Reconstructing ACLs Without Disrupting Growth

With more kids playing competitive sports earlier and year-round, anterior cruciate ligament (ACL) tears in skeletally immature adolescents are on the rise. “Kids are exposed to the potential for injury at a much higher level than ever before,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.

Concerns about disrupting growth make performing ACL reconstruction in patients with open growth plates controversial. Yet, Shelbourne Knee Center has been successfully reconstructing ALCs in skeletally immature adolescents for more than 25 years—without growth plate disruption.

131 Cases, No Growth Disruption

The latest Shelbourne Knee Center study involved 131 adolescents at Tanner Stage 3 or 4 who underwent primary ACL reconstruction using a contralateral patellar tendon graph (PTG) at the center between 1995 and 2015.1 The average patient age was 14.1 years (58 females and 73 males).

“Our results showed that if surgery and rehabilitation are done properly, ACL reconstruction in these patients allows for return of stability, range of motion, strength and ability to return to activity,” says William Claussen, PT, who conducted the study with Dr. Shelbourne. Claussen is one of nine physical therapists and athletic trainers at Shelbourne Knee Center and the rehabilitation department coordinator. While this study only collected data at two and five years, previous studies, including one published in Sports Health, have shown that young athletes return to full sport in an average of 5.3 months.2

A Consistent Process

Dr. Shelbourne performs the same ACL reconstruction procedure, honed over 38 years and 7,000+ ACL reconstruction surgeries, in all patients. In skeletally-immature patients, he meticulously places the bone plugs proximal to the physes and ensures that the graft is not over-tensioned. “PTG grafts are best for young athletes,” he says. “Hamstring tendons aren’t as strong and don’t heal as well as PTGs do. That’s an even bigger problem in adolescents with open growth plates who have many years of competition ahead of them.”

In addition, the same accelerated ACL post-op rehab protocol, which focuses on restoring full and equal range of motion (ROM) and then strength, is used in all patients. “Surgery restores stability and our rehab program restores ROM and strength,” says Claussen.

Favorable Study Results

Researchers recorded results and subsequent graft-tear rates through five years postoperatively.1 Methods were:

  • The International Knee Documentation Committee (IKDC) standards to assess ROM
  • KT1000 manual maximum difference between the knees to record stability
  • Isokinetic test at 60°/second to evaluate quadriceps muscle strength
  • The Cincinnati Knee Rating Scale (CKRS) and IKDC subjective survey to evaluate subjective results.

The mean preoperative stability was 4.4 mm, improving to 1.5 mm and 1.8 mm at two and five years, respectively, postoperatively. All patients achieved normal knee extension and 95% achieved normal flexion at five years postoperatively. By two years postoperatively, all patients had achieved full strength.

Mean IKDC and CKRS scores improved and 95% of patients had returned to at least Level 8 activity (participating in jumping, pivoting and twisting sports at the recreational level) by the two-year follow-up. The ACL graft-tear rate was 6.9% with a mean time to re-tear of 22 months postoperatively.

Continued Follow-Up

Claussen presented the study at the virtual national combined sections meeting of the American Physical Therapy Association in February 2021. Shelbourne Knee Center will continue to follow these patients for up to 30 years postoperatively.

“Our experience in ACL reconstruction in skeletally-immature adolescents enables us to safely and effectively treat these patients,” says Dr. Shelbourne.


  1. Claussen W, Shelbourne KD. Results following ACL reconstruction with contralateral patellar tendon graft in patients with open growth plates, 2020. Unpublished data
  2. Shelbourne KD, Sullivan AN, Bohard K, et al, Return to Basketball and Soccer After Anterior Cruciate Ligament Reconstruction in Competitive School-Aged Athletes. Sports Health. 2009 May; 1(3): 236–241.