Paediatric ACL

Managing anterior cruciate ligament (ACL) tears in paediatric patients presents unique challenges. Research has clearly shown that poor outcomes occur with nonsurgical treatment, but surgical intervention carries the risk of damage to the growth plates, resulting in leg length discrepancy or angular deformity of the legs. The standard of care should be a surgical treatment approach appropriate for each child’s potential for growth disturbance.

Assessing maturity and risk

The consequences of growth disturbance may be severe in children who have a great deal of growth remaining, but these consequences can be mitigated by careful preoperative evaluation of the patient’s skeletal and sexual maturity.

In general, chronologic age is an excellent predictor of maturity; however, because two children of the same age could have different skeletal ages, chronologic age alone is insufficient to predict how surgical treatment may disturb growth. Skeletal age may be predicted with radiographs or magnetic resonance imaging. One common method uses the Greulich-Pyle Atlas of Skeletal Maturation and compares radiographs of the left wrist and hand to a reference population. Physiologic age may be estimated using criteria developed by Tanner, which classifies sexual maturity from stage 1 (prepubescent) through stage 5 (adult).

Non-operative or surgical treatment

A non-operative treatment strategy for paediatric ACL tears may present several problems. Firstly, the child should not play sport or participate in free play. Due to their knee instability there is a very high risk of further damage to the knee during these activities. In addition, research provides compelling evidence that nonsurgical treatment is associated with a high probability of long-term knee damage. Patients often experience recurrent instability, meniscal damage, and sports-related instability. In most cases the risks of nonsurgical treatment are greater than the risks of surgery.

Surgical options

In most children a technique similar to that used in adult ACL reconstruction is used. A number of small technical modifications are used during surgery to minimise the risk of growth plate damage. For more information read ACL reconstruction.

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