With more kids playing competitive sports in grade school and more kids playing games year-round, anterior cruciate ligament (ACL) tears in skeletally immature adolescents are on the rise. Most ACL tears occur during games, and female soccer players have the highest risk. “Kids are exposed to potential for injury at a much higher level than ever before,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.
No Growth Plate Disturbances
Dr. Shelbourne has been studying ACL tears in skeletally immature adolescents for more than 25 years. He and colleagues have successfully reconstructed ACLs on about 300 adolescents at Tanner stage 3 or 4 of physical development with clearly open growth plates. None of these patients have had growth plate disturbances. “The chance of anything happening is tremendously over-stated,” says Dr. Shelbourne.
One study included 272 skeletally immature adolescents who had ACL reconstruction with a patellar tendon graft at Shelbourne Knee Center between 1987 and 2000. The intention was to perform surgery on adolescents at Tanner stage 4, however, determining the stage requires some guesswork. Clinical follow-up at a mean of 3.4 years after surgery showed that 7 patients had been at Tanner stage 3 at the time of surgery.
For both Tanner stage 3 and 4 patients (16 total) with clearly open growth plates:
- No patients had growth plate disturbances, gross leg deformities or gross leg-length discrepancies.
Subjective results at a mean of 5.6 years after surgery showed:
- Modified Noyes survey: Mean score of 97.6 ± 2.9
- International Knee Documentation Committee survey: Mean score of 95.4 ± 6.9.
All patients returned to competitive sports after surgery. Study results were published in the American Journal of Sports Medicine.1
“We realized inadvertently that it was safe to do surgery on adolescents at Tanner stage 3,” says Dr. Shelbourne. The mean age at the time of ACL reconstruction was 14.8 ± 0.68 years (14.8 ± 0.56 years for boys and 14.7 ± 0.96 years for girls). This was the first study of the use of patellar tendon grafts in skeletally immature adolescents who have clearly open growth plates and are Tanner stage 3 or 4.
25+ Years of Experience With Adolescent ACLs
Skeletally immature adolescents with ACL tears are typically referred to pediatric orthopedic specialists. “They are not knee specialists. These patients should see a knee specialist with experience taking care of kids with open growth plates,” says Dr. Shelbourne. In an attempt to spare the growth plates, pediatric orthopedic specialists often try to avoid drilling a hole in the growth plates or use hamstring grafts. These surgical techniques hinder recovery and return to sports.
The patellar tendon graft (PTG) used at Shelbourne Knee Center is the gold standard for ACL reconstruction, including in skeletally immature adolescents. “Bone–patellar tendon–bone grafts are best for young athletes,” says Dr. Shelbourne. “Hamstring tendons aren’t as strong and don’t heal as well as bone–patellar tendon–bone grafts do. That’s an even bigger problem in adolescents with open growth plates who have many years of competition ahead of them.” Meticulous surgical technique for placing the bone plugs proximal to the growth plates and not over-tensioning the graft also help ensure optimal outcomes in skeletally immature adolescents.
Treatment for Younger Kids With ACL Tears
Ninety-eight percent of ACL tears occur in kids who are Tanner stage 3 and 4 and appropriate candidates for surgery, says Dr. Shelbourne. When an ACL tear does occur in a younger child at Tanner stage 1 or 2, “it’s better to wait for them to be Tanner 3 and then do surgery,” he says. “We discourage competitive basketball and soccer until they are ready for surgery, but there are lots of other sports they can play, like track, swimming, tennis and golf.”
For more information about how Shelbourne Knee Center treats ACL injuries in skeletally immature adolescents, call 888-FIX-KNEE.
Reference
- 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 Jul-Aug;32(5):1218-22. Epub 2004 May 18.