Anterior cruciate ligament reconstruction in the skeletally immature

Abstract

Purpose of review: The number of midsubstance anterior cruciate ligament injuries in the skeletally immature is increasing. Most injuries occur in children and adolescents who are participating in high-energy sports. Consequently, there is an increased desire for a rapid return to a high activity level. This has placed increased pressure on the orthopaedic surgeon to treat this injury surgically. Recent findings: The literature has been focused using our understanding of the anatomy and physiology of the skeletally immature, to improve surgical treatment options. Optimal surgical techniques minimize injury to the physes, yet provide isometric, anatomic reconstruction of the anterior cruciate ligament. Tunnels should be placed at the anatomic anterior cruciate ligament insertion sites, and should either avoid the physes, or, if transphyseal, be kept to a minimum diameter. Care should be taken so that no bone graft or fixation devices cross the growth plate, and the graft should have good fill of the tunnel. Summary: Orthopaedic surgeons are taking a more aggressive approach to anterior cruciate ligament injuries in this population as our understanding of injuries and patients improves. The literature supports physeal sparing and transphyseal, anatomic reconstructions of the anterior cruciate ligament in this group. Further research needs to be completed in order to have a clear treatment algorithm for each skeletal maturity level.