AANA Lab Course 1002 -3rd Annual Fellows/Chief Residents-ACL Reconstruction in Skeletally Immature Patients-Courtney A. Holland, M.D.

ACL Reconstruction in Skeletally Immature Patients-Courtney A. Holland, M.D.

Pdf Summary

This presentation by Dr. Courtney A. Holland focuses on anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, addressing the challenges and management strategies unique to this population. Pediatric ACL injuries are increasingly common due to rising youth sports participation, with the knee being the most frequently injured joint, especially in soccer and football.<br /><br />Management requires understanding growth plate (physeal) biology to avoid growth disturbances. Non-surgical treatment often leads to repeated instability and secondary meniscal and cartilage damage. Surgical treatment aims for knee stability while minimizing physeal injury.<br /><br />Assessing skeletal maturity through growth spurts, Tanner staging, bone age, and imaging guides treatment decisions. Pediatric ACL reconstruction options include delayed reconstruction, physeal-sparing techniques, partial transphyseal, and complete transphyseal reconstructions.<br /><br />Delayed reconstruction, involving activity restriction and bracing, can lead to increased meniscal and chondral injuries. Studies indicate that earlier surgical intervention reduces secondary damage and instability.<br /><br />Physeal-sparing techniques seek to avoid growth plate damage in younger patients with wide open physes (Tanner 1-2), including the "over-the-top" extra-articular method and all-epiphyseal intra-articular technique. The all-epiphyseal approach is more anatomic and shows better functional outcomes but demands precise surgical skills and imaging guidance.<br /><br />Partial transphyseal techniques preserve the femoral physis while using a transphyseal tibial tunnel and are suited for patients in Tanner stages 2-3. Complete transphyseal reconstruction, similar to adult techniques, is reserved for adolescents near skeletal maturity (Tanner 3-5) and involves careful tunnel placement to avoid physeal bars.<br /><br />Postoperative outcomes show that pediatric patients have higher rates of graft failure (15-25%), with risks exacerbated by early return to sports and exposure to injury-prone situations. Rehabilitation and injury prevention, including parental education and delayed return to cutting sports (12 months), are critical for reducing re-injury.<br /><br />In summary, early reconstruction with an appropriate technique tailored to skeletal maturity leads to better outcomes and less secondary joint damage. Delaying surgery increases meniscal and chondral injuries. Ongoing research continues to refine approaches to optimize safety and function in this high-risk pediatric population.

Keywords

anterior cruciate ligament reconstruction

pediatric ACL injuries

skeletally immature patients

growth plate biology

physeal-sparing techniques

delayed reconstruction

partial transphyseal reconstruction

complete transphyseal reconstruction

postoperative graft failure

rehabilitation and injury prevention