Pediatric and adolescent ACL injury and sports medicine: The early years

Abstract

Since the 1970s, sports medicine has grown rapidly into a multispecialty discipline with development of societies, courses, journals, and fellowships. With a major focus on understanding knee injuries, the normal function of the ACL was first defined and an appreciation of the functional instability that results from its compromise with onset of premature degenerative joint disease. Arthroscopy created a revolution in diagnosis and management of ACL injuries. Prior attitudes regarding the skeletally immature scholastic-aged athlete were twofold: no significant injuries occurred until skeletal maturity; children heal injuries without difficulty or sequelae. It always seemed to this author that the scholastic-aged athlete represented the largest group exposed to sports injuries, most of which were minor and resolved with limited treatment requirements. Recognition, however, of significant intra-articular injuries in the truly skeletally immature began to be reported and now is a fact of sports medicine. Management of ACL injury in the truly skeletally immature athlete was initially done nonoperatively because of fear of surgical damage to the femoral and tibial physes. With further observation of this treatment method’s outcomes, it was realized that attempts to return to play created additional instability and secondary intra-articular injury in an already functionally compromised knee. Patients need to be assessed for their physiologic maturity and not just their chronological age. Surgical methods were suggested with the use of various tissues, tunnels, and techniques. Reconstructions were based on physiologic maturity and were classified as physeal sparing, partial transphyseal, and complete transphyseal methods. Graduated rehab methods must be instituted with return to normal functional parameters prior to return to sport. Short time outcomes of most of these methods appear to be successful in preventing ongoing functional knee instability. In reported appropriately selected patients and surgical procedures, iatrogenic physeal injuries have been limited. The surgeon must act as a knee counselor relative to risks to the contralateral knee and ability to return to full activity and choice of sports. Pediatric and adolescent sports medicine initially emerged within the concept of “sports medicine” writ large. It is very rewarding to note that it has since developed into a bona fide multidisciplinary sub-subspecialty with practitioner fellowship trained in pediatric and sports medicine orthopedics.