Anterior Cruciate Ligament (ACL) injury | Treatments

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If your child has been diagnosed with an ACL tear, you may have many questions and concerns. You may want to locate a pediatric orthopedic surgeon with expertise caring for growing patients. You may want to ensure that your child’s caregiver works with a team that can guide your child toward a safe return to play. You may want to be certain that your child takes steps to prevent future ACL injuries. Whatever your question or concern, we can answer it and provide the best care available for your child.

How are ACL tears treated?

Complete tears do not heal on their own. Usually, surgery is indicated for ACL tears. Surgical options for youth, teens and young adults vary by the patient’s age and musculoskeletal maturity.

What are the surgical options for ACL repair?

Almost all children, teens and young adults are good candidates for ACL reconstruction surgery. In the past, orthopedic surgeons and sports medicine physicians did not routinely recommend surgery for children and young teens with torn ACLs. That's because the conventional surgical approach required the surgeon to drill tunnels through the grown plate. (The growth plate, or physis, is the area at the end of the bone that produces new bone tissue and is responsible for bone growth).

This type of ACL surgery can damage the growth plate and interfere with the patient’s future growth. The standard recommendation was to wait until after puberty to complete the surgery. The problem with this approach is that a child with a torn ACL risks further injury to the knee with even everyday activity.

In 1977, Lyle Micheli, MD,director of the Sports Medicine Division, devised a surgery to replace the ACL of a three-year-old child born without the ligament. He avoided the growth plate by transferring the patient’s iliotibial band (the ligament running from the hip to the shin) around and into the knee. This operation has been subsequently used in younger children with ACL tears, with excellent long-term success and no growth disturbances.

Subsequent studies led by Micheli and Mininder Kocher, MD, MPH, associate director of the Sports Medicine Division, have documented the success of this surgery and other procedures developed to manage the risk of growth plate injury in children and adolescents.

Today, Boston Children's orthopedic surgeons can determine the best surgical option for each young patient with a torn ACL based on her physical examination, imaging studies and a determination of her relative state of maturation by doing bone-age measurements.

What is physeal-sparing surgery? What is Boston Children’s experience with this procedure?

Physeal-sparing surgical techniques are customized to the growing child’s age: pre-pubescent, adolescent or older adolescent. Physeal-sparing surgery eliminates the need to drill tunnels across the growth plate and avoids disturbing the growth plate in younger patients. 

Boston Children’s orthopedic surgeons have completed more than 300 physeal-sparing reconstruction surgeries, with 95 percent of children returning to sports and no reported cases of growth plate disturbance. The risk of re-tearing the graft is about 4 percent. This surgery is the preferred approach for pre-pubescent patients up to about 13 years old.

What is transphyseal reconstruction? What is Boston Children’s experience with this procedure?

Transphyseal reconstruction is closer to a traditional adult ACL surgery, but keeps the primary fixation away from the growth plate.

Boston Children’s orthopedic surgeons have completed more than 1,000 transphyseal reconstruction surgeries on pubescent patients, with 93 percent of athletes returning to sports, and no cases of growth plate disturbance. The risk of re-tearing the graft ranges from 5–7 percent. This is the preferred approach for teenagers between the ages of about 13 to 16 or 17.

What is ACL reconstruction?

Young adult patients who have finished growing, typically ages 15 to 16 for females and 16 to 17 for males, are candidates for ACL reconstruction. In this procedure, the orthopedic surgeon takes a graft from the patient’s hamstring or patella tendon, removes the end of the torn ACL and drills tunnels through the growth plate to attach the reconstructed ACL.

What is bridge-enhanced (TM) ACL repair (BEAR)?

Bridge-enhanced™ ACL repair (BEAR™) uses stitches and a bridging scaffold (a sponge injected with the patient’s blood) to stimulate healing of a torn ACL. For over 20 years, this tissue engineered scaffold has been studied and researched at Boston Children's Hospital, and its use in patients is currently regulated closely by the FDA. The bridge-enhanced ACL repair procedure is performed exclusively at Boston Children's Hospital. There are no other clinics or hospitals that have this device or can truthfully offer this technique to patients.

A 10-patient safety study concluded in 2015, and the BEAR II trial is currently underway.

Is there a way to prevent ACL injuries?

Despite relative success of surgeries to repair the torn ACL, it is clear that it is equally important to devise strategies to prevent this serious injury.

In 2013, Boston Children’s Sports Medicine Division opened The Micheli Center for Sports Injury Prevention at its Waltham location. Each child receives a comprehensive assessment to determine her risk factors for injury, including ACL injury. These assessments are child- and sport-specific. The child and family are provided recommendations to help prevent injury in sports training and competition.

Are there emotional considerations with an ACL injury?

An ACL tear can have a major emotional impact on an athlete and her family. Most ACL patients are athletes, and their identity and peer group are tied to their sport and teammates. We recommend athletes with an ACL injury remain involved with the team and connect with peers who have had an ACL injury. If a patient seems to have a hard time coping, we suggest talking about it with parents, friends, coaches, teachers or a doctor. Our sports psychology team also can help athletes cope with the stress of an injury, as well as fears about re-injury.

What questions should parents and patients ask their surgeon?

•   How many ACL reconstruction procedures have you performed on teens and children?
•   What is your success rate?
•   What is your return-to-sports rate?
•   What is your re-tear rate?

Dr. Mininder Kocher on ACL injury

Boston Children’s is so much more than a hospital—it’s a community of researchers, clinicians, administrators, support staff, innovators, teachers, patients and families, all working together to make the impossible possible. ”
- Sandra L. Fenwick, President and CEO

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