Doctor Examining Child's Knee Whilst Looking at X-Ray

Nick London looks at a new development in the world of ACL repair and asks whether paediatric ACL reconstruction should be performed by specialist knee surgeons or general paediatric surgeons.

Earlier this year, Arthrex, the global medical device company, received FDA clearance in the US to use a new implant in the treatment of paediatric patients with anterior cruciate ligament (ACL) injuries. TightRope, as it’s been branded, is noteworthy for several reasons, but the real eye opener is that the implant is designed to support the repair of cruciate ligaments rather than their reconstruction.

In a ligament repair, the torn pieces of the ligament are reconnected, but that’s a little like stitching together a torn elastic band under tension. As you might imagine, traditionally such ligament repairs haven’t fared very well. That’s why knee surgeons have tended to use the more reliable reconstruction technique, which uses a graft from other tendons to create a sort of scaffold that gives the ligament added strength and support.

Repair of cruciate ligaments, either in the paediatric or the adult population, is still highly controversial. To date, it isn’t proven and it certainly isn’t risk-free, despite a worrying misconception among some.

ACL repair not a ‘free hit’

There is a view that ACL repair, while risky, is worth a try. If it fails, so the argument goes, you can always revert to an ACL reconstruction and the patient will be no worse off.

I don’t believe that’s true.

Any surgery carries risk. A failed ACL repair increases the potential risk of meniscal or chondral (cartilage) damage and we know that the failure rate for ACL repair is higher than for ACL reconstruction. There is also a known detrimental effect on the knee from multiple surgeries. It is not, in my view, reasonable to claim that an ACL repair is ‘worth a go’ and that if it doesn’t work the patient can have a reconstruction and be no worse off.

The evidence for primary repair of ACLs is not sufficient to outweigh the risk at the current time, but that may not always be the case. Yorkshire Knee Clinic will, therefore, continue to monitor the situation and we will be extremely interested in the findings produced by the TightRope trial and
other appropriate studies.

As an aside, I might add that all patients should be very wary of accepting any new treatment unless it and they are part of a well-organized and supported study.

Who should treat paediatric knee injuries?

The news of Arthrex’s device raised another issue that my colleague Dave Duffy also touched on recently in this post. When a child suffers an ACL injury, who should treat them? Should it be the knee surgeon who performs high volumes of that particular surgery, or should it be the paediatric surgeon who may have more experience in working with children, but a more generalised skillset?

We have seen something of a trend for cruciate ligament reconstruction surgery to be performed by paediatric orthopaedic surgeons who may in the course of a year perform a wide range of surgeries but relatively small numbers of ACL reconstructions.

They are, of course, experts in managing the paediatric population and we certainly need to be respectful of the fact that paediatric patients have different needs medically, psychologically and physically (because these are growing bones).

Yet among expert, high volume, soft tissue knee surgeons performing ligament surgery, the growing consensus view is that those patients would be best treated by surgeons doing lots of ACL reconstruction surgery all the time, while recognising that paediatric patients are not just – from a medical perspective – little adults.

My view (with an obvious and significant bias) is that paediatric ACL reconstruction should be performed by specialist knee surgeons performing high volumes of that type of surgery.

If your child has sustained a significant knee injury, book an appointment now for swift diagnosis or phone us on 03453 052 579.

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