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CURRENT CONCEPTS

ACL Tears in Athletes with Many surgical treatment options have been introduced,

Open Physes
including primary repair and reconstruction, using both extra-
articular as well as intraarticular procedures. Reports on

primary repair and extraarticular reconstruction procedures
have shown only little success at providing long-term

knee stability. On the other hand, intraarticular anatomical
reconstruction of the ACL may result to physeal injury and
Francesco Giron, MD, PhD
lower extremity deformities. Others suggest that surgical
SOD Traumatologia e Ortopedia
correction with the use of techniques similar to those used
Generale, Azienda Ospedaliera in adult reconstruction produces satisfactory mechanical
Universitaria Careggi, Firenze, ITALY
results without physeal damage, varus or valgus angulation
or leg-length discrepancy.

In this article we will discuss the various aspects of this

pathology, reviewing the most recent literature, in order to
Traditionally, intrasubstance tears of the anterior cruciate attempt to give some useful guidelines for surgeons involved
ligament (ACL) were once thought to be rare among
pediatric patients. This belief was motivated by the fact that in the management of this often difficult group of patients.

midsubstance tears were assumed to occur only in adults, From an anatomical point of view, the ACL develops in utero,
and the tibial eminence fracture was considered to be the appearing at twenty-four weeks of gestation as a confluence

pediatric equivalent of the ACL tear in adults. However in of collagen ligament fibers that blend with the periosteum.
the past twenty years, complete ruptures of the ACL in It comprises two functional and anatomic bundles, the
anteromedial and posterolateral bundles. The anteromedial
adolescent patients have been rising in prevalence because
of increased participation and higher levels of competition bundle originates on the femur at the transition between
the intercondylar line and the cartilage margin, and it inserts
among young athletes especially in sports that involve
cutting, pivoting, twisting and collision such as soccer, along the medial aspect of the intercondylar eminence.
basketball, volleyball and football.
The posterolateral bundle originates at the anteroinferior

aspect of the femoral ACL origin, and it inserts just lateral
Nowadays a midsubstance tear of the anterior cruciate to the central aspect of the intercondylar eminence. The
ligament in children is no longer considered a rare injury. In
a recent study of high school athletes, female soccer players sizes of the anteromedial and posterolateral bundles can
vary according to patient height, weight, and body mass
were found to have the highest rate of ACL injury, with an
incidence of 14.08 per 100,000 exposures; male football index (BMI). Additional considerations include the anatomy
of the tibial and femoral physes. The distal femoral physis
players had the second highest rate, with 13.87 injuries contributes 70% of the total femoral length and 37% of the
per 100,000 exposures. Stanitski et al. noted that 47% of
total limb length over the course of skeletal development, at
preadolescent and 65% of adolescent athletes presenting an average rate of 10 mm per year. The distance between
with an acute hemarthrosis of the knee were ultimately
the femoral physis and the femoral origin of the ACL remains
diagnosed with acute ACL rupture.
unchanged from gestation through skeletal maturity and

Management of ACL injuries in the skeletally immature averages approximately 3 mm. The proximal tibial physis
patient is still controversial. While in adults the traditional contributes approximately 55% of the total tibial length and

arthroscopically assisted ACL reconstruction with bony 25% of the total limb length over the course of skeletal
tunnels allows excellent results in terms of knee stability development, at a rate of 6.4 mm per year.
recovery, this technique was usually avoided in younger
When dealing with a knee injury in a child a proper physical
patients with significant growth remaining because drilling
across the growth plate carries a risk of future physeal evaluation, an accurate interview in the presence of the
parents, and maturity assessment are paramount in
malfunction and resultant growth disturbance and angular diagnosing an ACL tear. A focused history investigating on
deformity. Thus traditional care of the skeletally immature
chronicity, mechanism of injury, and symptoms is critical.
patient with an ACL tear has relied on bracing and activity Any event of swelling or effusion in the knee requires further
modification until the young athlete is close enough to
investigation. The presenting signs and symptoms of an ACL
skeletal maturity to undergo transphyseal reconstruction. tear in pediatric patients are similar to those experienced by
However, nonsurgical management gradually leads to
recurrent instability, resulting in secondary injuries to the adults. The athlete may experience a pop at the time of injury.
Initial examination of the patient should rule out concomitant
surrounding articular cartilage and menisci, and in early
degenerative changes of the joint.
musculoskeletal injuries. Examination of the knee should
includeinspection for acute hemarthrosis, which is helpful
in determining the severity of the injury. ACL injuries can be

present in up to 65% of adolescents presenting with acute
traumatic hemarthrosis.

20 ISAKOS NEWSLETTER 2014: Volume II