Introduction
Australia reports the highest rates of anterior cruciate ligament (ACL) injuries globally, with a particularly steep increase among young people. Since 2005, paediatric ACL reconstructions have risen, reflecting greater sports participation, year-round training, and improved injury recognition.
An ACL tear in a child can be distressing for families. Parents often receive conflicting advice, such as avoiding surgery, concerns about growth plate damage, or recommendations to wait and see. Understanding the current evidence is essential for making informed decisions.
Why is paediatric ACL surgery different?
ACL reconstruction in children differs significantly from adult procedures. Children have open growth plates, which are areas of developing cartilage near the ends of long bones responsible for growth. Surgical techniques that cross or disrupt these plates risk bone deformity or leg length differences.
Therefore, the surgical approach must be selected based on your child’s age, sex, and skeletal maturity, rather than just height or chronological age. A thorough assessment, including X-rays to determine bone age, is essential before choosing the appropriate technique.
Should my child have surgery?
This is the most frequently asked question from parents, and it is entirely reasonable.
Previously, non-operative management was often recommended for children with ACL tears, with surgery delayed until growth plates closed. Recent evidence has changed this perspective. Children managed without surgery often have ongoing instability, and can sustain additional, sometimes irreparable, meniscal and cartilage damage.
Delaying ACL reconstruction in children increases the risk of meniscal tears, which cannot be fully restored once damaged. Early meniscal injury also accelerates the onset of osteoarthritis later in life. For most active children with a complete ACL tear, surgical reconstruction provides the best long-term outcome when the appropriate technique is used.
Choosing the right surgical technique
The choice of surgical technique depends primarily on your child’s remaining growth. Dr Pai carefully assesses skeletal maturity before recommending an approach.
Physeal-sparing reconstruction places the graft entirely within the epiphysis, avoiding the growth plates. This technique is preferred for younger children with significant growth remaining, typically under 12 years old or in early puberty. Although technically demanding, it avoids the risk of physeal injury from the graft crossing the growth plate. Most children return to sport, and growth-related complications are uncommon at medium to long-term follow-up.
Transphyseal reconstruction uses tunnels that pass through the growth plates, similar to adult procedures. This approach is suitable for older adolescents nearing skeletal maturity. When performed with soft-tissue grafts and precise tunnel placement, the risk of significant growth disturbance is low.
Lateral extra-articular procedure (LEAP) in children
Children and adolescents are at higher risk of ACL graft re-rupture than adults. For this reason, Dr Pai routinely considers adding a lateral extra-articular procedure (LEAP) at the time of reconstruction in paediatric patients. This procedure reinforces the rotational stability of the knee and can reduce re-rupture rates.
Graft selection
In children, soft-tissue grafts, most commonly hamstring tendons, are preferred over bone-containing grafts such as the patellar tendon. Bone plugs within the growth plate carry a higher risk of physeal disruption. The hamstring graft is harvested through a small incision on the inside of the knee and provides a strong, reliable scaffold for ligament reconstruction.
In some cases, the quadriceps tendon may be considered as an alternative, particularly for revision procedures or when hamstring tendons are unavailable.
What is involved in paediatric ACL reconstruction?
The steps involved in a paediatric anterior cruciate ligament reconstruction surgery include:
1. Knee arthroscopy
The knee is examined thoroughly to confirm the ACL tear and identify any secondary injuries. Meniscal tears and cartilage damage are addressed simultaneously.
2. Graft harvest
The hamstring tendons are harvested through a small incision on the inside of the knee.
3. Tunnel placement
Bone tunnels are carefully positioned to avoid or minimise physeal disruption, guided by X-ray screening in theatre.
4. Graft passage and fixation
The graft is passed through the tunnels and secured with fixation devices appropriate for a growing skeleton.
5. Lateral extra-articular procedure
A strip of tissue from the outside of the knee is re-routed to provide additional rotational control.
After surgery, your child will be discharged the same day or after 1 night in hospital, depending on age and procedure complexity.
Recovery and return to sport
Recovery from paediatric ACL reconstruction follows a similar timeline to adults, but the rehabilitation program is tailored for a growing child.
A large systematic review of ACL reconstruction in skeletally immature patients found a mean return-to-sport time of 8.3 months, with 89% of children returning to sport and 84% returning to their pre-injury level of activity.
Return to sport is determined by meeting objective strength and movement milestones, not by time alone. Dr Pai collaborates with your child’s physiotherapist to ensure readiness before competition. Returning too early increases the risk of re-injury, so these criteria are strictly followed.
Frequently asked questions
Is Dr Pai comfortable performing paediatric ACL reconstruction?
Yes. Dr Pai completed a 6-month term at Shriners Hospital for Children in Portland, USA, during which he gained specific experience in managing ACL injuries in young patients.
ACL reconstruction in children requires a different surgical approach, different technique selection, and a different mindset from adult surgery. Dr Pai is trained and experienced in paediatric ACL reconstruction.
My child still has years of growth left. Is it safe to operate now?
What happens if we choose not to operate?
How long will my child be off school?
Will my child need physiotherapy?
What is the risk of re-injury?
Next step
Talk through your options
If your child has injured their ACL, Dr Vishal Pai can examine their knee, review their scans and explain all the options, including treatment without surgery.