Surgical-experimental principles of anterior cruciate ligament (ACL) reconstruction with open growth plates

Abstract

ObjectiveTo review surgical and animal experimental studies performed with open growth plates in relation with pediatric anterior cruciate ligament (ACL) reconstruction.BackroundWhen it comes to the treatment of ACL injured children, there is a lack of current international guidelines, leaving the treating physicians with a therapeutic dilemma. A variety of surgical and animal experimental studies have been undertaken over the last decades in relation with open growth plates and ACL-reconstruction.MethodBased on our own previous animal experimental data, we highlighted 15 specific points concerning pediatric ACL-reconstruction and reviewed additional literature concerning these individual items.ResultsPediatric ACL-reconstruction could be proven to be safe in animal models. Growth abnormalities, risk factors and factors, which were specifically related to biological healing processes in children, were identified. From them surgical principles for safe pediatric ACL replacements can be deducted. Applying these principles through a correct technical execution of surgery may prevent clinically significant growth changes.ConclusionOver the last 2 decades it has been shown that a technically correct pediatric ACL reconstruction has little risk in creating clinically significant growth abnormalities. Animal experiments support this hypothesis despite the fact that the gained knowledge cannot be fully generalized to humans. More long time follow-up is needed to fully understand the complete risk factors related to ACL surgery with open growth plates.Electronic supplementary materialThe online version of this article (doi:10.1186/s40634-015-0027-z) contains supplementary material, which is available to authorized users.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

“…The main goal with respect to skeletal age assessment is to define remaining knee growth. Protecting the physis and perichondral ring from damage during ACL reconstruction is an important consideration 45 —an insult to a growth area that is near completion of growth can result in premature closure.…”

Resultados en la cirugía por rotura del ligamento cruzado anterior en pacientes con edad pediátrica.

“…La existencia de una pastilla ósea ocupando la fisis es otro factor que aumenta el riesgo de cierre fisario precoz. Por otro lado, una tensión excesiva del injerto y un túnel no centrado (periférico) y oblicuo han sido descritos como otros 2 factores que favorecen la aparición de alteraciones en el crecimiento fisario 6,7 . Kercher et al 8 por otro lado demostraron que túneles de 8 mm de diámetro a través de la fisis afectan al 3% de la superficie fisaria en el caso de la tibia, lo que está por debajo del 7% previamente mencionado.…”

“I never made it to the pros…” Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury—Current evidence and future directions

“…This means that each patient should be analyzed carefully and individually [ 10 ]. In the presence of an open physis, treatment options for ACL injuries become contentious, due to the risk of surgical physeal insults, which may result in limb-length discrepancies or limb malalignment [ 15 , 16 ]. The anatomic placement of the graft during reconstructive procedures is also difficult due to the proximity of the growth plate to the aperture of the femoral tunnel [ 17 ].…”

“…Synthetic grafts and bone-patellar tendon-bone autografts should generally be avoided in the pediatric population because of the risk of growth disturbances [ 18 , 33 ]. It is also recommended that drilling bone tunnels through a growth plate should be performed at a steep angle and a width of < 9 mm, to minimize the cross-sectional area of the tunnels with the aim of reducing the risk of disturbing the epiphyseal plate [ 10 , 16 , 19 , 20 , 34 ]. Additionally, the surgeon is able to confirm that tunnels are free of bone debris.…”