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, 6 (2), 132-40

Pediatric ACL Injuries: Evaluation and Management

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Pediatric ACL Injuries: Evaluation and Management

Nathan A Mall et al. Curr Rev Musculoskelet Med.

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.

Figures

Fig. 1
Fig. 1
AP and lateral radiographs of the right knee of a skeletally immature athlete. The AP may be difficult to assess the displacement of the tibial eminence fracture, whereas on the lateral radiograph the fracture is easily identified. (Adapted from [15], with permission.)
Fig. 2
Fig. 2
Subsequent sagittal images a-c and an axial image demonstrate what appears to be an intact or partially torn ACL. At arthroscopy this patient was noted to have had a complete ACL tear. (Adapted from [18], with permission.)
Fig. 3
Fig. 3
a–e The all-epiphyseal ACL reconstruction technique is shown. a A guidewire is placed in the distal femoral epiphysis parallel to the physis to the center of the femoral attachment point of the ACL. A Retrograde drill (Arthrex, Naples FL) is used in the tibia to create a tunnel in the tibial epiphysis. Proper placement can be confirmed with an intraoperative CT scan. b The femoral tunnel is drilled. A passing suture is placed up the cannulated guide pin of the Retrodrill and retrieved out the femoral tunnel. c The passing suture is used to bring a Nitinol wire and the lead sutures of the graft through the knee. The femoral end of the Nitinol wire then is retrieved out the medial portal. d The lead sutures on the graft are used to pull the graft through the femoral tunnel and into the tibial tunnel. e The Nitinol wire then is used to aid in placement of the tibial Retroscrew. The knee is brought into extension and the graft tensioned and secured in the femur with an interference screw. (Adapted from [59], with permission.)
Fig. 4
Fig. 4
a AP and b lateral radiographs of a skeletally immature patient treated with the transphyseal technique for ACL reconstruction
Fig. 5
Fig. 5
a The ACL attached to the proximally displaced fracture fragment. b Two sutures through the ACL that will be used for reduction of the displaced eminence fragment. c A similar view with the sutures pulled tight and the eminence piece reduced. (Adapted from [15], with permission.)

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