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An ACL tear and ACL reconstruction are challenging for adults and older adolescents. If a young athlete suffers a torn ACL, you might be conflicted about what to do. Is ACL surgery for a child safe?

Michael asks:

Dr. Geier,
My 11-year-old son suffered a torn ACL, tear in the posterior horn of his lateral meniscus and a bone bruise 2 weeks ago while playing football. His orthopaedic surgeon doesn’t suggest ACL surgery due to open growth plates. My son thinks ONLY of football and is quite accomplished. He won the Central Texas Pop Warner championship as a starting QB. We’ve heard of the iliotibial band that wraps around femur and is connected superior-anteriorly on the tibia. 
Thank you for any information you deem relevant to this situation.

Is ACL surgery for a child safe?

The debate about ACL reconstruction in kids with open growth plates is still a contested one, but there are a few points I would make. Yes, I agree that traditionally many orthopaedic surgeons suggested that young kids wait until they are done growing or close to done before having surgery. By waiting, they potentially avoid the small chance that they develop a leg-length-discrepancy or angular deformity of that leg as he or she grows.

Risk of delaying ACL surgery in kids

I think that fewer surgeons are pushing young patients to wait several years and stop playing sports now, though. There have been several papers recently presented or published that showed a much higher incidence of secondary damage to the menisci and articular cartilage in as little as one year from nonoperative treatment of ACL tears in skeletally immature athletes. It is hard to know if it is related to the activity levels of these kids and how hard it is to hold them back.

But the problem with that secondary damage to the meniscus and articular cartilage, if it occurs, is that those changes potentially cause irreparable damage. I saw one of the leaders in pediatric ACL surgeries in the US speak at a meeting, and he said (paraphrasing), “Even if a leg-length-discrepancy or angular deformity occurs, we have treatments to fix that. Some articular cartilage damage and meniscal tears can lead to arthritis changes that we might never be able to fix.”

And if a meniscus tear already exists, there are two other problems. One, the young athlete will often have too much pain from it to avoid surgery. Second, young kids often have meniscus tears that can be repaired as opposed to trimmed out. In theory, if they keep pounding on it with activity, they risk propagating the meniscus tear and prevent it from being repairable.

Is ACL surgery for a child safe?
A hamstring tendon has been used to reconstruct the ACL in this patient (runs from upper right to lower left).

Technique for ACL reconstruction in children

As for ACL surgery for a child and the specific technique, there is a lot of debate about whether we should perform a nonanatomic reconstruction, where we put the graft or reroute a structure in ways that don’t cross the growth plates but are also not where the ligament normally is, or an anatomic one, where we drill through the growth plates. My preference is to do an anatomic procedure where I carefully drill small holes but use fluoroscopic imaging to try to minimize damage to the growth plates and place a hamstring graft. I prefer the knee stability that this technique provides. But again, there is much debate about the specifics of the techniques.

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