tunnel when using an anterome-
dial portal technique. In a report by Hui et al,18 15 patients
with Tanner stage 1 and 2 were treated with transphyseal
anatomic ACLR and showed no growth disturbances at an
average follow-up of 25 months; however, the authors
reported 10 patients with open physes, 4 patients with
closing physes, and 1 patient with closed physes at the
time of the follow-up.
Techniques involving all-epiphyseal ACLR have been
reported,19 but these techniques are technically challenging
and may lead to acute graft angles or require the use of
intraoperative fluoroscopy. Some authors advise that to
safely perform femoral tunnel drilling in the distal femur,
the drill must be oriented from the ACL footprint to the pop-
liteus tendon insertion,37 which may lead to a drilling orien-
tation that results in a horizontal tunnel with an acute
angle between the graft and the femoral tunnel opening.
Biomechanical cadaveric studies have demonstrated that
the OTT femoral technique has adequate graft fixation,23
provides anterior and rotational stability, and decreases
posterior joint contact stresses in the ACL-deficient knee
compared with the all-epiphyseal technique.26
The proximal tibial physis contributes approximately
55% of the total tibial length and 25% of the total limb
length over the course of skeletal development at a rate
of 6.4 mm per year. The possibility and safety of drilling
through the tibial growth plate without creating growth
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The American Journal of Sports Medicine
disturbances are supported by large animal studies28 and
clinical studies. To minimize the risk of disturbing the
growth plate, we drilled the holes through the central
aspect of the plate using the smallest possible drill hole
and displacing the smallest possible volume of the growth
plate.15 Stadelmaier et al33 have demonstrated that a soft
tissue graft, filling drill holes through the growth plate,
prevents closure of the physes. We performed MRI to eval-
uate the growth plates and graft aspects at the end of
growth in 3 patients; we observed that the graft was still
visible through the growth plate scar. Animal studies
have shown that there is transient hypertrophy of the
physis tissue at the passing site of the graft, but the growth
plate recovers well from the trauma of drilling and the
placement of a soft tissue graft. The solid integration of
the graft into bone with the early development of
Sharpey-like fibers has been described.29
We used a double-stranded semitendinosus graft as our
graft of choice in young patients (Tanner stage 2 or less)
to minimize the volume of growth plate disruptions.7 Differ-
ent graft options have been described for ACLR in children.
We favor using a hamstring graft, as this leads to lower
complication rates. Bone-tendon-bone grafts may induce
local growth arrest if they are placed across the physis. Dis-
ruption of the anterior proximal tibial physis during har-
vesting of patellar tendon bone grafts may cause a tibial
recurvatum deformity. Fuchs et al13 described no limb-
length discrepancy or early physeal arrest in 10 skeletally
immature athletes who underwent transphyseal intra-artic-
ular ACLR using patellar tendon allografts. Hui et al18
described using live-donor, family-related hamstring allog-
rafts to avoid harvest-related problems. We did not observe
any donor site morbidity or early graft failure in our series.
We observed 2 medial meniscal tears (16%) in our
series. Csintalan et al10 have reported that patients with
ACL injuries with open physes are less likely to be women
and had fewer medial meniscal injuries compared with
patients with closed physes. Samora et al32 have reported
that lateral meniscal tears are more common than medial
meniscal tears. The posterior horn is injured in most
patients and is usually in a repairable configuration and
vascular zone. Cohen et al9 reported that 65.3% of the
patients in their series had meniscal tears. McIntosh
et al27 described 11 meniscal tears among 16 patients,
with 7 patients treated with meniscal repair; 3 primary
meniscal repairs failed and required further partial
meniscectomies.
In children, we believe that there is less risk with the
surgical treatment for ACL tears compared with the com-
plications of a nonfavorable outcome resulting from nonop-
erative treatment. Nonoperative treatment may lead to
chronic instability, meniscal tears, and cartilage degenera-
tion14,25; early surgical intervention provides better out-
comes, particularly in preventing further meniscal
injuries.17,22,30 However, for very young children, we
believe that there are flaws in ACLR using the OTT tech-
nique in the femur and transtibial techniques in the tibia.
Although we achieved good knee stability, and there were
no graft ruptures until the end of growth, we observed 3
ACL graft ruptures (25%) during sports-related activities
Vol. 42, No. 12, 2014
after closure of the growth plates in our long-term series.
McIntosh et al27 reported a traumatic graft disruption
rate of 12.5% (2 patients) before 2-year follow-up (4 and
24 months). Most studies on open-physis ACLR report
data only up to the growth plate closure, which may under-
estimate the graft failure rate by missing graft ruptures
during adulthood. Koizumi et al20 have reported that the
rerupture rates in adults and in adolescents with open
physes with an average age of 14 years are similar using
double-bundle physeal-sparing ACLR in adolescents and
anatomic double-bundle ACLR in adults. The increased
failure rate observed in our study may also be explained
by the smaller hamstring grafts that the young children
had compared with the adults. Some authors24 have dem-
onstrated that hamstring grafts with a diameter of
7 mm correlated with higher ACL graft failure rates. At
the time that our surgeries were performed, the data dem-
onstrating that double-stranded hamstring grafts have
a higher failure rate than quadruple-stranded grafts
were weak. Also, we could argue that the high failure
rate in this series may be related to young age. There are
reports showing higher failure rates among young ath-
letes.36 The lack of studies describing long-term follow-up
after ACLR in skeletally immature patients limits this
analysis. Kumar et al21 treated 32 patients with Tanner
stage 1 or 2 with transphyseal ACLR, with an average
hamstring graft diameter of 8 mm (range, 7-9 mm) and
a minimum 16 years’ follow-up. In their series, there was
only 1 failure of the graft in a patient with Ehlers-Danlos
syndrome who had undergone surgery at the age of 10.5
years. We do believe that the high failure rate among our
group of patients is related to the combination of a nonideal
surgical technique, graft diameter, and young age.
This study had some limitations. We did not evaluate
the other risk factors that may be associated with ACL
injuries in young athletes and children, such as hormonal
risk factors, muscle imbalance, intercondylar notch width,
posterior tibial slope, quadriceps angle, anterior pelvic tilt,
or femoral anteversion.11,35 In addition, our series was lim-
ited to 12 patients, but it is one of the largest series with
a long-term follow-up of patients with Tanner stage 1 or 2.
Treating ACL tears in very young children is still a chal-
lenging and unresolved orthopaedic problem. Many differ-
ent techniques have been described, but there is no ideal
surgical solution. We strongly recommend further studies
to report long-term follow-up beyond the growth plate clo-
sure, as there may be a high failure rate after adulthood
despite good short-term clinical follow-up outcomes. Ide-
ally, ACLR in children should provide long-term knee sta-
bility, prevent further knee injuries, and allow highly
demanding sports activities.
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