Treating Anterior Cruciate Ligament Tears in Skeletally Immature Patients

Abstract

Purpose To systematically review the current evidence for conservative and surgical treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients. Methods A systematic search of PubMed, CINAHL, EMBASE, CCTR, and CDSR was performed for surgical and/or conservative treatment of complete ACL tears in immature individuals. Studies with less than six months of follow-up were excluded. Study quality was assessed and data were collected on clinical outcome, growth disturbance, and secondary joint damage. Results We identified 48 studies meeting the inclusion criteria. Conservative treatment was found to result in poor clinical outcomes and a high incidence of secondary defects, including meniscal and cartilage injury. Surgical treatment had only very weak evidence for growth disturbance, yet strong evidence of good postoperative stability and function. No specific surgical treatment showed clearly superior outcomes, yet the studies using physeal-sparing techniques had no reported growth disturbances at all. Conclusions The current best evidence suggests that surgical stabilization should be considered the preferred treatment in immature patients with complete ACL tears. While physeal-sparing techniques are not associated with a risk of growth disturbance, transphyseal reconstruction is an alternative with a beneficial safety profile and a minimal risk of growth disturbance. Conservative treatment commonly leads to meniscal damage and cartilage destruction and should be considered a last resort. Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

All-Epiphyseal, All-Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients

“…37,38 There is no consensus yet on the optimal surgical technique to best re-create the biomechanics of the native ACL. [39][40][41] Kocher et al 4 reported that 78% of surgeons surveyed had performed an ACL reconstruction in a skeletally immature patient but that no single technique predominated.…”

Twin athlete brothers with open physes operated for ACL reconstruction on the same day, but with different elapsed times after injury: a 5-year follow-up

“…There is disagreement on how to approach ACL injuries in younger patients 1 2 4. When facing a patient with ACL injury and instability, many surgeons choose to conduct a more conservative treatment, while others wait for a higher level of skeleton maturity before they can proceed to reconstructing this structure.…”

“…These patients match Tanner’s classification for stages III and IV. However, for all patients with Tanner stages I and II, the debate continues and results in different approaches in the presence of the injury 1 2. Since these patients have a high physical development potential, transphyseal reconstruction might wound the growing physes and consequently result in sequelas during this further development.…”

Review of Outcomes in Pediatric Patients Undergoing Anterior Cruciate Ligament Repairs With Regional Nerve Blocks

“…Similarly, a recent systematic review conducted by Vavken and Murray (2011) examined six studies using various physeal sparing surgical techniques and found that in children with a mean age of 12 years, no growth deformity was noted at an average of nearly 4 year post surgery follow-up. Hudgens and Dahm's (2012) review of the literature also supported that operative intervention increases knee stability and decreases the risk for further injury without significant risk of growth disturbance in the skeletally immature population.…”

“…The goal of these approaches is to protect the disruption of the growth plate to minimize the incidence of growth arrest and joint deformity (Hudgens & Dahm 2012;Vavken & Murray, 2011). The Division of Sports Medicine at Boston Children's Hospital (BCH) has developed a series of innovative age-specific physeal sparing surgical reconstruction techniques for use in treatment of ACL injury in patients with skeletal immaturity.…”