In young patients with significant growth remaining, standard ACL reconstruction can potentially affect the growth plates because the graft and hardware cross the growth plates of the femur (thigh bone) and tibia (shin bone).
Dr. Chudik developed a special procedure to reconstruct the anterior cruciate ligament (ACL) without crossing or injuring the growth plates. This technique minimizes the risk of affecting growth while restoring function and stability to the knee.
What Is the Pediatric Growth-Plate-Sparing ACL Reconstruction?
The ACL is one of the four major ligaments of the knee. It is a rope-like structure in the center of the knee that helps maintain normal stability.
A torn ACL does not heal, and the knee will typically continue to be unstable or give way during sports that require pivoting, changing direction, jumping, or landing. Even when risky activities are restricted, living with an ACL-deficient knee can place abnormal stress on the meniscus, resulting in tears and accelerated degeneration of the cartilage and arthritis.
During ACL reconstruction, the torn ligament is replaced with a graft because simple repair usually is not possible. Common grafts include:
- Hamstring tendons
- Bone-patellar tendon-bone
- Quadriceps tendon
- Allograft tissue
For pediatric patients, Dr. Chudik prefers the patient’s own hamstring graft because it has shown better long-term results with a lower risk for arthritis.
In young patients with significant growth remaining, standard ACL reconstruction can potentially cause growth abnormalities because the graft and hardware cross the growth plates. Dr. Chudik’s pediatric technique creates the bone tunnels in the tibia and femur without crossing the growth plates, minimizing the risk of affecting growth.
Development Rationale
Standard ACL reconstruction requires the graft and hardware to cross the growth plates in the femur and tibia. In young patients with significant growth remaining, this can potentially cause growth abnormalities.
At the same time, an untreated ACL tear can result in continued knee instability and place abnormal stress on the meniscus, leading to meniscus tears, cartilage degeneration, and arthritis.
Dr. Chudik developed a procedure that reconstructs the ACL without crossing the growth plates. The goal is to restore knee function and stability while minimizing the risk of affecting growth.
Who Is a Candidate?
This procedure may be considered for young, physically active patients with an ACL tear who still have significant growth remaining.
ACL reconstruction may be appropriate when knee instability interferes with sports involving pivoting, cutting, jumping, or landing, or when associated meniscus or cartilage injuries are present.
Patients who are unable or unwilling to complete the required postoperative rehabilitation program should not have surgery. A current or previous knee infection is also a concern, although it is not an absolute contraindication.
How the Procedure Is Performed
The procedure is performed as outpatient surgery, allowing the patient to go home the same day. General anesthesia and a femoral, adductor canal, or IPACK block may be used.
Dr. Chudik performs the surgery with the assistance of an arthroscope, a small camera inserted through small incisions that allows him to view the inside of the knee.
The torn remnants of the ACL are preserved. Bone tunnels are created in the tibia and femur without crossing the growth plates, and the graft is placed anatomically where the injured ACL was located.
During surgery, the other ligaments, meniscus, and cartilage of the knee are also evaluated and treated appropriately.
The graft is held in position with special fixation devices that usually do not need to be removed. The hardware can be removed after the graft has incorporated.
Recovery and Rehabilitation
After surgery:
- A plaster splint keeps the knee in terminal extension for one week
- Crutches and partial weight bearing are used for approximately four weeks following an isolated ACL reconstruction
- A postoperative knee brace is used for 24 hours if a regional block was used, or for six weeks if the meniscus or another ligament was also repaired or reconstructed
- The wound should be kept clean and dry for the first 10 to 14 days
- Light showering is allowed after two weeks, but the wounds should not be submerged in water for three weeks
- Return to school may occur in less than one week as long as the leg can be elevated and the patient can use crutches
- Physical therapy to restore motion, strength, and proprioception (balance) may continue for four to six months
After the knee is fully rehabilitated, Dr. Chudik performs ACL Return to Sport Testing to determine whether rehabilitation is complete and whether movement patterns known to increase the risk of injury to the reconstructed ACL or the other knee have been corrected.
Return to walking and regular daily activities usually occurs once the patient is off crutches, approximately four to six weeks after surgery. Return to running may occur at about three months, with return to sports at approximately four to six months after surgery.
Risks and Outcomes
Potential surgical risks and complications include:
- Infection
- Nerve injury resulting in numbness around the knee; a small area of temporary or permanent numbness around the incisions is not uncommon
- Postoperative infection that may require removal of the graft
- Re-rupture or stretching of the reconstructed ligament, resulting in recurrent instability, which is more common with allografts
- Knee stiffness requiring prolonged rehabilitation or repeat surgery
- Rare pain from the fixation device used to hold the graft
- Rarely, a blood clot in the veins of the calf or thigh that may travel to the lungs
The goals of surgery are to reconstruct the torn ACL, repair other damaged structures including the meniscus or cartilage, and restore function and stability to the knee. The growth-plate-sparing technique minimizes the risk of affecting growth by avoiding the growth plates during reconstruction.
Why Dr. Chudik for Pediatric Growth-Plate-Sparing ACL Reconstruction
Dr. Chudik developed a special pediatric ACL reconstruction technique that allows the ACL to be reconstructed without crossing the growth plates, minimizing the risk of affecting growth.
He performs the procedure arthroscopically, places the graft anatomically where the injured ACL was located, and evaluates the other ligaments, meniscus, and cartilage during surgery.
Following rehabilitation, Dr. Chudik uses ACL Return to Sport Testing to determine whether the knee is fully rehabilitated and whether movement patterns associated with ACL injury risk have been corrected before the patient returns to activities.