When Should Children Get ACL Surgery? The Pediatric (Kids) ACL, Part 2
Unfortunately, the Anterior Cruciate Ligament does not heal once torn. We have learned in previous Blogs that the ACL protects our meniscus or cushion cartilage, and the meniscus protects the joint surface (articular cartilage) from damage.
Once the articular cartilage is gone, this is what we know as simply “arthritis”. Skiing, playing basketball, football or soccer without an ACL puts our knee at significantly higher risk to develop arthritis by damaging the cushion cartilage or meniscus.
So, once the ACL is torn, we really only have 3 choices:
1. Live without an ACL and modify our lifestyle to avoid the cutting and twisting type of activities that put our knee cartilage at risk without an ACL.
2. Live without an ACL and NOT modify our lifestyle.
We then need to understand that we are putting our knee at higher risk for damage. It doesn’t mean we will tear it up, just that we are at a much higher risk for damage. We published that skiers without an ACL have more than a 20 fold risk of sustaining an injury requiring surgery during any one season versus their normal kneed counterparts.
3. Get the ACL fixed.
Makes it seem like its a no-brainer to fix your ACL once its torn, doesn’t it? Not so fast. When we fix the ACL we have to make drill holes through the bone, these drills go right through where the growth plates usually lie. A complete new risk factor in the pediatric ACL patient.
The Growth plate #kidsacl
Fortunately, these surgeries damage the growth plate very infrequently, less than 50 cases reported in the World’s literature over the years. Never the less, if this were to happen, it can be quite devastating. One time, especially if its your child, feels like 100%. How about choices number one or two, living without an ACL?
controlling their lifestyle - a losing battle #childrensacl
As much as we think we can control our children’s lifestyle, we really aren’t very good at it. Maybe the organized sports side can be controlled, but we really don’t see them running on the playground, getting to class, playing tag at recess or even just horsing around.
Studies have shown that children under the age of 12 when they tear their ACL, will have arthritic changes on X-ray over 50% of the time by the age of 18 when treated without surgery. So, non-surgical management isn’t always the most benign treatment either.
LET'S TALK SURGICAL OPTIONS #pedatricacl
There are so many surgical options out there for treating the young child tearing their ACL trying to minimize the risk of either arthritis or growth plate disturbance. Surgical techniques have been developed that do not require drill tunnels, tunnels that do not cross the growth plate, and even repairing the torn ACL directly without replacing it.
All of these have a certain risk of failure to growth plate disturbance ratio. For example, repairing the torn ACL may have the least risk to the growth plate, but also may end up having a higher re-tear rate depending on the quality of the torn ligament.
Utilizing a cadaver graft (allograft) to replace the ACL may be tempting as we are not “robbing Peter to pay Paul” is such a young athlete, but cadaver grafts have an unacceptably high failure rate in young, less than 20 years old, athletes.
The athletes own tissue needs to be used when replacing the torn ACL in this age population. All of these issues need to be weighed before deciding what is best for your child, athlete or patient.
SURGICAL ALGORITHMS FOR THE PEDIATRIC ACL INJURY #kidssportsmedicine
A very loose algorithm that I follow for the athlete with both open growth plates and a torn ACL goes something like this:
Age 13-15 - Growth plates are closing, the risk of growth plate disturbance is so minimal that the patient should be treated like an adult with the surgeons best ACL operation recommendation.
Age 9-12 - Lots of growth left so any ACL operation should avoid bone plugs crossing the growth plates.
This means soft tissue only grafts should be used, typically either a hamstring autograft or a quadriceps tendon autograft. The more hyper-lax the patient is globally, the more that I will use a quadriceps tendon graft to replace the ACL.
Age 8 and Under - So much to lose here with either non-operative management or an ACL graft that crosses the growth plate. This is the group where I would consider an all extra-articular reconstruction, or even repairing the ACL directly if the tissue is of good quality. Stem cells or other growth factors may be added to augment this repair.
Thats what I know, or at least what I think I know, in 2016, when it comes to the pediatric ACL.
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