Arthroscopic Pediatric Growth-Plate-Sparing ACL Reconstruction is a technique developed by Dr. Chudik that allows skeletally immature athletes with ACL tears to be reconstructed without damaging the open growth plates of the femur and tibia. Conventional ACL reconstruction techniques drill bone tunnels that cross the growth plates, which can produce growth abnormalities in patients with significant growth remaining. Dr. Chudik’s technique avoids the growth plates entirely. Pediatric athletes can be treated at the time of injury rather than waiting years for skeletal maturity, preserving the knee from progressive meniscus and cartilage damage that occurs during prolonged instability.
What Is the Pediatric Growth-Plate-Sparing ACL Reconstruction?
The anterior cruciate ligament (ACL) is one of the four major ligaments of the knee, a rope-like structure in the center of the knee that maintains normal stability. A torn ACL does not heal, and the knee continues to be unstable during pivoting, cutting, jumping, and landing. Even with restriction of risky activities, living everyday life without ACL reconstruction places abnormal stresses on the meniscus, leading to tears and accelerated cartilage degeneration that progresses to arthritis. ACL tears are increasingly prevalent in young athletes.
In ACL surgery, the torn ligament is replaced (reconstructed) with a graft, because simple repair is usually not possible. Common grafts include hamstring tendons, bone-patellar tendon-bone, quadriceps tendon, or allografts from cadavers. Dr. Chudik prefers the patient’s own hamstring graft, which has shown better long-term results with lower arthritis risk.
Conventional ACL reconstruction requires the graft and hardware to cross the growth plates of both the femur (thigh bone) and the tibia (shin bone). In skeletally mature adults, this is unproblematic. In young patients with significant growth remaining, crossing the open growth plates can damage the physis and produce growth abnormalities including limb-length discrepancy and angular deformity.
Dr. Chudik developed a special procedure that reconstructs the ACL without crossing the growth plates. Bone tunnels are placed within the epiphyses of the femur and tibia, on the joint side of the growth plates rather than across them. The technique avoids the growth plates entirely and minimizes the risk of growth disturbance.
Development Rationale
Before growth-plate-sparing techniques were developed, surgeons faced a difficult choice in skeletally immature ACL-injured athletes:
- Reconstruct the ACL conventionally, accepting the risk of growth disturbance from tunnels crossing the open growth plates
- Delay reconstruction until skeletal maturity, requiring the young athlete to live with an unstable knee for months or years
- Modify activity to avoid pivoting sports, accepting the loss of athletic participation during the growth period
Each option had significant downsides. Conventional reconstruction risked growth abnormality. Delayed reconstruction allowed progressive meniscus and cartilage damage during the years of instability, with patients arriving at eventual reconstruction with secondary injuries. Activity modification was rarely accepted by competitive young athletes.
Dr. Chudik developed the growth-plate-sparing technique to address all three concerns:
- Reconstruct the ACL at the time of injury, not at skeletal maturity
- Avoid the growth plates with tunnels placed entirely within the epiphyses
- Use anatomic placement of the graft within the safe epiphyseal regions
The technique allows pediatric athletes to be treated when they are injured, minimizing the secondary meniscus and cartilage injuries that accumulate with continued instability.
Who Is a Candidate?
Candidates typically have:
- An ACL tear in a skeletally immature patient with significant remaining growth
- Open growth plates on imaging
- An active athletic patient committed to the postoperative rehabilitation program
- Functional instability or imaging evidence of associated meniscus or cartilage injury that argues against delayed reconstruction
Persons unwilling or unable to complete the postoperative rehabilitation program should not have surgery. Active or prior knee infection is a concern but not an absolute contraindication.
How the Procedure Is Performed
The procedure is performed as outpatient surgery under general anesthesia with a femoral nerve block. Dr. Chudik uses an arthroscope (small camera) to visualize the inside of the knee through small incisions.
The torn ACL is identified, and the torn remnants are preserved. Other ligaments, meniscus, and cartilage are evaluated and treated as needed. Dr. Chudik prioritizes meniscus repair over removal whenever the tear pattern allows.
Bone tunnels are then created in the tibia and femur. In the conventional adult technique, these tunnels cross the growth plates. In the pediatric growth-plate-sparing technique, the tunnels are placed entirely within the epiphyses, on the joint side of the growth plates. The graft (typically hamstring tendon harvested from the same knee) is placed anatomically where the original ACL connected, and held in position with special fixation devices that usually do not need to be removed. Hardware can be entirely removed after the graft has incorporated.
Recovery and Rehabilitation
Recovery follows a protected protocol:
- Postoperative plaster splint with the knee in terminal extension for one week
- Crutches and partial weight-bearing for approximately four weeks for an isolated ACL reconstruction
- Postoperative knee brace for 24 hours if a regional block was used, or six weeks if the meniscus was repaired or another ligament was reconstructed
- Wound care: clean and dry for the first 10 to 14 days; light showering after two weeks; no submersion under water for three weeks
- Return to school in less than one week as long as the leg can be elevated
- Physical therapy to restore motion, strength, and proprioception (balance) for up to four to six months
After full rehabilitation, Dr. Chudik’s ACL Functional Capacity Evaluation is performed to confirm rehabilitation is complete and identify any errors in movement patterns that put patients at risk for re-injury or contralateral injury. Movement pattern errors are corrected before return to sport.
Return to walking and regular daily activities follows once crutches are no longer needed (about four to six weeks). Return to running is typically about three months post-op. Return to sport is typically four to six months post-op.
Risks and Outcomes
Specific surgical risks include:
- Infection (post-operative infection may require graft removal to treat)
- Nerve injury (numbness in the skin around the knee, often small areas, temporary or permanent)
- Re-rupture or stretching of the reconstructed ligament, causing recurrent instability (more common with allografts)
- Knee stiffness requiring prolonged rehabilitation or repeat surgery
- Pain from the fixation device (rare)
- Clot in the veins of the calf or thigh (deep venous thrombosis, rarely with pulmonary embolus)
The growth-plate-sparing technique has been shown to allow ACL reconstruction in skeletally immature athletes without the growth abnormalities that conventional adult techniques can produce. Outcomes are good when the technique is performed correctly and the postoperative rehabilitation is completed.
Why Dr. Chudik for Pediatric Growth-Plate-Sparing ACL Reconstruction
Dr. Chudik developed the arthroscopic growth-plate-sparing ACL reconstruction technique and treats pediatric ACL injuries from across a wide referral area. Patient selection, surgical technique, and rehabilitation supervision are all informed by his experience with the specific challenges of the skeletally immature knee. For young athletes who would otherwise face years of activity modification or the risk of conventional reconstruction across open growth plates, the technique provides a path back to sport at the time of injury.