Technical Information about ACL Injuries in Children.
Last updated Thursday, January 13, 2005
Treatment and managementWhat is the goal of treatment for anterior cruciate ligament (ACL) injuries in children? The goal of treatment of the ACL insufficiency in the child is similar
to that of the adult; the prevention of recurrent giving way episodes
(17). Recurrent instability ACL insufficient patient leads to meniscal
tears, and osteochondral damage predisposing to premature degenerative
arthritis. If repeat injuries can be prevented by non operative means
this is desirable in any age group, especially in the pediatric age
group. One of the more important factors in preventing repeat injuries
is activity modification, particularly avoiding high level athletic
activities that require jumping, pivoting, contact, or participation on
unpredictable surfaces.Who should consider surgery for anterior cruciate ligament (ACL) injury in children and adolescents? ACL deficiency in the skeletally immature has resulted in a high
incidence of secondary meniscal injuries, degenerative joint disease,
and symptomatic instability in both sports and daily activities
(13,18-20). Skeletally immature patients are in fact much less likely
to limit their activities and adapt to ACL insufficiency than
skeletally mature counterparts. Therefore, many skeletally immature
patients must be considered surgical candidates; since the risk of
injury from operative intervention may be less than the potential
damage caused by repeated injury.What kinds of surgery are recommended for anterior cruciate ligament (ACL) injuries in children and adolescents? Several surgical stabilization procedures have been described in the
literature. Primary repair of interstitial tears of the ACL in children
has been shown to be minimally successful (21,22).
As in adults primary repair alone of interstitial tears has a high
failure rate and should not be considered as adequate or appropriate
treatment for this injury. Primary repair with appropriate augmentation
however may offer some advantages in this age group over reconstruction
alone.
The primary repair of avulsion injuries have been shown to be more
successful (23). This is particularly true when there is a bony
avulsion that can be anatomically restored. It must be cautioned
however that pure avulsion injuries are uncommon and frequently
avulsion injuries exists in conjunction with interstitial ACL tears.
Arthroscopic inspection is usually necessary to determine if a bony
avulsion is truly an isolated avulsion or has occurred in conjunction
with an interstitial tear.
Partial tears of the ACL in skeletally immature patients have been
documented. Studies have shown that partial tears of the ACL can result
in a satisfactorily result when treated without surgery (13,24). A good
result with a partial injury is dependent on the degree of laxity. If
laxity less is sufficient to allow a pivot shift phenomenon then an
unsatisfactory result is more likely without surgery.
Extraarticular reconstructions have been suggested as a way of
providing stability in this age group without compromising the physis.
Although these procedures avoid drilling through the physis, the
relative lack of isometrey of the graft can lead to increased laxity
over time (14,19). It is also felt that extraarticular procedures that
require dissection and fixation devices near the physis may run more
risk of interfering with growth than the careful drilling of a central
transphyseal hole. Extraarticular procedures in the skeletally immature
patient are generally not recommended except for the primary repair of
torn secondary restraints (25).
Intraarticular reconstruction without transphyseal drill holes have
been described (26,27). These procedures generally utilize a groove
over the front of the tibia and groove over the top of the femur or an
"over the top" position on the femur thus avoiding transphyseal drill
holes. The results of these procedures have been mixed. Like
extraarticular reconstructions, this type of procedure decreases the
relative graft isometry. The effect of hardware used for graft fixation
near the growth plate is unclear. The anterior position of the graft on
the tibia has resulted in graft impingement and persistently abnormal
MRI signals within the graft tissue (27).
The most commonly accepted method for intraarticular ACL
reconstruction in the skeletally immature patient utilizes a
transphyseal tibial drill hole and an "over the top position" on the
femur as noted in (12). It is felt that the relatively central tibial
drill hole will not cause an angular deformity if disturbance in growth
occurs. Avoidance of a femoral drill hole extending laterally lessens
the possibility of asymmetrical growth arrest on the distal femur. The
dissection on the distal lateral thigh however and the use of fixation
devices near the lateral femoral physis may create some risk for growth
disturbance (28).
Several studies have been reported of ACL reconstruction in
skeletally immature patients utilizing both tibial and femoral drill
holes (14,19). The reported results are generally acceptable, but most
studies are reported on patients who are close to skeletal maturity. A
recent study by Matava and Siegel however has shown symmetrical
subsequent growth from both the tibial and femoral physes following the
creation of transphyseal drill holes (29).
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