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Anterior Cruciate Ligament Injuries in Children With Open Physes

Evolving Strategies of Treatment

Chris P. Bales, MD^*, Joseph H. Guettler, MD^*, and Claude T. Moorman, III, MD

From ^* William Beaumont Hospital, Royal Oak, Michigan, and Duke University Medical Center, Durham, North Carolina

Address correspondence to Joseph H. Guettler, MD, Performance Orthopaedics, 24255 Thirteen Mile Road, Suite 100, Bingham Farms, MI 48025 (e-mail: jguettlermd{at}wideopenwest.com).

Injury to the anterior cruciate ligament is one of the most common sports-related injuries of the knee. Before the 1980s, the incidence of this injury in skeletally immature patients was thought to be rare. However, with the increasing participation of children in sports-related activities and an increased awareness and diagnostic capability of the medical community, midsubstance tears of the anterior cruciate ligament have become more common in patients with open physes. Significant controversy exists regarding management of anterior cruciate ligament injuries in children with open physes. Traditional management has been nonoperative, consisting of physical therapy, bracing, and activity modification. Surgical reconstruction has generally been postponed until the patient is nearing, or has reached, skeletal maturity. In contrast to this traditional treatment algorithm, the recent literature uniformly indicates that nonoperative management of anterior cruciate ligament tears in children results in less than optimal results. Compliance is certainly an issue, and even though patients may refrain from organized sports activities, they are still going to be "kids." Recurrent instability, pain, and an inability to return to the preinjury level of athletics often result. Even more worrisome are the risks of secondary meniscal tears and the possibility of early degenerative joint disease. Recently, there has been an increased interest in early, aggressive operative management to restore stability to the immature knee. Proponents of nonoperative treatment point to the risk of growth arrest associated with violation of the physis. Proponents of early operative stabilization advocate that restoration of stability provides for opportunity to return to full activity and provides good long-term outcomes, all with minimal risk to the physis. This article reviews both the basic science and clinical research on this controversial topic.

Key Words: anterior cruciate ligament (ACL) • injury • reconstruction • open physis • adolescent