Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts

Abstract

Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequency. Treatment strategies have evolved as recent studies have identified unique considerations specific to the skeletally immature patient. The current literature now supports the trend toward early operative treatment to restore knee stability and prevent progressive meniscal and/or articular cartilage damage, but the optimal approach to ACL reconstruction in this age group remains controversial. Despite the reported clinical success of transphyseal reconstruction, iatrogenic growth disturbance secondary to physeal damage remains a genuine concern. The reluctance to place drill-holes across open physes has led to the development of numerous "physeal-sparing" reconstruction techniques using anatomic femoral and tibial footprints that have adequately restored anteroposterior and rotational knee stability in biomechanical studies but have demonstrated mixed results in the clinical setting. The intent of this review is to (1) highlight the unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete, (2) discuss preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury, (3) review transphyseal and physeal-sparing reconstruction techniques and highlight surgical technical considerations, (4) present clinical outcomes according to patient and technique-specific factors, and (5) review age-specific injury prevention treatment strategies and a novel treatment algorithm based on skeletal maturity. ACL reconstruction in the skeletally immature athlete typically results in a successful clinical outcome, yet the optimal surgical technique is still controversial. This review will help guide the management of ACL injuries in the pediatric athlete.

Development and Validation of a Pediatric Sports Activity Rating Scale

“…37 Further, although parents helped their children read the scale as needed, the children provided their own answers. Developing and validating the scale in younger children affords applicability to this important younger demographic, who have been the subject of recent interest in sports injuries (eg, ACL rupture, 18 osteochondritis dissecans, and patellar instability) and surgical intervention. Although the influence of parental reading assistance is unclear, the results indicate that this scale is reliable and valid in these younger children as well.…”

Transphyseal ACL Reconstruction in Skeletally Immature Patients: Does Independent Femoral Tunnel Drilling Place the Physis at Greater Risk Compared to Transtibial Drilling?

“…5,25,27,39 Many techniques have been described for ACL reconstruction in skeletally immature patients. 6,9,28 Transphyseal ACL reconstruction involves drilling bone tunnels across an open physis and fixing a soft tissue graft away from the physis. Although multiple case series have noted transphyseal ACL reconstruction to be safe and effective, 3,4,8,12,20,21,33 some animal studies have described limb shortening, deformity, and growth arrest after transphyseal tunnel placement, especially in relatively large tunnels and tunnels placed eccentrically through the physis.…”

Nonanatomic Anterior Cruciate Ligament Reconstruction With Double-Stranded Semitendinosus Grafts in Children With Open Physes

“…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 We describe the long-term outcomes of partial transphyseal ACLR combining transphyseal tibial drilling and the over-the-top (OTT) femoral technique in skeletally immature patients with a sexual development stage below Tanner 2. Transphyseal tibial drilling and the OTT femoral 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.…”