A Specialized Approach for Skeletally Immature Patients
Repairing a torn ACL in a young, growing athlete presents a significant challenge for orthopedic surgeons. Traditional ACL reconstruction methods used for adults involve drilling tunnels through the tibia and femur to pass the new ligament graft. In an adolescent with open physes, or growth plates, this can risk damaging the cartilage and bone, potentially leading to growth disturbances, angular deformities, or a discrepancy in leg length. The Clocheville technique was developed to specifically address this problem by providing a stable and functional reconstruction while protecting the patient's future growth.
How the Clocheville Technique Works
This innovative surgical procedure is named after the French orthopedic hospital where it was developed. It employs a specific surgical strategy that respects the anatomy of the growing knee. The process involves several key steps:
- Graft Harvest: The surgeon harvests the central third of the patient's own patellar tendon, along with small bone blocks attached to it. This graft provides excellent strength and biological incorporation. The harvest site is then carefully repaired.
- Creation of Tunnels: Unlike traditional methods, the Clocheville technique avoids drilling tunnels through the physis. Instead, it places the femoral and tibial tunnels in locations that do not cross the growth plate. For the tibia, a groove is created on the anterior surface, while the femur may use a modified epiphyseal technique to ensure the graft is positioned appropriately.
- Graft Fixation: The harvested patellar tendon graft, with its bone blocks, is then positioned into the prepared tunnels and fixed securely. The fixation methods are chosen to allow for stable healing and minimize any potential for growth plate damage.
- Minimally Invasive Access: The entire procedure is performed arthroscopically, using small incisions and a camera to visualize the joint. This minimally invasive approach reduces surgical trauma, leading to less pain and a faster initial recovery.
Indications and Patient Selection
The Clocheville technique is not for every ACL tear. Its use is specifically indicated for a select group of patients, including:
- Skeletally Immature Patients: Individuals with significant remaining growth, typically defined by open physes on X-rays.
- Significant Instability: Patients with objective knee instability that impairs their daily activities or athletic performance.
- Associated Injuries: Cases where an ACL tear is combined with a meniscal tear that requires surgical repair.
The decision to use this technique is based on a thorough evaluation by a pediatric orthopedic surgeon, who will assess the patient's growth remaining, activity level, and overall knee condition.
Clocheville Technique vs. Other Pediatric ACL Methods
| Feature | Clocheville Technique | All-Epiphyseal Technique | Transphyseal Drilling |
|---|---|---|---|
| Patient Age | Young, open physes | Very young, open physes | Older, near skeletal maturity |
| Graft Material | Central third patellar tendon (autograft) | Hamstring, fascia lata (autograft) | Hamstring, patellar tendon (autograft) |
| Tunnel Placement | Partially extra-articular to avoid physis | Entirely within epiphysis | Tunnels cross the physis |
| Physeal Protection | Excellent; tunnels avoid growth plates | Excellent; tunnels avoid growth plates | Poor; risk of physeal arrest |
| Potential Complication | Graft-site morbidity, hardware issues | Graft tunnel widening, potential for fixation challenges | Growth disturbance, angular deformity |
| Recovery Time | Moderate | Moderate | Moderate |
Benefits and Potential Risks
The primary benefit of the Clocheville technique is its ability to reconstruct the ACL effectively while safeguarding the patient's growth potential. This preserves normal joint development and allows the young patient to return to sports and physical activities with a stable knee. Outcomes have generally been favorable, with studies reporting good to very good results and high patient satisfaction.
However, as with any surgery, there are potential risks, including:
- Graft-site morbidity: Pain, tenderness, or weakness at the site where the patellar tendon was harvested.
- Infection: A risk with any surgical procedure.
- Stiffness or Loss of Motion: Post-operative stiffness can occur, though it is often managed with physical therapy.
- Graft Failure: While uncommon, the new graft can fail or re-rupture, especially with a return to high-demand sports.
- Hardware Complications: Issues with fixation hardware, though less common with modern techniques.
Rehabilitation and Recovery
Following surgery, a structured rehabilitation program is essential for a successful outcome. The program typically progresses in phases:
- Immediate Post-op: Focuses on pain management, swelling control, and early weight-bearing and range of motion.
- Phase 2: Restoration of Motion: Concentrates on regaining full knee extension and flexion, while protecting the healing graft.
- Phase 3: Strengthening and Stability: Includes progressive strengthening exercises for the quadriceps, hamstrings, and other leg muscles to improve knee stability.
- Phase 4: Return to Sport: Involves sport-specific drills and functional testing to ensure the knee is ready for the demands of athletic activity. The process is often longer and more conservative for skeletally immature athletes to protect the maturing knee.
Long-Term Outcomes and Considerations
Clinical studies have shown that the Clocheville technique can provide stable and durable results over the mid-to-long term. The avoidance of physeal injury is a key long-term benefit, preventing the potential for growth deformities that can occur with alternative methods. Continued follow-up with the surgeon is recommended to monitor the patient's growth and overall knee health. The success of the surgery relies not only on the technique itself but also on a dedicated rehabilitation program and a cautious return to sport.
Conclusion
The Clocheville technique represents a significant advancement in pediatric sports medicine, offering a specialized solution for ACL tears in young patients with open growth plates. By meticulously protecting the physis, the procedure allows these athletes to benefit from a reliable ACL reconstruction while safeguarding their future growth. Its use of a robust patellar tendon graft and arthroscopic approach has yielded promising results, establishing it as a valuable tool for a challenging clinical scenario.
For more detailed clinical information on this technique, consult the original study: The possibilities of using the patellar tendon in the treatment of anterior cruciate ligament ruptures in adolescents with wide open growth plates: the Clocheville technique.
