Pediatric ACL in Sports, Prognosis, Decision Making and Outcomes of Management

Vol 3 | Issue 2 |  July-Dec 2018 | Page 16-21 | Reha N. Tandoğan, Metin Polat.

Authors: Reha N. Tandoğan[1], Metin Polat [2].

[1] ankaya Orthopedics, Ankara, Turkey,
[2] Orthopedic Surgeon, Cankaya Orthopedics, Ankara, Turkey

Address of Correspondence
Dr. Reha N. Tandogan,
Cinnahcaddesi 51/4 Cankaya Ankara, Turkey


Anterior cruciate ligament (ACL) injuries in pediatric & adolescent patients may occur as tibial eminence fractures, mid-substance ligament injuries and peel-off injuries of the femoral insertion site. ACL injuries in adolescents nearing skeletal maturity may be treated as adults without risk of deformity or leg length discrepancy. Treatment of ACL injuries children with wide open physes and substantial remaining growth are controversial. Disappointing functional results and an increased prevalence of secondary meniscal and cartilage damage with conservative management have led to an increased utilization of surgical treatment in these children. ACL reconstruction with soft tissue grafts and physeal sparing techniques are considered the gold standard of surgical management. Primary repair combined with healing enhancement techniques for femoral peel-off injuries with minimal damage to the body of the ACL can be used in select cases. The rates of growth disturbance after ACL surgery remain low with modern techniques and are usually clinically insignificant. However, a higher rate of failure and need for revision has been reported in pediatric & adolescent ACL injuries compared to adults. The risk of failure increases in patients with allografts and who return to high risk impact sports.
Keywords: Paediatric ACL tEAR, Physeal sparing techniques, repair


1. McConkey MO, Bonasia DE, Amendola A. Pediatric anterior cruciate ligament reconstruction. Curr Rev Musculoskelet Med. 2011 Jun;4(2):37-44.
2. Werner BC, Yang S, Looney AM, Gwathmey FW Jr. Trends in pediatric and adolescent anterior cruciate ligament ınjury and reconstruction. J PediatrOrthop. 2016 Jul-Aug;36(5):447-52.
3. Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpelä A. The risk for a cruciateligamentinjury of theknee in adolescentsandyoungadults: a population-basedcohortstudy of 46 500 peoplewith a 9 yearfollow-up. Br J Sports Med. 2008 Jun;42(6):422-6.
4. Bonnard C, Chotel F. [Kneeligamentandmeniscalinjury in childrenandadolescents]. RevChirOrthopReparatriceApparMot. 2007 Oct;93(6 Suppl):95-139.
5. Stracciolini A, Stein CJ, Zurakowski D, Meehan WP 3rd, Myer GD, Micheli LJ. Anterior cruciate ligament injuries in pediatric athletes presenting to sports medicine clinic: a comparison of males and females through growth and development.Sports Health. 2015 Mar;7(2):130-6.
6. Shaw KA, Dunoski B, Mardis N, Pacicca D. Knee morphometric risk factors for acute anterior cruciate ligament injury in skeletally immature patients. J Child Orthop. 2015 Apr;9(2):161-8.
7. Dare DM, Fabricant PD, McCarthy MM, Rebolledo BJ, Green DW, Cordasco FA, Jones KJ. Increased lateral tibial slope is a risk factor for pediatric anterior cruciate ligament injury: an MRI-based case-control study of 152 patients. Am J Sports Med. 2015 Jul;43(7):1632-9.
8. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012 Sep1;42(9):733-49.
9. Baxter MP. Assessment of normal pediatric knee ligament laxity using the genucom. J PediatrOrthop. 1988; 8(5):546-50.
10. Moksnes H, Engebretsen L, Risberg MA. Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study. Knee Surg Sports TraumatolArthrosc. 2008; 16(3):214-23.
11. Dumont GD, Hogue GD, Padalecki JR, Okoro N, Wilson PL. Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relationship of treatment time and patient-specific factors. Am J Sports Med. 2012;40(9):2128-33.
12. Samora WP 3rd, Palmer R, Klingele KE. Meniscal pathology associated with acute anterior cruciate ligament tears in patients with open physes. J PediatrOrthop. 2011; 31(3):272-6.
13. Newman JT, Carry PM, Terhune EB, Spruiell MD, Heare A, Mayo M, Vidal AF. Factors predictive of concomitant injuries among children and adolescents undergoing anterior cruciate ligament surgery. Am J Sports Med. 2015Feb;43(2):282-8.
14. Anderson AF, Anderson CN. Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction. Am J Sports Med. 2015 Feb;43(2):275-81.
15. Guenther ZD. Meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? ClinOrthopRelat Res. 2014;472(3):990-7.
16. Woods GW, O’Connor DP. Delayed anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2004 Jan-Feb;32(1):201-10.
17. Ardern CL, Ekås GR, Grindem H, Moksnes H, et al. L. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Br J Sports Med. 2018 Apr;52(7):422-438.
18. Moksnes H, Engebretsen L, Eitzen I, Risberg MA. Functional outcomes following a non-operative treatment algorithm for anterior cruciate ligament injuries in skeletally immature children 12 years and younger. A prospective cohort with 2 years follow-up. Br J Sports Med. 2013 May;47(8):488-94.
19. Moksnes H, Engebretsen L, Risberg MA. Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: a prospective MRI study. Am J Sports Med. 2013 Aug;41(8):1771-9.
20. Vavken P, Murray MM. Treating anterior cruciate ligament tears in skeletally immature patients. Arthroscopy. 2011 May;27(5):704-16.
21. Ramski DE. Anterior Cruciate Ligament Tears in Children and Adolescents: A meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014 Nov;42(11):2769-76
22. Kay J, Memon M, Shah A, Yen YM, Samuelsson K, Peterson D, Simunovic N, Flageole H, Ayeni OR. Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis. Knee Surg Sports TraumatolArthrosc. 2018 Jun 6. doi: 10.1007/s00167-018-5012-5.
23. Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR. Over 90 % of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports TraumatolArthrosc. 2018 Apr;26(4):1019-1036
24. Seil R, Weitz FK, Pape D. Surgical-experimental principles of anterior cruciate ligament (ACL) reconstruction with open growth plates. J ExpOrthop. 2015 Dec;2(1):11. doi: 10.1186/s40634-015-0027-z.
25. Guzzanti V, Falciglia F, Stanitski CL. Preoperative evaluation and anterior cruciate ligament reconstruction technique for skeletally immature patients in Tanner stages 2 and 3. Am J Sports Med. 2003; 31(6):941-8.
26. Shea KG, Belzer J, Apel PJ, Nilsson K, Grimm NL, Pfeiffer RP. Volumetric injury of the physis during single-bundle anterior cruciate ligament reconstruction in children: a 3-dimensional study using magnetic resonance imaging. Arthroscopy. 2009; 25(12):1415-22.
27. Nawabi DH, Jones KJ, Lurie B, Potter HG, Green DW, Cordasco FA. All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis. Am J Sports Med. 2014 Dec;42(12):2933-40.
28. Domzalski M, Karauda A, Grzegorzewski A, Lebiedzinski R, Zabierek S, Synder M. Anterior cruciate ligament reconstruction using the transphyseal technique in prepubescent athletes: Midterm, prospective evaluation of results. Arthroscopy. 2016 Mar 8. pii: S0749-8063(15)01002-6.
29. Calvo R, Figueroa D, Gili F, Vaisman A, Mocoçain P, Espinosa M, León A, Arellano S. Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study. Am J Sports Med. 2015 Feb;43(2):289-94.
30. Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate ligament reconstruction in skeletally immature patients with transphyseal tunnels. Arthroscopy. 2012 Nov;28(11):1710-7.
31. Larson CM, Heikes CS, Ellingson CI, Wulf CA, Giveans MR, Stone RM, Bedi A. Allograft and autograft transphyseal anterior cruciate ligament reconstruction in skeletally immature patients: outcomes and complications. Arthroscopy. 2016May;32(5):860-7.
32. Astur DC, Arliani GG, Debieux P, Kaleka CC, Amaro JT, Cohen M. Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes. Knee Surg Sports TraumatolArthrosc. 2016 Mar;24(3):792-5.
33. Pennock AT, Chambers HG, Turk RD, Parvanta KM, Dennis MM, Edmonds EW. Use of a Modified All-Epiphyseal Technique for Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient. Orthop J Sports Med. 2018 Jul 2;6(7):2325967118781769.
34. Frosch KH, Stengel D, Brodhun T, Stietencron I, Holsten D, Jung C, ReisterD,Voigt C, Niemeyer P, Maier M, Hertel P, Jagodzinski M, Lill H. Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy. 2010; 26(11):1539-50.
35. Collins MJ, Arns TA, Leroux T, Black A, Mascarenhas R, Bach BR Jr, Forsythe B.Growth abnormalities following anterior cruciate ligament reconstruction in the skeletally immature patient: a systematic review. Arthroscopy. 2016 May 7. pii:S0749-8063(16)00244-9.
36. Pierce TP. Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of Transphyseal Versus Physeal-Sparing Techniques. Am J Sports Med. 2016 Apr 4. pii: 0363546516638079.
37. Shifflett GD, Green DW, Widmann RF, Marx RG. Growth arrest following acl reconstruction with hamstring autograft in skeletally immature patients: a review of 4 cases. J PediatrOrthop. 2016 Jun;36(4):355-61.
38. Zimmerman LJ, Jauregui JJ, Riis JF, Tuten HR. Symmetric limb overgrowth following anterior cruciate ligament reconstruction in a skeletally immature patient. J PediatrOrthop B. 2015 Nov;24(6):530-4.

How to Cite this article: Tandoğan R N, Polat M. Pediatric ACL in sports, prognosis, decision making and outcomes of management. Journal of Clinical Orthopaedics July-Dec 2018;3(2):16-21.

(Abstract    Full Text HTML)      (Download PDF)