Operative Versus Nonoperative Treatment and Timing of Surgery in Skeletally Immature Patients with Anterior Cruciate Ligament Tear

Introduction

As the percentage of the pediatric population engaged in organized athletic activity continues to climb, rates of sports-related injuries have increased commensurately. In particular, the rate of anterior cruciate ligament (ACL) reconstruction in skeletally immature patients has increased steadily over the past 20 years, with ACL tears now representing a large percentage of total knee injury claims in young athletes. Multiple factors have likely contributed to this increased incidence of ACL injury, including improved injury recognition and awareness and the growing trend for youth athletes to focus on single sports at an earlier age and engage in high-intensity, year-round training. Furthermore, the skeletally immature athlete has a number of age-dependent characteristics that increase their risk for ACL injury, including weakness as a result of growth spurts, physeal susceptibility to injury, and the potential for wide variations in skill, size, and maturity level of the different athletes. In addition, young athletes do not have fully matured sensorimotor function or well-developed neuromuscular control of joint motion and stability. Overall, there are two main treatment options for the skeletally immature patient following an ACL injury: nonoperative or operative management. Additionally, reconstruction can be early or delayed. Historically, ACL reconstruction in the skeletally immature patient was delayed until skeletal maturity or close to skeletal maturity due to concern for iatrogenic physeal injury. This approach also takes advantage of a patient’s interval development in psychological maturity, which may increase compliance with postoperative rehabilitation protocols. Conversely, recent work has suggested improved outcomes with early surgical stabilization of ACL tears versus nonoperative or delayed treatment. Consequently, both treatment type and timing of surgery are important considerations when planning ACL reconstruction in the skeletally immature patient with an ACL tear.