Prevention, treatment, and rehabilitation of anterior cruciate ligament injuries in children

Abstract

As more children and adolescents participate in competitive organized sports, there has been an increase in the reported incidence of anterior cruciate ligament (ACL) injuries in these age groups. ACL injuries in skeletally immature athletes present a challenge, as reconstruction must preserve the physis of the distal femur and of the proximal tibia to avoid growth disturbances. Historically, a skeletally immature athlete with an ACL injury was treated with a brace and activity modification until skeletal maturity, with ACL reconstruction being performed at that time in the "non-copers" who experienced instability. More recently, evidence has shown that delayed reconstruction may lead to increased damage to the meniscus and articular cartilage. As a result, early reconstruction is favored to protect the meniscus and allow continued physical activity. While adolescents at or those near skeletal maturity may be treated with standard reconstruction techniques, they may result in growth disturbances in younger athletes with significant growth remaining. In response to the growing need for ACL reconstruction techniques in skeletally immature individuals, physeal-sparing and physeal-respecting reconstruction techniques have been developed. In addition to the advancements in surgical technique, ACL injury prevention has also gained attention. This growing interest in ACL prevention is in part related to the high risk of ACL re-tear, either of the ACL graft or of the contralateral ACL, in children and adolescents. Recent reports indicate that well-designed neuromuscular training programs may reduce the risk of primary and subsequent ACL injuries.

Keywords: neuromuscular training; physeal-sparing; skeletally immature; surgical techniques.

Figure 1

Algorithm for ACL reconstruction in young patients. Abbreviation: ACL, anterior cruciate ligament.

Figure 2

Physeal-sparing ACL reconstruction with iliotibial band autograft. Notes: (A) Iliotibial band harvest is performed through a 3–4 cm incision from the lateral joint line to the anterior third of the iliotibial band. A second incision over the medial proximal tibia is utilized for graft fixation to the tibia. (B) A Cobb elevator is used to elevate subcutaneous fat from the iliotibial band. (C) The central 15–20 mm of iliotibial band is identified and elevated from the underlying vastus lateralis. (D) A meniscal knife or cutting tendon stripper is passed proximally to extend the anterior and posterior iliotibial band cuts and release the graft at the proximal end. (E) The free end of the graft is tubularized with a whipstitch. A graft of 150 mm is desirable. (F) The free end of the iliotibial band graft is passed around the back of the lateral femoral condyle in the “over the top” position. With the knee flexed to 90° and the leg in neutral rotation, tension is applied to the free end of the graft, while the graft is sewn to the lateral femoral periosteum. (G and H) The tibial periosteum is incised, and the graft is secured to the periosteum of the medial proximal tibia. Abbreviation: ACL, anterior cruciate ligament.