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Current Reviews in Musculoskeletal Medicine

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01-06-2013 | Knee (SL Sherman, Section editor)

Pediatric ACL injuries: evaluation and management

Authors: Nathan A. Mall, George A. Paletta

Published in: Current Reviews in Musculoskeletal Medicine | Issue 2/2013

Abstract

The anterior cruciate ligament (ACL) is a stabilizing structure to both anterior translation of the tibia with respect to the femur as well as rotation of the knee joint. Children and adolescents are susceptible to these injuries, and there are some who believe the incidence of ACL injuries in this population is increasing due to year round single sport participation. Pediatric ACL injuries are typically seen in several forms: tibial avulsion fractures, partial ACL tears, and full thickness ligament tears. There were and still are some who feel that ACL injuries should be treated non-operatively in the pediatric and adolescent population; however, recent literature refutes this notion. Several factors must be considered during pediatric and adolescent ACL reconstruction, each of which will be examined in this manuscript, including: status of the physis, reconstruction technique, and graft source.

Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med. 2009;37:1434–43.PubMedCrossRef

Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35:1756–69.PubMedCrossRef

Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 2003;85-A:1255–63.PubMed

Kocher MS, Saxon HS, Hovis WD, Hawkins RJ. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and the ACL Study Group. J Pediatr Orthop. 2002;22:452–7.PubMed

Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates. J Bone Joint Surg Am. 1974;56:236–53.PubMed

Noyes FR, Torvik PJ, Hyde WB, DeLucas JL. Biomechanics of ligament failure. II. An analysis of immobilization, exercise, and reconditioning effects in primates. J Bone Joint Surg Am. 1974;56:1406–18.PubMed

Koman JD, Sanders JO. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am. 1999;81:711–5.PubMed

Mohtadi N, Grant J. Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature. Clin J Sport Med. 2006;16:457–64.PubMedCrossRef

Woods GW, O'Connor DP. Delayed anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2004;32:201–10.PubMedCrossRef

10.

Tjoumakaris FP, Donegan DJ, Sekiya JK. Partial tears of the anterior cruciate ligament: diagnosis and treatment. Am J Orthop. 2011;40:92–7.PubMed

11.

Perugia D, Basiglini L, Vadalà A, Ferretti A. Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood. Int Orthop. 2009;33:243–8.PubMedCrossRef

12.

Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med. 2003;31:404–7.PubMed

13.

Tudisco C, Giovarruscio R, Febo A, Savarese E, Bisicchia S. Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth. J Pediatr Orthop B. 2010;19:403–8.PubMedCrossRef

14.

Bach BR, Warren RF, Wickiewicz TL. The pivot shift phenomenon: results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med. 1988;16:571–6.PubMedCrossRef

15.

Hirschmann MT, Mayer RR, Kentsch A, Friederich NF. Physeal sparing arthroscopic fixation of displaced tibial eminence fractures: a new surgical technique. Knee Surg Sports Traumatol Arthrosc. 2009;17:741–7.PubMedCrossRef

16.

Umans H, Wimpfheimer O, Haramati N, Applbaum YH, Adler M, Bosco J. Diagnosis of partial tears of the anterior cruciate ligament of the knee: value of MR imaging. Am J Roentgenol. 1995;165:893–7.CrossRef

17.

Lawrance JA, Ostlere SJ, Dodd CA. MRI diagnosis of partial tears of the anterior cruciate ligament. Injury. 1996;27:153–5.PubMedCrossRef

18.

Van Dyck P, Vanhoenacker FM, Gielen JL, Dossche L, Gestel JV, Wouters K, et al. Three tesla magnetic resonance imaging of the anterior cruciate ligament of the knee: can we differentiate complete from partial tears. Skeletal Radiol. 2011;40:701–7.

19.

Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62:687–95. 757.PubMed

20.

Guenoun D, Le Corroller T, Amous Z, Pauly V, Sbihi A, Champsaur P. The contribution of MRI to the diagnosis of traumatic tears of the anterior cruciate ligament. Diagn Interv Imaging. 2012;93:331–41.PubMedCrossRef

21.

Moore SL. Imaging the anterior cruciate ligament. Orthop Clin N Am. 2002;33:663–74.CrossRef

22.

Bak K, Scavenius M, Hansen S, Nørring K, Jensen KH, Jørgensen U. Isolated partial rupture of the anterior cruciate ligament. Long-term follow-up of 56 cases. Knee Surg Sports Traumatol Arthrosc. 1997;5:66–71.PubMedCrossRef

23.

Barrack RL, Buckley SL, Bruckner JD, Kneisl JS, Alexander AH. Partial vs complete acute anterior cruciate ligament tears. The results of nonoperative treatment. J Bone Joint Surg Br. 1990;72:622–4.PubMed

24.

Fritschy D, Panoussopoulos A, Wallensten R, Peter R. Can we predict the outcome of a partial rupture of the anterior cruciate ligament? A prospective study of 43 cases. Knee Surg Sports Traumatol Arthrosc. 1997;5:2–5.PubMedCrossRef

25.

Noyes FR, Mooar LA, Moorman CT, McGinniss GH. Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Joint Surg Br. 1989;71:825–33.PubMed

26.

Hole RL, Lintner DM, Kamaric E, Moseley JB. Increased tibial translation after partial sectioning of the anterior cruciate ligament. The posterolateral bundle. Am J Sports Med. 1996;24:556–60.PubMedCrossRef

27.

Zionts L. Fractures and dislocations about the knee. In: Green NE, Swiontkowski MR, editors. Skeletal trauma in children. Philadelphia: WB Saunders; 2009. p. 452–5.

28.

Skak SV, Jensen TT, Poulsen TD, Stürup J. Epidemiology of knee injuries in children. Acta Orthop Scand. 1987;58:78–81.PubMedCrossRef

29.

Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1959;41-A:209–20. discussion 220–2.PubMed

30.

Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am. 1977;59:1111–4.PubMed

31.

Griffith JF, Antonio GE, Tong CWC, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy. 2004;20:803–12.PubMed

32.

McCarroll JR, Rettig AC, Shelbourne KD. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988;16:44–7.PubMedCrossRef

33.

Buckley SL, Barrack RL, Alexander AH. The natural history of conservatively treated partial anterior cruciate ligament tears. Am J Sports Med. 1989;17:221–5.PubMedCrossRef

34.

Mizuta H, Kubota K, Shiraishi M, Otsuka Y, Nagamoto N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995;77:890–4.PubMed

35.

Vavken P, Fleming BC, Mastrangelo AN, Machan JT, Murray MM. Biomechanical outcomes after bioenhanced anterior cruciate ligament repair and anterior cruciate ligament reconstruction are equal in a porcine model. Arthroscopy. 2012;28:672–80.PubMedCrossRef

36.

Janarv PM, Nyström A, Werner S, Hirsch G. Anterior cruciate ligament injuries in skeletally immature patients. J Pediatr Orthop. 1996;16:673–7.PubMedCrossRef

37.

Aronowitz ER, Ganley TJ, Goode JR, Gregg JR, Meyer JS. Anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2000;28:168–75.PubMed

38.

Kaeding CC, Flanigan D, Donaldson C. Surgical techniques and outcomes after anterior cruciate ligament reconstruction in preadolescent patients. Arthroscopy. 2010;26:1530–8.PubMedCrossRef

39.

Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003–10.

40.

Swirtun LR, Jansson A, Renström P. The effects of a functional knee brace during early treatment of patients with a nonoperated acute anterior cruciate ligament tear: a prospective randomized study. Clin J Sport Med. 2005;15:299–304.PubMedCrossRef

41.

McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop. 1995;15:59–62.PubMedCrossRef

42.

Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1970;52:1677–84.PubMed

43.

Willis RB, Blokker C, Stoll TM, Paterson DC, Galpin RD. Long-term follow-up of anterior tibial eminence fractures. J Pediatr Orthop. 1993;13:361–4.PubMedCrossRef

44.

Beaty JH, Kumar A. Fractures about the knee in children. J Bone Joint Surg Am. 1994;76:1870–80.PubMed

45.

Gabriel MT, Wong EK, Woo SL-Y, Yagi M, Debski RE. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res. 2004;22:85–9.PubMedCrossRef

46.

Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19:332–6.PubMedCrossRef

47.

Cipolla M, Scala A, Gianni E, Puddu G. Different patterns of meniscal tears in acute anterior cruciate ligament (ACL) ruptures and in chronic ACL-deficient knees. Classification, staging, and timing of treatment. Knee Surg Sports Traumatol Arthrosc. 1995;3:130–4.PubMedCrossRef

48.

•• Lawrence JTR, Argawal N, Ganley TJ. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Am J Sports Med. 2011;39:2582–7. Surgical reconstruction of an acute ACL tear >12 weeks after the injury had greater irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction.PubMedCrossRef

49.

DeFranco MJ, Bach BR. A comprehensive review of partial anterior cruciate ligament tears. J Bone Joint Surg Am. 2009;91:198–208.PubMedCrossRef

50.

Buda R, Ferruzzi A, Vannini F, Zambelli L, Di Caprio F. Augmentation technique with semitendinosus and gracilis tendons in chronic partial lesions of the ACL: clinical and arthrometric analysis. Knee Surg Sports Traumatol Arthrosc. 2006;14:1101–7.PubMedCrossRef

51.

Busch MT, Fernandez MD, Aarons C. Partial tears of the anterior cruciate ligament in children and adolescents. Clin Sports Med. 2011;30:743–50.PubMedCrossRef

52.

Tanner JM, Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child. 1976;51:170–9.PubMedCrossRef

53.

Risser JC. The Iliac apophysis; an invaluable sign in the management of scoliosis. Clin Orthop. 1958;11:111–9.PubMed

54.

Scoles PV, Salvagno R, Villalba K, Riew D. Relationship of iliac crest maturation to skeletal and chronologic age. J Pediatr Orthop. 1988;8:639–44.PubMedCrossRef

55.

Gruelich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. Stanford: Stanford University Press; 1959.

56.

•• Hui C, Roe J, Ferguson D, Waller A, Salmon L, Pinczewski L. Outcome of anatomic transphyseal anterior cruciate ligament reconstruction in Tanner stage 1 and 2 patients with open physes. Am J Sports Med. 2012;40:1093–8. This study demonstrated that transphyseal anatomic single-bundle ACL reconstruction could be performed even in the youngest patients (Tanner stage 1 and 2 patients) and at a minimum of 2 years after surgery no growth disturbances were seen.PubMedCrossRef

57.

Milewski MD, Beck NA, Lawrence JT, Ganley TJ. Anterior cruciate ligament reconstruction in the young athlete: a treatment algorithm for the skeletally immature. Clin Sports Med. 2011;30:801–10.PubMedCrossRef

58.

Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87:2371–9.PubMedCrossRef

59.

Lawrence JTR, Bowers AL, Belding J, Cody SR, Ganley TJ. All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients. Clin Orthop Relat Res. 2010;468:1971–7.PubMedCrossRef

60.

•• 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;25:1415–22. This study indicates that only a small proportion of the growth plate is violated following transphyseal reconstruction.PubMedCrossRef

61.

Lertwanich P, Kato Y, Martins CAQ, Maeyama A, Ingham SJM, Kramer S, et al. A biomechanical comparison of 2 femoral fixation techniques for anterior cruciate ligament reconstruction in skeletally immature patients: over-the-top fixation vs transphyseal technique. Arthroscopy. 2011;27:672–80.

62.

Kennedy A, Coughlin DG, Metzger MF, Tang R, Pearle AD, Lotz JC, et al. Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques. Am J Sports Med. 2011;39:964–71.

63.

Courvoisier A, Grimaldi M, Plaweski S. Good surgical outcome of transphyseal ACL reconstruction in skeletally immature patients using 4-strand hamstring graft. Knee Surg Sports Traumatol Arthrosc. 2011;19:588–91.PubMedCrossRef

64.

Gebhard F, Ellermann A, Hoffmann F, Jaeger J-H, Friederich NF. Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of 4 different techniques. Knee Surg Sports Traumatol Arthrosc. 2006;14:797–803.PubMedCrossRef

65.

Paletta GA. Comparison of trans-physeal vs over-the-top reconstruction: Is there a difference? Big Sky, MT; 2005.

66.

Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate ligament reconstruction in skeletally immature patients with transphyseal tunnels. Arthroscopy. 2012.

67.

Kocher MS, Smith JT, Zoric BJ, Lee B, Micheli LJ. Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007;89:2632–9.PubMedCrossRef

68.

Guzzanti V, Falciglia F, Gigante A, Fabbriciani C. The effect of intra-articular ACL reconstruction on the growth plates of rabbits. J Bone Joint Surg Br. 1994;76:960–3.PubMed

69.

Matava MJ, Siegel MG. Arthroscopic reconstruction of the ACL with semitendinosus-gracilis autograft in skeletally immature adolescent patients. Am J Knee Surg. 1997;10:60–9.PubMed

70.

Stadelmaier DM, Arnoczky SP, Dodds J, Ross H. The effect of drilling and soft tissue grafting across open growth plates. A histologic study. Am J Sports Med. 1995;23:431–5.PubMedCrossRef

71.

Bonnard C, Fournier J, Babusiaux D, Planchenault M, Bergerault F, de Courtivron B. Physeal-sparing reconstruction of anterior cruciate ligament tears in children: results of 57 cases using patellar tendon. J Bone Joint Surg Br. 2011;93:542–7.PubMedCrossRef

72.

Shelbourne KD, Gray T, Wiley BV. Results of transphyseal anterior cruciate ligament reconstruction using patellar tendon autograft in tanner stage 3 or 4 adolescents with clearly open growth plates. Am J Sports Med. 2004;32:1218–22.PubMedCrossRef

73.

Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON Prospective Longitudinal Cohort. Sports Health Multidiscip Approach. 2011;3:73–81.

74.

Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: a review of 35 patients. J Bone Joint Surg Br. 1981;63-B:89–91.PubMed

75.

Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br. 1992;74:848–52.PubMed

76.

Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Relat Res. 1990;255:54–60.PubMed

77.

Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy. 2005;21:86–92.PubMedCrossRef

78.

Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: failure of arthroscopic treatment. Arthroscopy. 1993;9:446–50.PubMedCrossRef

79.

Medler RG, Jansson KA. Arthroscopic treatment of fractures of the tibial spine. Arthroscopy. 1994;10:292–5.PubMedCrossRef

80.

Kim Y-M, Kim S-J, Yang J-Y, Kim K-C. Pullout reattachment of tibial avulsion fractures of the anterior cruciate ligament: a firm, effective suture-tying method using a tensioner. Knee Surg Sports Traumatol Arthrosc. 2007;15:847–50.PubMedCrossRef

81.

Delcogliano A, Chiossi S, Caporaso A, Menghi A, Rinonapoli G. Tibial intercondylar eminence fractures in adults: arthroscopic treatment. Knee Surg Sports Traumatol Arthrosc. 2003;11:255–9.PubMedCrossRef

82.

Ahmad CS, Stein BE, Jeshuran W, Nercessian OA, Henry JH. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med. 2001;29:339–45.PubMed

83.

Binnet MS, Gürkan I, Yilmaz C, Karakas A, Cetin C. Arthroscopic fixation of intercondylar eminence fractures using a 4-portal technique. Arthroscopy. 2001;17:450–60.PubMedCrossRef

84.

Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: 5-year results. Arthroscopy. 2003;19:54–61.PubMed

85.

Doral MN, Atay OA, Leblebicioğlu G, Tetik O. Arthroscopic fixation of the fractures of the intercondylar eminence via transquadricipital tendinous portal. Knee Surg Sports Traumatol Arthrosc. 2001;9:346–9.PubMedCrossRef

86.

Liljeros K, Werner S, Janarv P-M. Arthroscopic fixation of anterior tibial spine fractures with bioabsorbable nails in skeletally immature patients. Am J Sports Med. 2009;37:923–8.PubMedCrossRef

87.

Vega JR, Irribarra LA, Baar AK, Iñiguez M, Salgado M, Gana N. Arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method. Arthroscopy. 2008;24:1239–43.PubMedCrossRef

88.

Louis M-L, Guillaume J-M, Launay F, Toth C, Jouvre J-L, Bollini G. Surgical management of type II tibial intercondylar eminence fractures in children. J Pediatr Orthop B. 2008;17:231–5.PubMedCrossRef

89.

Mahar AT, Duncan D, Oka R, Lowry A, Gillingham B, Chambers H. Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures. J Pediatr Orthop. 2008;28:159–62.PubMedCrossRef

90.

Eggers AK, Becker C, Weimann A, Herbort M, Zantop T, Raschke MJ, et al. Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med. 2007;35:404–10.

91.

Bong MR, Romero A, Kubiak E, Iesaka K, Heywood CS, Kummer F, et al. Suture vs screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy. 2005;21:1172–6.

Title: Pediatric ACL injuries: evaluation and management
Authors: Nathan A. Mall
George A. Paletta
Publication date: 01-06-2013
Publisher: Current Science Inc.
Published in: Current Reviews in Musculoskeletal Medicine / Issue 2/2013
Electronic ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-013-9169-8

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Pediatric ACL injuries: evaluation and management

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