Document Title: Shea-SM-May03.shtml
Article Title: Anterior Cruciate Ligament Injury in Paediatric and Adolescent Patients: A Review of Basic Science and Clinical Research
Authors: Kevin G. Shea, Peter J. Apel, and Ronald P. Pfeiffer.
Publication: Sports Medicine
Date: May 2003
Volume 33, Number 6, pages 455-471
Keywords: pediatric ACL reconstruction, injury, surgery, epiphyses, physes, growth plates, soft-tissue grafting, instability, deterioration, degeneration, osteoarthritis.

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Comments: This article gives a comprehensive overview of past research, and discusses the options and possibilities available when one is confronted with a torn ACL in a skeletally immature person. At present, the best options entail soft-tissue grafting, for example using the hamstring-group tendons. (As Aichroth showed in 2002, it appears safe for the bone tunnels to cross the growth plates, as long as care is taken to keep graft-fixation devices as far away as possible from the growth plates.) In any case, the graft should be placed isometrically (i.e. so that its length is not being forced to change as the knee moves throughout its range of motion, therefore avoiding the danger of the graft stretching out and subsequently failing); this can only be done with intra-articular graft placement. (The Micheli method, a popular option which entails an extra-articular reconstruction using the iliotibial band [ITB], very nicely avoids violating the growth plates, but unfortunately, it is biomechanically suboptimal.) Shea et al. note that simply giving the young patient a brace and recommending activity modification tends of be a little value. Because it is very difficult for a child to completely discontinue knee-demanding activities until skeletal maturity is reached, if the non-surgical route is followed, repeated giving-way incidents (and therefore severe, cumulative, and permanent degenerative changes in the knee [including not only meniscal tearing as well as articular-cartilage damage via bone-bruising, but also ever-increasing looseness of the secondary restraints as well as meniscal erosion due to abnormally loose knee motion], exactly as would occur in a chronically unstable adult knee) must be anticipated. The authors provide a penetratingly insightful critique into all the previous studies done in the realm of pediatric ACL reconstruction, and they note that the need for further study still remains.

ABSTRACT

Anterior cruciate ligament (ACL) injuries are recognised with greater frequency in children and adolescents. Non-operative treatment of ACL injuries in children may lead to knee instability and secondary injuries, especially in those who return to sports. ACL reconstruction is controversial in skeletally immature patients because of potential damage to the proximal tibial and distal femoral physes, which may lead to premature arrest and/or leg length discrepancies. This paper reviews studies of ACL injuries in children and adolescents, and examines basic science and clinical studies concerning physeal arrest secondary to ACL reconstruction tunnels. Some animal studies support the conclusion that ACL reconstructions in children have the potential to cause growth disturbances, and there are reports of growth plate complications due to ACL reconstruction in skeletally immature patients. There is evidence that ACL reconstruction can be performed in select skeletally immature patients, but the risk of growth plate complications must be considered.

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