ACL Reconstruction in Children

Introduction

The Anterior Cruciate Ligament (ACL) is a tough, fibrous, rope-like structure located in the centre of the knee. When the ACL gets torn, it does not heal on its own, often leading to a feeling of instability in the knee.

Fortunately, ACL reconstruction is a commonly performed surgery to restore stability to the knee. Many of these surgeries are now performed arthroscopically using minimally invasive techniques, resulting in smaller incisions and faster recovery times.

Treating ACL Ruptures in Children

However, it’s important to note that treating an ACL rupture in children differs from the standard treatment for an ACL rupture in adults. The anatomy and physiology of a child’s or adolescent’s knee vary significantly from those of an adult, necessitating a different approach to treatment.

The main difference lies in the presence of growth plates, or epiphysis, in a child’s knee. These are developing tissue regions at the ends of the femur and tibia responsible for the leg’s growth. In children, these growth plates are usually the weakest part of the knee. The same injury that would tear a ligament or cartilage in a mature knee is much more likely to fracture the bones through the growth plate in a child.

Before the surgery, your child’s condition will be thoroughly assessed, and a suitable treatment plan will be discussed with you.

Indications and Contraindications

Indications for ACL Reconstruction in Children:

  • Complete ACL Tear: Children who have experienced a complete tear of the ACL, especially if it results in knee instability, are candidates for ACL reconstruction.
  • Persistent Symptoms: When non-surgical treatments, such as physical therapy, do not adequately alleviate symptoms or instability, surgery may be considered.
  • High Activity Level: Active children engaged in sports or activities that demand a stable knee joint may benefit from ACL reconstruction to restore function and prevent future injuries.

Contraindications for ACL Reconstruction in Children:

  • Open Growth Plates: In younger children with open growth plates (physes), ACL reconstruction is generally avoided due to the potential risk of growth plate damage. The procedure may be delayed until the growth plates are closed.
  • Minimal Symptoms: Children with minimal symptoms or no functional impairment may not be suitable candidates for ACL reconstruction.
  • Patient and Family Preference: In some cases, the patient’s and family’s preference may lean towards conservative management, such as non-surgical treatment.
  • Medical Unfitness: Children with underlying medical conditions that make surgery high-risk may not be ideal candidates for ACL reconstruction.

The decision to pursue ACL reconstruction in children should be made after a thorough evaluation by a healthcare professional, considering the individual patient’s age, skeletal maturity, specific medical history, condition, and activity level. The risks and benefits should be carefully weighed in consultation with the child and their family.

Treatment Options

Immediate Care

If a child sustains a knee injury, they should stop the activity immediately and seek medical attention to prevent further damage. In the meantime, applying ice to the knee regularly for 20-minute intervals and elevating the knee to reduce swelling is advised. It’s also important to avoid bearing weight on the affected leg.

Treating ACL ruptures in children differs from adults due to growth plates in a child’s knee, which are vulnerable as they are located precisely where surgical holes are needed for ligament attachment.

If a standard ACL reconstruction is performed in a child or adolescent without considering this factor, it can lead to growth abnormalities at the knee.  The risk of such complications is higher in younger children.

Due to these risks, non-operative treatment is typically suggested initially.  This involves strapping the leg, prescribing strengthening exercises, and avoiding strenuous activities.

As a child reach the end of their growth phase, the growth plate undergoes a process of hardening (ossification) along with the rest of the bone. Typically, girls’ growth plates close around ages 14 or 15, while boys’ growth plates close later, at around 16 or 17 years of age.

Adolescents close to skeletal maturity: If the adolescent is close to skeletal maturity, the risks are small, and a standard ACL reconstruction is usually performed.

Younger children: For younger children, alternative techniques have been developed to reduce growth complications, significantly lowering the risk compared to standard methods.

These procedures serve as temporary measures to control symptoms until skeletal maturity when a formal reconstruction can be performed if necessary. Fortunately, these interventions have shown significant success, with many children able to return to sports without requiring a second procedure later on.

Risks and Benefits

Benefits of ACL Reconstruction in Children Procedure:

  • Restored Knee Stability: ACL reconstruction helps restore knee joint stability, reducing the risk of recurrent instability or giving way, which can lead to further injuries.

  • Pain Relief: The procedure often alleviates pain and discomfort associated with a torn ACL, allowing the child to return to normal activities without pain.

  • Functional Recovery: Children can regain the ability to participate in sports and physical activities that demand a stable knee joint, contributing to an improved quality of life.

  • Prevention of Secondary Injuries: ACL reconstruction can reduce the risk of secondary injuries, such as meniscus or cartilage damage, which may occur due to ongoing knee instability.

  • Minimized Long-Term Joint Damage: By addressing the ACL injury early in life, ACL reconstruction can help protect the long-term health of the knee joint, potentially reducing the risk of degenerative changes and osteoarthritis.

Risks of ACL Reconstruction in Children Procedure:

  • Growth Plate Damage: In skeletally immature children, there is a risk of damage to the growth plates, which can affect normal bone growth.

  • Re-Injury or Graft Failure: The graft used to reconstruct the ACL may fail to integrate properly or may be re-injured, requiring additional surgery.

  • Limited Range of Motion: Some children may experience a temporary or permanent limitation in knee joint range of motion following surgery.

  • Nerve or Blood Vessel Damage: Injury to nearby nerves or blood vessels during surgery is a potential risk, although it is relatively rare.

  • Complications from Anesthesia: As with any surgical procedure, there are potential risks associated with anesthesia, including allergic reactions or adverse effects.

  • Rehabilitation Challenges: Post-operative rehabilitation is crucial, and non-compliance or inadequate rehabilitation can lead to suboptimal outcomes.

Children and their families should discuss the potential benefits and risks of ACL reconstruction with their healthcare provider. The decision to undergo the procedure should be based on the child’s specific medical history, condition, age, and activity level, with careful consideration of the potential impact on growth and long-term joint health

Surgical Approach

Children’s anatomy varies from that of an adult, therefore any surgical procedures need to be adjusted adequately, to address those differences. Similarly, an ACL (Anterior Cruciate Ligament) reconstruction in children requires a specialised surgical approach to address the unique considerations of pediatric patients. The surgery is performed with the use of minimally invasive arthroscopic techniques.

Pediatric ACL reconstruction relies on the use of soft tissue grafts from the child’s own body, rather than artificial or cadaver tissues, which are often used in adults. The procedure is demanding and performed with utmost care to avoid injury to the growth plates and to avoid any disturbance of growth. The surgical technique is individualised, taking into account the child’s age, activity level, and specific anatomical factors to allow for a long-term knee stability reconstruction without any compromise to its growth or development.

Pre-Surgery Information

Before ACL surgery, the following procedures and preparations will take place:

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.  
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

When it comes to treating ACL (Anterior Cruciate Ligament) ruptures in adolescents, there are different approaches depending on the patient’s age and skeletal maturity.

Surgical Procedure

If the adolescent is nearing skeletal maturity, typically defined as around 14-16 years old for girls and 15-17 years years old for boys, the risks associated with ACL reconstruction are relatively small, and a standard procedure is typically performed. The surgery is carried out using arthroscopic techniques, which are minimally invasive and offer several benefits.

For younger children, surgeon must carefully choose graft options and a surgical techniques to avoid damaging the growth plates. These techniques involve harvesting the tendon grafts and drilling tunnels in a way that avoids the growing part of the knee.

  1. Anesthesia: The surgery is typically performed under general anesthesia.
  2. Incisions: Several small incisions are placed around the knee, to insert the camera and instruments.
  3. Graft: The surgeon harvests a graft from the back of patient’s knee, and prepares it.
  4. Tunnels: small tunnels for the graft are drilled in the bone, avoiding the growth plates. Alternatively, graft is passed around the knee, to avoid damage to the growing joint.
  5. Wound closure: The incisions are closed with sutures, and sterile dressings are applied.
  6. Post-operative care: After the surgery, the patient is moved to a recovery area, where they are closely monitored. Physical therapy and rehabilitation are an essential part of the recovery process.

Post-Surgery Information

Immediate Post-Surgery:

Upon discharge, the medical team will remove the large outer dressing, leaving a waterproof dressing in place. They may also apply a tube-grip bandage for additional support.

No brace or immobilisation will be necessary after surgery.

To reduce swelling, the patient should apply ice regularly for 20-minute intervals until the swelling subsides.

Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:

  • 1 week postop: for wound check,
  • 2 weeks postop: for sutures
  • removal
  • 6 weeks postop: for x-ray assessment of healing progressing,
  • Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.
  • A control MRI will also be needed to assess the reconstructed ligament

Physiotherapy should begin between two and five days after surgery, with the goal of achieving a quick return to a full range of motion and strengthening the quadriceps and hamstring muscles.

A comprehensive rehabilitation programme, including daily strengthening exercises, will be explained, and the child may need to use crutches for four to six weeks post-surgery.

The Recovery Process:

The recovery pathway for  adolescents is the same as for adults.

The younger children’s recovery differs depending on their age and the level of involvement in professional sports.

It is crucial for the patient to diligently follow the instructions of the medical team and physiotherapist to ensure a successful recovery and a safe return to an active lifestyle.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000