Anterior Cruciate Ligament Rupture in Skeletally Immature Patients

Abstract

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

Figure 1

Coronal and sagittal T1-weighted MRIs showing the knee of a 6-year-old girl, marking the femoral insertion of the anterior cruciate ligament.

Figure 2

Sagittal T1-weighted MRI showing the knee of a 13-year-old boy, measuring of the maximum oblique intraepiphyseal depth.

Figure 3

Sagittal T1-weighted and STIR-weighted MRIs showing the knee of a 15-year-old boy, with a complete anterior cruciate ligament rupture and associated meniscal tear.

Figure 4

A schematic diagram showing the transphyseal reconstruction technique. AP and lateral postoperative radiographs showing the knee of a 14-year-old boy with a transphyseal anterior cruciate ligament reconstruction.

Figure 5

A schematic diagram showing the extraphyseal reconstruction technique. The iliotibial band graft is harvested free proximally and left attached to the Gerdy tubercle distally, then brought through the knee in the over-the-top position posteriorly, through the knee and under the intermeniscal ligament anteriorly.

Figure 6

A schematic diagram showing the all-epiphyseal anatomical reconstruction technique. AP and lateral postoperative radiographs showing the knee of a 12-year-old boy with an all-epiphyseal anterior cruciate ligament reconstruction.

Figure 7

A schematic diagram showing the hybrid reconstruction technique, with an all-epiphyseal femoral tunnel and transphyseal tibial tunnel. AP and lateral postoperative radiographs showing the knee of a 13-year-old boy with this technique, associated with an anterolateral ligament reconstruction fixed with a suture anchor.

Figure 8

Chart showing the therapeutic treatment algorithm preferred by the authors for the choice of the anterior cruciate ligament reconstruction technique in patients with immature skeleton.