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Document Title: Bales-AJSM-Dec04.shtml
Article Title: Clinical Sports Medicine Update: Anterior Cruciate Ligament Injuries in Children With Open Physes -- Evolving Strategies of Treatment
Authors: Chris P. Bales, MD, Joseph H. Guettler, MD, and Claude T. Moorman, III, MD
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: December 2004
Volume 32, pages 1978-1985
Keywords: pediatric ACL injuries, children, open physes, epiphyses, growth-plate violation, extra-articular ACL reconstruction, intra-articular ACL reconstruction.
(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)
Comments: This article provides a good overview of the evolving strategies for dealing with torn ACLs in children (herein defined as being skeletally immature, hence with open growth plates [physes]). The authors note that nonoperative treatment (i.e. muscle-strengthening, use of bracing, activity modification) tends to be unsatisfactory, and children with chronic ACL tears fare no better than adults (i.e. their knees exhibit osteoarthritic degeneration just like those of older, chronically unstable knees). Because standard ACL-reconstruction techniques entail the drilling of bone tunnels, such methods would entail violating the growth plates in skeletally immature people. So, modified methods, known as "physeal-sparing" techniques, were introduced. Some of these involved a semi-extraarticular reconstruction. The problem is that these methods tended to result in a biomechanically suboptimal result. This led to the development of "physeal-respecting" approaches. The authors describe this as follows: small holes are drilled through the physes, and a soft-tissue (e.g. hamstring) graft is used in order to avoid the concern of bridging the growth plates with bone plugs (as would be the concern if the patellar-tendon graft were used). Fixation hardware is placed as closed as possible to the joint, so as to give maximum stiffness to the graft (i.e. no bungee-cord effect) and also to keep the hardware away from the growth plates. This "physeal-respecting" approach brings good success, since it not only restores knee stability (thereby averting the rapid deterioration of the knee that would result if the joint were left unstable until adulthood), but it also results in a knee motion that is as close to normal as in the standard adult ACL-reconstruction methods.
ABSTRACT
Injury to the anterior cruciate ligament is one of the most common sports-related injuries of the knee. Before the 1980s, the incidence of this injury in skeletally immature patients was thought to be rare. However, with the increasing participation of children in sports-related activities and an increased awareness and diagnostic capability of the medical community, midsubstance tears of the anterior cruciate ligament have become more common in patients with open physes. Significant controversy exists regarding management of anterior cruciate ligament injuries in children with open physes. Traditional management has been nonoperative, consisting of physical therapy, bracing, and activity modification. Surgical reconstruction has generally been postponed until the patient is nearing, or has reached, skeletal maturity. In contrast to this traditional treatment algorithm, the recent literature uniformly indicates that nonoperative management of anterior cruciate ligament tears in children results in less than optimal results. Compliance is certainly an issue, and even though patients may refrain from organized sports activities, they are still going to be "kids." Recurrent instability, pain, and an inability to return to the preinjury level of athletics often result. Even more worrisome are the risks of secondary meniscal tears and the possibility of early degenerative joint disease. Recently, there has been an increased interest in early, aggressive operative management to restore stability to the immature knee. Proponents of nonoperative treatment point to the risk of growth arrest associated with violation of the physis. Proponents of early operative stabilization advocate that restoration of stability provides for opportunity to return to full activity and provides good long-term outcomes, all with minimal risk to the physis. This article reviews both the basic science and clinical research on this controversial topic.
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