Treating ACL injuries in children: the great debate

While ACL injuries among adults are prevalent and surgery is the obvious answer, this is not the case for ACL repair among children. Esteemed consultant knee surgeon Professor Nick London explores a recent advancement in ACL repair and debates whether specialist knee surgeons or general paediatric surgeons should handle paediatric ACL reconstruction.

What are the latest developments in ACL treatment for children?

Earlier this year, Arthrex, the global medical device company, obtained FDA clearance in the United States for the use of a new implant in treating anterior cruciate ligament (ACL) injuries in paediatric patients. Dubbed TightRope, this implant stands out for several reasons, but its most striking feature is its focus on supporting the repair of cruciate ligaments rather than their reconstruction.

In a ligament repair, the torn segments of the ligament are reconnected, akin to mending a torn elastic band under tension. Traditionally, such ligament repairs have had limited success, leading knee surgeons to typically opt for the more reliable reconstruction technique. This approach involves using a graft from other tendons to create a scaffold that enhances the ligament's strength and stability.

The idea of repairing cruciate ligaments is a highly debated topic, regardless of whether the patient is a child or adult. Its effectiveness has yet to be proven, and it is not devoid of risks, despite a prevalent misconception among some individuals.

ACL repair is not a “free hit”

ACL repair should not be seen as a risk-free option. While some argue it's worth attempting because a failed repair can be followed by a reconstruction without worsening the patient's condition, I disagree.

Any surgery carries risks, and a failed ACL repair can increase the chances of further knee damage. Additionally, the failure rate for ACL repair is higher than for reconstruction, and multiple surgeries can have a detrimental effect on the knee. Claiming that ACL repair is worth trying with the safety net of reconstruction overlooks these risks.

The current evidence for primary ACL repair doesn't justify the risk. That being said, this may change in the future. At Yorkshire Knee Clinic, we will closely follow studies like the TightRope trial to update our approach.  Patients must be cautious about accepting new treatment, unless part of a well-organised study.

Who should treat paediatric knee injuries?

The emergence of Arthrex's device has sparked a discussion, echoing a recent point made by my colleague Dave Duffy. The question at hand is who should treat a child with an ACL injury - a specialised knee surgeon who performs a high volume of ACL surgeries, or a paediatric surgeon who may perform a wide range of surgeries each year, but fewer ACL reconstructions?

While these surgeons are highly skilled in paediatric care, it is crucial to consider the unique medical, psychological, and physical needs of young patients, who are still in the process of developing their bones. Despite this, within the community of expert knee surgeons, the debate continues.

However, within the community of expert knee surgeons specialising in ligament surgeries, there is a growing consensus that patients, including paediatric cases, benefit most from surgeons who frequently perform ACL reconstructions. This perspective acknowledges that paediatric patients, from a medical standpoint, are not merely “little adults.”

In my opinion, which admittedly carries bias, paediatric ACL reconstructions should be conducted by knee surgeons who specialise in high-volume ACL surgeries.

Within the community of expert knee surgeons, the debate continues.

If your child is suffering from an ACL injury and you would like to book a consultation with Professor London, do not hesitate to do so by visiting his Top Doctors profile today.