A child’s ACL tear – It’s not just another ACL
Because of the potential damage that can occur to the growth plates (physes) anterior cruciate reconstruction in paediatric patients needs to be approached in a different light to adult reconstruction cases.
Paediatric ACL reconstructions require significant technical expertise in order to minimize the risk of damaging growth plates and preserving menisci. Surgeons with paediatric training are best placed to provide this.
Traditionally children with ACL ruptures have been instructed to avoid sports, wear a supportive brace and wait until they are closer to skeletal maturity before proceeding with reconstruction. Non operative management like this is still an option however studies have shown that delay in surgical repair of the ACL, greater than 12 weeks, increases the risk of meniscal tears and secondary chondral surface damage due to persistent knee instability. In reality, it is difficult for a child to be brace and activity compliant despite the doctor’s instructions.
Consequently it has become more common for surgeons to recommend early intervention. Many methods have been described for paediatric patients. The type of method chosen primarily depends on how much growth remaining the child has ie their Tanner stage.
Adult like reconstruction techniques can be utilised, ie transphyseal techniques, however care must be taken to minimize the cross sectional area of physis that is violated when making the femoral and tibial tunnels to pass the graft. The tunnels need to be as close to right angles to the physis as possible to minimise the cross sectional area affected. Studies have shown that up to 7% of the cross sectional area of the growth plate can be violated without causing growth disturbance. Furthermore the fixation used to secure the graft must not tether the physis therefore traditional adult like interference fit screws are generally avoided. Alternatively all epiphyseal and extra articular reconstruction techniques have also been described to avoid the graft crossing the physis thus minimising growth arrest however these techniques are technically more challenging.
The size of the graft also needs to be considered. The size of a hamstring graft for example is proportional to the age of the child. In children of pre pubescent age, harvesting their own hamstring may be insufficient therefore an alternative type of graft needs to be considered. Recent publications have demonstrated that a donor allograft tendon can be used with good results rather than harvesting donor tendon from a parent as has been done in some centres.
In addition to considerations regard ACL reconstruction techniques the surgeon must also have expertise and a low threshold for meniscal repair techniques as debridement of the meniscus, particularly the lateral meniscus, in a child, results in rapid chondral wear and post traumatic arthritis.
In order to approach treatment of a child with an ACL tear the surgeon must have thorough knowledge of all these issues and also experience with the variety of reconstruction techniques as described in order to offer their patient the most appropriate surgery for their age.