All Epiphyseal Reconstruction for Pediatric ACL Tears

Jan 17, 2022 at 05:34 pm by steve

Amit Momaya, MD

Kids love to run, jump, climb and dance. They love playing soccer, football, basketball, baseball and hockey. Unfortunately, when they twist or pivot the wrong way, they can tear the anterior cruciate ligament (ACL) in their knee.

Reconstruction in adults is a matter of drilling through the thigh bone and shin bone and connecting them with a graft. But what complicates the injury in children under 14 is that the growth plate is still open and the child is still growing. Attempting to reconstruct the ACL as we would in adults may cause lifelong problems, including a difference in leg length and failure for the child to reach his normal height.

In the past, it was common for surgeons to delay ACL repairs in children until the growth plate closed in order to avoid potential abnormalities in bone development. However, studies show that leaving a tear untreated puts the meniscus and other knee structures at risk of serious damage. So how can the knee be stabilized without future growth issues?

"All epiphyseal reconstruction is a relatively new approach that stabilizes the knee without the need for drilling through the growth plate," orthopedic surgeon, chief of sports medicine and UAB team physician Amit Momaya, MD, said.

Although the number of ACL tears in children has increased in recent decades, most physicians don't see enough pediatric cases to gain expertise in this technique. So young patients in Alabama who need ACL reconstruction are often referred to either UAB or Children's of Alabama.

This surgery can be done arthroscopically, which minimizes recovery time and scarring. It's a good option for children whose bones are large enough, typically age 10 and above. For smaller children, another physeal-sparing technique uses the iliotibial band.

"In the all epiphyseal procedure, the torn ligament is removed and an autograft is inserted to follow the natural anatomical placement of the ACL," Momaya said. "With this approach, we've seen good outcomes in improving joint stability and reducing stress when young athletes return to play."

ACL tears can be mistaken for sprains, and it isn't uncommon for patients to make multiple trips to a doctor before the diagnosis is found.

"We tend to see this type of injury in middle school children, especially those playing sports that involve sudden changes in direction and pivoting," Momaya said. "If a child is showing symptoms, it's important to not assume it's just a sprain. Knee injuries should be followed to be sure there isn't a tear that needs to be repaired. Due to differences in anatomy, girls are actually more likely to have an ACL tear than boys, but physicians tend to see more boys who have the injury because more boys participate in sports."

This reconstruction technique has a good track record for allowing young athletes to return to playing the sports they enjoy, but it's important to allow time for healing and strengthening the knee.

"It is vital to guarding against reinjury," Momaya said. "Training to strengthen the muscles around the knee, balance exercises, and flexibility are important. Training can also help athletes become more aware of how they move. This helps them learn to protect their knees by avoiding moves that put them at unnecessary risk."

In addition to the benefits the all epiphyseal approach offers now, when a child becomes an adult and she is playing with her own children, it may help her avoid pain and the need for an early knee replacement by preventing stress from over constraint that can happen with other types of surgery.

"It's good to see kids recover and be free from pain, enjoying the sports they love again," Momaya said.

Sections: Clinical

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