Pediatric and Adolescent ACL Injury and Sports Medicine: The Early Years

Fig. 1.1

Non-transphyseal ACL reconstruction with (a) patellar tendon or (b) semitendinosus/gracilis autograft

Fig. 1.2

Partial transphyseal ACL reconstruction with a tibial tunnel and central patellar or hamstring autografts with over-the-top femoral fixation

Fig. 1.3

Complete transphyseal ACL reconstruction using femoral and tibial transphyseal tunnels and a patellar tendon autograft with bone plug or hardware fixation including an alternative femoral fixation

Guzzanti and coworkers presented recommendations for ACL reconstruction based on evaluation of lower extremity growth remaining with patients being identified as high-risk (>7 cm), intermediate-risk (>5–7 cm), and low-risk (<5 cm) projected lower extremity growth [7, 8].

Postsurgical lower extremity deformities due to physeal injury are due to multiple factors. A survey of an elite group of orthopedic sports orthopedic surgeons regarding outcomes of ACL reconstructions in skeletally immature patients showed a significant number of unsatisfactory outcomes [9]. The poor outcomes were associated with a combination of poor judgment and/or technical errors in addition to lack of appropriate pre-op evaluation of growth remaining by assessing the patient’s chronologic, not physiologic, age. There was lack of recognition of the ACL’s anatomic origin’s closeness to the femoral distal medial physis at the over-the-top position with surgical injury to the perichondral ring of LaCroix. Reported technical iatrogenic issues include too large transphyseal tunnels (>6–8 mm), high drill temperatures, excessive graft tension, graft size, and presence of transphyseal bone blocks and/or hardware. Consequential limb deformities included longitudinal (usually undergrowth, possible overgrowth), angular (usually valgus), and recurvatum due to proximal anterior tibial physeal injury.

What Have We Learned About Pediatric and Adolescent ACL Injuries?

Hemarthrosis is a sign of a major intra-articular injury involving the ACL, peripheral meniscus, and/or an osteochondral fracture.

The overall incidence of lateral and medical meniscal tears associated with an ACL tear is about equal. Lateral meniscal tears predominate in the acute setting, and more medial tears are seen in the non-acute setting. Repairs are indicated for appropriate meniscal peripheral tear patterns. Attempts to salvage meniscal tissue should be done to restore the meniscal load-sharing function with articular cartilage.

Physeal transgression of a channel which is 5–6% of the physeal area with an in tunnel tendon graft appears to be safe regarding prevention of a physeal arrest.

Partial ACL tear outcomes are very patient dependent especially the posterolateral ACL bundle status and the secondary restraints’ residual magnitude of tibial translation and pivot shift (Fig. 1.4). Activity-level stratification by sport demand has been proposed ranging from low to moderate to high demands [10]. Low-demand activities must be accepted by the athlete. Compliance is often difficult. Nonoperative treatment does not mean no treatment.