Management of ACL intra-substance tears in growing children and teenagers
Background: The incidence of anterior cruciate ligament (ACL) tears in pediatric and adolescent populations has increased significantly, rising approximately 2.3% annually. Management remains controversial due to the competing risks of secondary meniscal or chondral degeneration from knee instability versus potential growth disturbances following surgical reconstruction in skeletally immature patients.
Objective: This article aims to define the clinical indications for surgical intervention and clarify the contemporary role of conservative management in growing children with ACL injuries.
Key Points: Initial assessment requires differentiating physiological joint laxity from symptomatic instability and utilizing MRI to identify concomitant meniscal pathology, despite lower diagnostic specificity in younger children. Conservative management, involving a three-phase neuromuscular rehabilitation protocol, may be appropriate for patients under 12 years (Tanner stage 1) who exhibit perfect stability and no associated lesions. However, longitudinal data indicate that up to 57% of non-operative patients eventually require reconstruction due to secondary instability or meniscal tears. Surgical techniques, categorized as all-epiphyseal or transphyseal, must prioritize tendon grafts, small-diameter tunnels, and physeal-sparing fixation. While reconstruction facilitates a high rate of return to sport (approximately 80–93%), complications include a 4–8.7% risk of growth disturbances and high rates of graft rupture or contralateral injury.
Conclusion: Pediatric ACL management requires individualized strategies based on skeletal maturity and clinical stability. While conservative protocols are viable for select stable patients, surgical reconstruction is indicated for persistent instability or associated meniscal tears to prevent long-term degenerative changes. Combined anterolateral procedures and delayed return to sport may mitigate high graft failure rates.
