Pediatric ACL: Evaluation and Management
Intrasubstance anterior cruciate ligament (ACL) tears in skeletally immature patients are being reported with increasing frequency. Children and adolescents often are noncompliant with conservative treatment and have higher demands for knee stability than their adult counterparts. Consequently, nonsurgical or delayed surgical management has been associated with poor outcomes, including recurrent instability, increased meniscal and chondral damage, and decreased return to athletic participation. Even so, physicians often are faced with a treatment dilemma because clinical and basic science studies have demonstrated risk of limb-length discrepancy and angular deformity with ACL reconstruction. Prior to undergoing ACL reconstruction, skeletal maturity and growth potential should be determined so patients can be risk-stratified and the appropriate surgical technique can be selected. Vertical transphyseal drill tunnels have been used to decrease physeal damage and minimize the chance of growth deformity; however, these techniques result in nonanatomic ACL graft placement. Physeal sparing techniques that avoid damage to the growth plate by drilling anatomic tunnels completely within the epiphysis and have been shown to be biomechanically superior to extraarticular and modified physeal sparing procedures. These all-epiphyseal reconstruction techniques can be used to effectively and safely treat patients with significant growth remaining. Patients nearing skeletal maturity can be treated with adult type transphyseal reconstruction techniques with quadrupled hamstring autografts. When performing transphyseal ACL reconstruction in patients nearing skeletal maturity, soft-tissue grafts should be placed across the physis to minimize the risk of growth deformity.
Intrasubstance tears of the anterior cruciate ligament (ACL) in children and adolescents, historically considered relatively rare, are being reported with increasing frequency. While epidemiological data on the incidence of ACL tears in skeletally immature athletes are limited, the rate of ACL reconstructions in these patients has been increasing over the last 20 yr. This increase in pediatric ACL surgery is thought to be commensurate with increased injury incidence; however, this phenomenon also may represent a shift from nonsurgical to surgical management preferences because of improved surgical techniques and increased awareness that meniscal and chondral pathology may be associated with nonsurgical or delayed surgical treatment.
Surgical reconstruction techniques can be categorized into three groups: transphyseal, physeal sparing, and hybrid techniques. The type of surgical treatment should be determined by the patient's physiologic and skeletal age at the time of injury. Appropriate treatment is paramount in avoiding iatrogenic growth disturbance and restoring normal knee function and stability.
Abstract and Introduction
Abstract
Intrasubstance anterior cruciate ligament (ACL) tears in skeletally immature patients are being reported with increasing frequency. Children and adolescents often are noncompliant with conservative treatment and have higher demands for knee stability than their adult counterparts. Consequently, nonsurgical or delayed surgical management has been associated with poor outcomes, including recurrent instability, increased meniscal and chondral damage, and decreased return to athletic participation. Even so, physicians often are faced with a treatment dilemma because clinical and basic science studies have demonstrated risk of limb-length discrepancy and angular deformity with ACL reconstruction. Prior to undergoing ACL reconstruction, skeletal maturity and growth potential should be determined so patients can be risk-stratified and the appropriate surgical technique can be selected. Vertical transphyseal drill tunnels have been used to decrease physeal damage and minimize the chance of growth deformity; however, these techniques result in nonanatomic ACL graft placement. Physeal sparing techniques that avoid damage to the growth plate by drilling anatomic tunnels completely within the epiphysis and have been shown to be biomechanically superior to extraarticular and modified physeal sparing procedures. These all-epiphyseal reconstruction techniques can be used to effectively and safely treat patients with significant growth remaining. Patients nearing skeletal maturity can be treated with adult type transphyseal reconstruction techniques with quadrupled hamstring autografts. When performing transphyseal ACL reconstruction in patients nearing skeletal maturity, soft-tissue grafts should be placed across the physis to minimize the risk of growth deformity.
Introduction
Intrasubstance tears of the anterior cruciate ligament (ACL) in children and adolescents, historically considered relatively rare, are being reported with increasing frequency. While epidemiological data on the incidence of ACL tears in skeletally immature athletes are limited, the rate of ACL reconstructions in these patients has been increasing over the last 20 yr. This increase in pediatric ACL surgery is thought to be commensurate with increased injury incidence; however, this phenomenon also may represent a shift from nonsurgical to surgical management preferences because of improved surgical techniques and increased awareness that meniscal and chondral pathology may be associated with nonsurgical or delayed surgical treatment.
Surgical reconstruction techniques can be categorized into three groups: transphyseal, physeal sparing, and hybrid techniques. The type of surgical treatment should be determined by the patient's physiologic and skeletal age at the time of injury. Appropriate treatment is paramount in avoiding iatrogenic growth disturbance and restoring normal knee function and stability.
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