ACL tears are one of the most common injuries seen in my office.  The treatment of these injuries has been a topic of much debate in the orthopedic world.   Surgical refinements and follow up studies have helped guide the way.  Over the past few years, I have performed a number of ACL reconstruction surgeries on young people, with ages typically ranging from 11 to 14.  This has been a topic of much debate in the orthopedic world, and there is no one perfect recommendation for everyone.  Part of performing the reconstruction involves creating bone tunnels.  These tunnels tend to pass through the growth plates, or section of the bone that grow to lengthen the bone and make you taller / longer.   In adults, these growth plates are shut down, and making the tunnels does not cause a problem.  In kids, the concern has always been the possibility of creating a ‘growth arrest’ or having the bone stop growing, leading to differences in leg length, or abnormal growth.

Much has been learned about this from kids that have developed growth arrests for other reasons.  The treatment in the pediatric orthopedic world for this is to remove the area of bone that has created the problem in the growth plate, and place a soft tissue graft in its place.  This has been successful.  So…..the reconstructed ligament looks a lot like a soft tissue graft.  In a way, the ACL reconstruction is done in the same way we would treat a growth problem in the first place.  As a result, the risk of growth arrest may be lower with a hamstring graft than a bone-tendon-graft.

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With this in mind, I am often, yet not always, a proponent of reconstructing the ACL rather than waiting for skeletal maturity in young people.  The risk of growth arrest is rare, although not impossible.  Telling an athletic child to stop playing is tough.  Playing with an ACL injury can lead to more injury – potentially permanent damage.  Children and adolescents rehab well after surgery, rarely have stiffness problems, and with supportive, realistic parents, make a great recovery.
Reconstructed ACL

Arthroscopic view of a reconstructed ACL graft

Graft choice is often a big part of the surgical discussion.  You can read more about ACL graft choices.  The use of a soft tissue ligament graft has been met with great success.   Studies to date do not suggest that one graft is better than the other (hamstring / BTB).  There is some data showing that auograft does a little better than allograft.  While graft choice is important, it is just one of many important decisions to be made surgically that affects outcome, not the only one.  Tunnel placement, for example, may be more important.

Recurrence of instability is a concern.  Therapy directed at rehabilitation and neuromuscular education is important.  The risk of re-injury, or injuring the contralateral knee is somewhere between 10-15%.  A well healed, well placed graft will only be successful with the right re-training routine.
Overall, I have seen great results in this situation.  It is extremely important that parents, kids and surgeon (me) communicate well and fully understand the risks and expectations from ACL surgery at this age, including the repercussions for the future of the athlete.
Dr. Scott Hacker is a Sports Medicine Orthopedic Surgeon in San Diego, CA, Team Surgeon to the US Olympic Team.  He specializes in sports medicine and sports injuries, knee and shoulder surgery.
If you have questions about ACL tears in young people, please feel free to contact me at Ask Dr. Hacker or through my office.

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