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12.09.2018 | Knee

Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes

Knee Surgery, Sports Traumatology, Arthroscopy
Tommaso Roberti di Sarsina, Luca Macchiarola, Cecilia Signorelli, Alberto Grassi, Federico Raggi, Giulio Maria Marcheggiani Muccioli, Stefano Zaffagnini



The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal “over-the-top” technique.


Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34–123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile].


Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [− 0.4; 1.0] for the standard force evaluation and 0.0 mm [− 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [− 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed.


This study demonstrates that the modified all-epiphyseal single-bundle “over-the-top” technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life.

Level of evidence

Case series, IV.

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