A new study has investigated a pioneering surgical approach for treating acute proximal Anterior Cruciate Ligament (ACL) tears in children. Traditionally, managing ACL injuries in a growing child presents unique challenges, primarily due to the risk of damaging the growth plates during traditional reconstruction. This research explores the safety and efficacy of an arthroscopic direct ACL repair, a technique that aims to restore the native ligament while preserving the crucial physeal anatomy.
The Problem with Paediatric ACL Tears
Paediatric ACL injuries have become increasingly common with the rise in children’s participation in competitive sports. Left untreated, a torn ACL can lead to chronic knee instability, increasing the risk of secondary injuries to the menisci and articular cartilage, and potentially leading to early-onset osteoarthritis. While reconstruction techniques have advanced, they often involve drilling through the growth plates, which carries a risk of growth disturbance or leg length discrepancies. The need for a safe and effective joint-preserving option has driven a renewed interest in ACL repair.
A Novel Repair Technique
The study focused on 20 patients under the age of 16 who had suffered acute proximal ACL ruptures. The surgical procedure involved a direct arthroscopic repair of the torn ligament, which was then augmented with a temporary internal brace. This brace, made from a non-absorbable braided tape, acts like an internal seatbelt, providing immediate stability and protecting the repair while the patient’s own tissue heals. This brace was then removed after three months, allowing the newly repaired ligament to function independently.
Excellent Short-Term Results
The outcomes of this approach were highly encouraging at the two-year follow-up. All patients showed significant improvements in knee function scores, including the Lysholm, Tegner, and KOOS scales. Crucially, the study reported no cases of failure, complications, or growth disturbances. Objective measurements with an accelerometer also confirmed that there was no significant difference in knee stability when compared to the uninjured leg. These findings highlight that direct ACL repair, particularly for proximal tears, is a safe and effective option that can provide excellent short-term outcomes and may represent an attractive alternative to traditional reconstruction methods.
Professor Wilson’s Comments
“I’m particularly proud of this paper. Of course, Gordon Mackay was the genius who first conceived the concept of direct ligament repair with internal bracing. At the time, we were running two projects with Arthrex in parallel — Gordon focusing on direct repair and myself exploring reinforcement using FibreTape to augment the strength of reconstructed ligaments. My approach became known as reinforcement internal brace reconstruction, whereas Gordon’s was direct repair with an internal brace.
What no one had done up until that point — and what I took on — was to apply the concept of ACL repair in the paediatric patient. This is, of course, the perfect indication: enabling a child to return from an ACL rupture to full sporting activity within four months. It’s an incredibly valuable approach for many reasons, not least because of the profound psychological impact of removing a young person from sport for a year following traditional reconstruction.
ACL repair in children is also less invasive and technically well-suited to the paediatric setting because of the excellent healing potential in this age group. Our paper was the first to demonstrate this application in children, and it paved the way for what is now considered the standard of care in appropriately selected cases.
One of the greatest concerns in paediatric ACL surgery has always been the risk of growth plate disturbance. Repair techniques, however, require only very small drill holes through the growth plate, thereby significantly reducing this risk. Early on, we encountered an issue when removing the internal brace too soon, at around three months post-op, which led us to extend the removal interval to six months — a timeline that has now been widely adopted.
Overall, I remain extremely proud of having helped pioneer this approach, which I believe continues to represent the gold standard for ACL repair in children where the ligament is repairable.”
For a comprehensive review of the detailed findings, methodology, and analysis, the full research paper is available for your perusal.
Sources used in report overview:
- https://pubmed.ncbi.nlm.nih.gov/32040677/
- https://kneepreservation.co.uk/acl-repair-in-children
- https://www.circlehealthgroup.co.uk/hospitals/ross-hall-hospital/acl-internal-brace-procedure
