ACL injuries in children and teenagers require a different approach to adult ACL injuries. One of the main reasons for this is the presence of growth plates, also known as physes.

When planning ACL surgery in younger patients, protecting these growth areas is an important consideration. Treatment decisions are based not only on the injury itself, but also on the child’s age, skeletal maturity, activity level, and remaining growth.

Dr Alex Nicholls has contributed to research examining transphyseal ACL reconstruction and the impact of surgery around growth plates in paediatric patients.

What Are Growth Plates?

Growth plates are areas of developing cartilage located near the ends of bones in children and adolescents.

These areas are responsible for bone growth during childhood and adolescence. As a child matures, the growth plates gradually close and become solid bone.

Because growth plates are still open in younger patients, they must be considered carefully during orthopaedic surgery.

Why Do Growth Plates Matter in ACL Surgery?

In ACL reconstruction surgery, tunnels are created within the femur and tibia to reconstruct the ligament.

In children and teenagers, these tunnels may pass near or through growth plates depending on:

• Age

• Skeletal maturity

• Surgical technique

• Remaining growth

Historically, there were concerns that ACL surgery involving growth plates could potentially affect normal bone growth.

This led to significant research into how paediatric ACL surgery can be performed safely while maintaining knee stability.

What Is a Transphyseal ACL Reconstruction?

A transphyseal ACL reconstruction is a surgical technique where tunnels pass through the growth plates as part of the ACL reconstruction.

This technique is commonly used in adolescents who still have some growth remaining.

Modern surgical planning aims to:

• Minimise disruption to growth plates

• Restore knee stability

• Reduce the risk of further injury

The approach is tailored to the individual patient’s age and skeletal maturity.

Why Is ACL Stability Important in Young Athletes?

An unstable ACL-deficient knee can place the meniscus and cartilage at risk of further injury, particularly in active children and teenagers who continue participating in sport.

Repeated instability episodes may contribute to:

• Meniscal tears

• Cartilage injury

• Ongoing knee dysfunction

Treatment decisions aim to balance:

• Protecting growth plates

• Maintaining long-term knee health

• Allowing safe return to activity where appropriate

How Is Skeletal Maturity Assessed?

Assessing skeletal maturity is an important part of planning paediatric ACL surgery.

This may involve:

• Clinical assessment

• Growth history

• Imaging studies

• Evaluation of remaining growth potential

Understanding skeletal maturity helps determine:

• Whether surgery is appropriate

• Which surgical technique may be most suitable

• How growth plates should be managed during surgery

Do Growth Plates Always Prevent Surgery?

No.

Modern paediatric ACL surgery techniques are designed specifically for younger patients with open growth plates.

Research over time has improved understanding of:

• Safe tunnel positioning

• Surgical technique modifications

• Risk factors for growth disturbance

• Long-term outcomes in paediatric ACL reconstruction

The presence of growth plates does not automatically mean surgery should be avoided.

What Does Current Research Show?

Research in paediatric ACL reconstruction has focused heavily on whether surgery around growth plates can be performed safely.

Studies have examined:

• Risk of growth disturbance

• Growth plate changes after surgery

• Knee stability outcomes

• Return-to-sport outcomes

Dr Alex Nicholls has contributed to research examining transphyseal ACL reconstruction and the incidence of physeal bar formation following surgery in paediatric patients.

This research helps improve understanding of how ACL surgery can be planned safely in growing athletes.

Recovery After Paediatric ACL Surgery

Recovery after ACL surgery in children and teenagers is gradual and structured.

Early Recovery

Initial rehabilitation focuses on:

• Swelling management

• Regaining movement

• Protecting the knee

Strength and Rehabilitation

Progression includes:

• Strength rebuilding

• Balance and movement control

• Functional rehabilitation

• Sport-specific exercises

Return to Sport

Return to sport depends on:

• Strength

• Knee stability

• Functional testing

• Recovery progression

Timelines vary between individuals.

When Should You Seek Specialist Assessment?

Assessment by a knee specialist may be helpful if a child or teenager experiences:

• Knee instability

• Ongoing swelling

• Difficulty returning to sport

• Recurrent “giving way” episodes

• Persistent knee pain after injury

Early assessment helps determine:

• Whether the ACL is injured

• Whether growth plates remain open

• What treatment options may be appropriate

Summary

Growth plates are an important consideration when treating ACL injuries in children and teenagers. Because younger athletes are still growing, paediatric ACL surgery requires careful assessment and individualised planning.

Modern surgical techniques and ongoing research continue to improve understanding of how ACL reconstruction can be performed safely while protecting long-term knee function and growth.

This article is based in part on Dr Alex Nicholls’ research examining transphyseal ACL reconstruction and growth plate-related outcomes in paediatric patients.

Read the full publication:
Transphyseal ACL reconstruction resulted in small incidence of tibial physeal bars at 1-year follow-up