ACL Rupture In Children Treatment Surgical Procedure

If the adolescent is close to skeletal maturity the risks are small and a standard ACL reconstruction is usually performed. The surgery is performed arthroscopically. Professor Munjed Al Muderis is skilled in All-Inside ACL Reconstruction which is a minimally invasive surgical alternative to traditional ACL reconstruction surgery. 

Both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the ACL with a tendon graft. The ruptured ligament is removed and the bone prepared in order for it to accept the new graft which replaces the old ACL. Options for the tendon graft are outlined below. The difference between traditional ACL surgery and All-Inside ACL surgery is the approach taken, in particular the drilling of a tibial tunnel. Traditional ACL reconstruction techniques involve drilling a tunnel from the outer tibial cortex into the proximal tibia and knee joint. Through this tunnel the ACL graft is inserted and securely fixed onto the tibia. This tibial tunnel is a significant source of pain following ACL surgery.

However, with All-Inside ACL reconstruction such a tibial tunnel is not created. Instead a specialised tool called a reamer is used to create a tibial socket, which does not violate the tibial cortex as it does in traditional ACL surgery. All-Inside ACL surgery also doesn’t involve any formal incisions, only three to four small arthroscopy incisions.

The advantages of All-Inside ACL surgery include less pain and a faster recovery time than traditional techniques. Due to the specialised instrumentation used All-Inside ACL surgery can also help to create a more anatomic ACL reconstruction.


ACL Grafts:

There are a number of different surgical options that can be used to reconstruct the ACL ligament. These include the use of autologus hamstring or patellar tendon graft, cadaveric donor grafts and synthetic grafts (LARS). From the literature there is no overall significant difference between any of the options; but each method has its own advantages and disadvantages and one may be better suited in each individual situation.

The graft of choice is then prepared in order to take the form of a new tendon and is passed through into the bone.

The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (this usually takes about six months).


There are pros and cons for each graft option:

Graft Type



Hamstring tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Scar reasonably small and causes no irritation
  • Relatively weaker than the other options
  • May stretch
  • Donor site pathology (weakness in hamstring)

Patellar tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Stronger than hamstring tendon graft
  • Scar cause irritation especially kneeling
  • Donor site pathology (weaker patellar tendon and bone)

Cadaver graft

  • No donor site pathology
  • Faster operation than hamstring or patellar tendon graft
  • Eventually fully replaced by new tissue
  • Chance of rejection
  • Chance of transmission of infection
  • Weakest of all graft options
  • Depends on availability


  • No donor site pathology
  • Fastest of all the graft options
  • New tissue integrates with it
  • Minimal scar
  • Strongest of all the graft options
  • Faster return to full activity
  • Requires good experience with the technique and the material
  • Implant does not dissolve with time


Alternative Approaches:

In a younger child alternative techniques have been developed to reduce the possibilities of growth complications. These techniques involve placing the ligament graft in a non-anatomic position or one that does not quite duplicate normal ligament function. This is done by either drilling holes that go around rather than through the growth plates or by avoiding drilling holes altogether and instead wrapping the graft around the bone. Growth abnormalities can still occur but the incidence is much less than with standard techniques.  

These procedures are designed to be a temporary measure to control symptoms until skeletal maturity when a traditional reconstruction can be performed. Such procedures have proven to be quite successful with many children returning to sports and not needing a second procedure later on.