ACL Injuries in the Skeletally Immature Patient
ACL Injuries in the Skeletally Immature Patient
Abstract & Commentary
Synopsis: The use of soft tissue grafts through small, central drill holes appears the safest way to reconstruct ACL tears in patients with significant growth remaining.
Source: Simonian PT, et al. Anterior cruciate ligament injuries in the skeletally immature patient. Am J Orthop 1999;28:624-628.
The controversy surrounding the best treatment option for skeletally immature patients with anterior cruciate ligament (ACL) tears is addressed in this review paper by Simonian and colleagues. They note that injuries of the ACL in children are more frequent than once thought. Possible explanations for this increased frequency include an increase in the number of children participating in organized sports, as well as an increased recognition of knee ligament injuries secondary to heightened awareness by the medical community and improved diagnostic methods. Treatment options for this injury depend upon the anatomic site of the injury. Partial ACL injuries with minimal laxity may do well if treated nonsurgically in the skeletally immature patient. Avulsion injuries can typically be repaired primarily. Simonian et al caution that in avulsion injuries one should always assess the integrity of the ligament, as interstitial ligament injuries can exist concurrently with ACL avulsion fractures.
When significant growth remains, options for care of interstitial ACL tears include: conservative care until skeletal maturity, primary repair, reconstruction using grafts placed either extra-articularly, "over the top" intra-articularly, or intra-articularly through drill holes placed eccentrically or centrally.
Simonian et al site references for the lack of success of primary repair and caution that "extra-articular" or "over the top" intra-articular repairs are nonisometric. This review favors intra-articular repair with soft tissue grafts placed through small, central drill holes made atraumatically and fixed distal to the physis. Soft tissue grafts (without bone plugs) are recommended to avoid formation of a bone bridge across the physis.
They caution that all skeletally immature patients who undergo an ACL reconstruction should be closely monitored as they continue to grow so that if growth arrest does occur, it is recognized promptly and a definitive diagnostic plan instituted to minimize morbidity.
Comment by Letha Y. Griffin, MD, PhD
Although Simonian et al present a nice overview of this topic, Dr. Roger Lyons at the Medical College of Wisconsin does caution at the end of the article, "There are no studies in children showing that ACL reconstruction is superior to initial non-operative therapy followed by surgical stabilization at maturity." The problem with this treatment option, however, is that it is difficult to control the activity of a prepubescent child. One must, as with all surgical procedures, weigh risks and benefits. We must assess the individual patient’s risk of reinjury vs. that of premature growth arrest given proper attention to surgical details, as described in the article.
McCarroll et al’s1 review of this topic emphasizes that compliance with a conservative care program is enhanced if parents and children are given a specific time for reconstruction (i.e., in June, after the completion of the freshman year of high school), rather than "when growth centers begin to close." It is important to emphasize, as McCarroll et al do, that treatment considerations in prepubescent children with significant growth remaining (Tanner stages I and II) are different than those in the postpubescent, skeletally immature patient who is approaching skeletal maturity. The latter (Tanner stages III and IV) can be approached as adults when treating this injury.
Reference
1. McCarroll JR, et al. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med 1985;16(1):11-21.
When performing ACL reconstruction in the skeletally immature patient, one should use:
a. only absorbable suture.
b. small drill holes, centrally located.
c. absorbable interference screws for fixation.
d. allograft rather than autograft.
e. a parapatellar lateral approach.
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