Review Question - QID 211865

The patient is presenting with a right anterior cruciate ligament (ACL) tear with open physes and a limited range of motion. Physical therapy would be the most appropriate treatment option at this time to restore range of motion prior to final decision making on reconstruction.

ACL tears in pediatric patients can be treatment dilemmas due to the risk of physeal closure with traditional graft and tunnel placement. Nonoperative treatment of these injuries has been associated with increased secondary meniscus tears, early degenerative changes, and decreased return to play. Surgical treatment involves reconstruction with physeal respecting techniques in patients with wide open physes, which may necessitate conventional reconstruction once the patient has reached skeletal maturity. Patients should undergo a course of physical therapy to obtain full range of motion of the knee prior to surgical intervention in order to avoid excess knee stiffness.

Beynnon et al. performed a randomized controlled trial of patients undergoing accelerated and nonaccelerated rehabilitation protocols following ACL reconstruction. They reported there to be significant quadriceps strength at 3 months post-op in the accelerated rehab group compared to the nonaccelerated group, but this difference diminished at 2 years follow-up. The authors concluded that there is no difference in outcomes at 2-years with regards to knee laxity, muscle strength, patients satisfaction, and proprioception following an accelerated or nonaccelerated rehab protocol.

Bales et al. reviewed the treatment of ACL injuries in pediatric patients with open physes. The authors cited studies that characterized the nonoperative treatment of ACL tears as suboptimal with frequent secondary meniscus tears, degenerative changes, and poor return to sport. The authors recommended surgical treatment with physeal respecting approaches, which included smaller tunnels (7-8 mm) and the use of soft tissue graft to avoid bone bridging.

Figure A is the AP radiograph of the right knee with open physes and no apparent fracture or dislocation. Figure B is the sagittal T1 MRI of the right knee with an ACL tear.

Incorrect answers:
Answer 1: Reconstruction of the ACL with bone-patellar tendon-bone autograft is associated with physeal bridging in pediatric patients, which can lead to a valgus deformity of the distal femur and a recurvatum deformity of the proximal tibia.
Answer 3: Use of quadrupled hamstring autograft in this patient may be appropriate as it avoids bone blocks across the physis, but should be done so after the full range of motion has been obtained.
Answer 4: Allograft reconstruction of the ACL has been associated with higher failure rates in younger patients and should be avoided in this patient population.
Answer 5: A physeal-sparing technique may be appropriate for this patient, but should be delayed until the patient is sufficiently rehabilitated with the full range of motion.