ACL reconstruction technique improves outcomes in pediatric patients

A new study demonstrates the superiority of a specific technique to perform anterior cruciate ligament (ACL) reconstruction in children. In recent years, the number of ACL surgeries in pediatric athletes has skyrocketed.

The study, conducted by researchers at Hospital for Special Surgery (HSS) in New York City, shows that a technique called the All-Inside, All-Epiphyseal ACL Reconstruction (AE) provides great knee stability and effectively controls joint stress. "The AE technique is not available except in a few select centers around the country including HSS," said Frank Cordasco, M.D., surgical director of the Ambulatory Surgery Center and member of the Sports Medicine and Shoulder Service at HSS. "We believe the AE should be the preferred procedure for ACL reconstruction in the skeletally immature." The study will be presented on July 13 at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held in Baltimore.

Twenty years ago, very few children or adolescents presented at doctors' offices with ACL injuries. Today, these injuries are common because children and young adolescents are participating in sports earlier in life and at a higher level of competition. Young athletes are also increasingly specializing in one sport, putting them at risk for overuse injuries once only seen in professional athletes. In addition, since the Title IX ban on sex discrimination in school sports, the number of female athletes has increased and females are more prone to ACL injury.

Performing ACL reconstruction in patients who are still growing is difficult. The ACL can be thought of as a rope that connects the thighbone to the shinbone. The rounded ends of the thighbone and shinbone are called epiphyses and the ACL dangles between them. Open growth plates are located directly behind the epiphyses in children and adolescents, but not in adults.

In an adult ACL reconstruction, the torn ligament is removed from the knee, holes are drilled through the ends of the thighbone and shinbone, and a tissue graft is inserted in place of the removed ligament. In this way, the reconstruction mimics the natural ACL footprint. ACL reconstruction is difficult in children because if an adult-type reconstruction were performed, the graft would cross the growth plates, potentially causing damage that can result in uneven limb lengths or angular deformities. Thus, for many years, ACL injuries in children were managed with benign neglect, or surgical procedures that were not anatomic and required large incisions to avoid injuring the growth plate. In recent years, however, clinicians realized that non-operative treatment resulted in damage to menisci and articular cartilage thereby leading to early arthritis. Advances in technology, instrumentation and techniques are now available which allow surgeons to perform the AE reconstruction without risk of injury to the growth plate. These procedures are more technically demanding and are available at only a few centers around the country including HSS.