Should Your Child Have ACL Surgery?

Attitudes are Changing for ACL Reconstruction for Children

ACL reconstruction surgery is the standard treatment for young, active people who sustain an ACL tear. But what happens when that person is a child? Should ACL surgery be delayed until the child is older, or should ACL reconstruction be performed before skeletal maturity?

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Surgery in Children May Be Delayed, but This Is Changing

The anterior cruciate ligament (ACL) is a ligament within the knee important for joint stability. Traditionally, when a child had an ACL injury, surgeons were reluctant to operate and reconstruct the ligament right away for fear of damaging the growth plate.

The concern was that before a child has reached skeletal maturity (about 12-13 years old in girls, and 14-15 years old in boys), this type of surgery presented a risk of injuring the growth plate. Growth plate problems resulting from ACL surgery could lead to unequal leg lengths or angular deformity.

However, recent research shows that the risk of growth plate problems is much less than the risk of permanent knee damage if the ACL is not fixed.

What Are Growth Plates?

The growth plates are a part of the bone that allow it to grow in length. Most bone growth occurs near the ends of long bones in these growth plates. Two of the most active growth plates in the body are just above and just below the knee joint. These growth plates contribute to the length of both the thigh bone (femur) and shin bone (tibia).

How Does ACL Surgery Affect the Growth Plate in Children?

Traditional ACL reconstructive surgery involves making a tunnel in the bone directly in the area of these growth plates. At the time of skeletal maturity, the growth plate closes. Once the growth plate is closed (or nearly closed), the risk of causing a growth disturbance is gone. However, by drilling a hole through an open growth plate, the body may close the growth plate early. This could lead to complete growth plate closure, causing leg length inequality, or partial growth plate closure, causing angular deformity.

Angular deformity could, in turn, lead to knock knees (genu valgus) and bow legs (genu varus), These conditions progressively worsen with further growth and could lead to increased risk of problems such as joint damage and arthritis.

Changing Attitude Toward ACL Tears and Reconstruction in Children

Knees that are unstable as a result of ACL tears have a high chance of meniscus tears and cartilage injury. Many surgeons have recommended that ACL surgery in children be delayed until the child has reached skeletal maturity. The hope is that, by delaying surgery, your child may avoid the potential complications of growth plate injury as a result of ACL surgery.

However, two factors have led to more surgeons recommending early ACL surgery, even in children. First, recent research has evaluated the risk of growth plate injury in comparison to the downside of delaying surgical treatment of the torn ACL. The risk of meniscus tears and cartilage injury was found in a recent study to be higher than the risk of growth disturbances.

Second, there are modifications to traditional ACL surgery that allow the growth plate to be minimally affected in children. Your healthcare provider may also recommend a specific type of graft to help minimize the chance of growth plate injury if surgical treatment is pursued. Therefore, more surgeons are recommending early ACL surgery in children.

A Word From Verywell

The bottom line is that the risks of waiting (joint instability, meniscus tears, and cartilage injury) appear to be greater than the risk of growth plate injury in early ACL reconstruction with current surgical approaches. As a result, ​surgeons today are more likely to recommend early ACL reconstruction.

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Article Sources
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  2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Growth Plate Injuries. 2014.

  3. Espandar R, Mortazavi SM, Baghdadi T. Angular deformities of the lower limb in children. Asian J Sports Med. 2010;1(1):46-53. doi:10.5812/asjsm.34871

  4. Hagino T, Ochiai S, Senga S, et al. Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg. 2015;135(12):1701-1706. doi:10.1007/s00402-015-2309-4

  5. Lawrence JT, Argawal N, Ganley TJ. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Am J Sports Med. 2011;39(12):2582-2587. doi:10.1177/0363546511420818

Additional Reading
  • American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting, July 2009.