ACL Surgery in Growing Children

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A few weeks ago I wrote about some recent studies reporting a rise in ACL injuries in kids and discussed some of the causes of this trend.  Since then I have had a few questions about treatment of these adolescent ACL injuries, so today I am going to explain how the thinking on this has evolved over the years and how I approach ACL reconstruction in children.

Years ago, most surgeons recommended delaying ACL reconstruction in children until the growth plates had closed.  Growth plates are areas of developing cartilage tissue near the ends of long bones that regulate growth and determine the length and shape of the mature bone.  Because ACL reconstruction involves drilling holes in the bone that in children would cross the growth plates, there is a chance that the growth would be arrested in that knee, causing a leg-length discrepancy or angular deformity in the leg.

As knowledge about how this injury affects kids evolves and new research is published, orthopaedic surgeons are finding that the risk of interrupting the natural growth pattern is small compared to the risks associated with a delayed reconstruction. An ACL rupture causes knee instability, which means that if surgery is delayed, return to sports (or most physical activity) is strongly discouraged because of the risk of secondary injury.  Several studies have shown that delaying ACL reconstruction significantly increases the risk of damage to the menisci and articular cartilage in the knee – and while we do have surgeries that can correct leg-length discrepancies, damage to the meniscus or cartilage can lead to life-long problems with osteoarthritis that are much harder to manage.  It is almost impossible, and in light of the childhood obesity surge, undesirable, to prevent children from participating in physical activity.

While most sports medicine orthopaedic surgeons will now recommend early surgery for ACL injuries in children, there is still contention about the best method of surgery.  While some surgeons try to get around the issues of the growth plates all together by doing non-anatomical reconstructions that avoid crossing the plates, I believe this method does not provide the knee stability that anatomical reconstruction does.  There have been studies showing that anatomical reconstruction provides superior stability, and that if certain principles are followed, risk of growth plate injury is minimized.  I prefer using hamstring tendon grafts and keeping the bone tunnels I drill through the growth plates as small as possible, and have had good outcomes with this procedure.

Ultimately, it will be up to the parents and child to discuss with their surgeon which treatment option is right for their child’s ACL injury.  In my practice, I don’t want to limit a kid from being a kid – which means my goal is to get them back to all of their activities with as little risk as possible.