ACL reconstruction: Is surgery the appropriate treatment in young kids?

Recently I’ve performed ACL surgery on 11- and 12-year-old kids. Whether or not to perform an ACL surgery on an athlete who is still growing has been the subject of debate for a long time, and I think it might be helpful to discuss the risks and benefits in a post here. As I’ve discussed in previous posts, ACL injuries are very common. In most athletes and athletic individuals, surgery is almost always recommended to return the patient back to sports. ACL surgery in kids who aren’t done growing, however, is not quite as straightforward a decision.  Questions to ask your doctor before ACL surgery.

As I’ve said previously, sewing the ACL back together (a repair, so to speak) does not work well. The surgeon has to make a new ligament (reconstruction). This process involves taking tissue from the patient’s knee and putting it into the knee through tunnels that are drilled in both the tibia and the femur. What is concerning for young kids is that these tunnels, if drilled where they would normally be drilled for fully-grown kids and adults, would cross open growth plates in their bones. In theory, drilling tunnels through the growth plates can lead to growth arrest in these parts of the knee. If the small area of the growth plate where the tunnel crosses it were to stop growing, the child could end up with a leg length discrepancy, or one leg longer than the other, or with a leg that is more angled than the other.

Functional ACL rehabilitation
An athlete kicks a soccer ball while balancing on the side of her ACL surgery.

Risk of growth arrest

In the past, many surgeons tended to err on the side of caution. If a young child who had not gone through puberty was diagnosed with an ACL tear, it was often advised that the patient not have surgery for several years until he or she was finished with the growth spurt. As you can imagine, children can be very difficult to hold out of sports and athletic activities, so there has been concern about the possibility of further injury to the knee and about the success of playing without an ACL. In order to perform a surgery on young children and get them back to sports with a stable knee, some surgeons tried to alter the technique of the surgery so that the ligament was placed in the knee in a way that it did not cross the growth plates. Some surgeons have had success with these non-anatomic techniques, although some studies have suggested that the knees are not quite as stable as ACL reconstructions done in adults through a normal technique.

So what’s the right decision for parents of a young child who tears his or her ACL before finishing puberty? First of all, I think that the child, the parents, and the surgeon should have a long talk to discuss a number of factors, including the child’s age and how much growth remains, the child’s current and future sports career, and the risks and benefits of proceeding with surgery now as opposed to waiting months or years.

Risk of avoiding ACL surgery

In general, I tend to err on the side of early surgery and trying to provide a stable knee for the child. I think it’s often unrealistic to expect a child to be able to stop playing sports or performing athletic activities, even exercise or sports at home. My fear is that without an anterior cruciate ligament, the child’s knee will start to buckle or give way. If so, it’s certainly possible that the child does more damage to his or her knee. If the knee is unstable and buckles with activity, it’s likely that he or she tears the meniscus or damages the articular cartilage. Some of these secondary injuries can do long-term damage to the knee. Several studies have been performed in recent years that showed a very significant increase in meniscal tears and other damage with delayed surgery, so the trend seems to be inching towards early reconstruction.

Now, as I said, I think free-flowing communication with the child and the parents is important, and if they express concern over possible risks of growth arrest at the knee, I certainly allow them to make the decision that they feel is in their best interests. I’m often asked about wearing a custom ACL brace to protect the knee. While I think that these braces can be helpful, it’s still possible that the child’s knee buckles even in the brace. I usually feel that if the knee gives way with sports, even in a brace, surgery might be the best option at that point to prevent any further damage to the knee.

Hamstring tendon graft from ACL surgery
A hamstring tendon has been used to reconstruct the ACL in this patient (runs from upper right to lower left).

ACL reconstruction techniques in kids

I typically advocate surgery as it’s done in adults, meaning placing the graft in a way that recreates the anatomy of the normal ACL as much as possible while still trying to protect the growth plates. I do prefer hamstring grafts in these patients, as I feel that the risks of growth arrest are lower with hamstring grafts in skeletally immature athletes. In my personal experience I’ve had good success with these surgeries in younger athletes and fortunately have not had issues with leg length discrepancy or angular deformities. Several current studies have shown similar good outcomes. The critical point here is that ACL surgery in young children is a significant injury, and good communication between the athlete, parents, and surgeon is critical to thoroughly explain all of the pros and cons of surgery in these growing athletes.

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