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Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient John F. Meyers,

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Presentation on theme: "Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient John F. Meyers,"— Presentation transcript:

1 Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient John F. Meyers, M.D. Michael R. Magoline, M.D. Orthopaedic Research of Virginia John F. Meyers, M.D. Michael R. Magoline, M.D. Orthopaedic Research of Virginia

2 ACL Injuries in the Skeletally Immature Overview Introduction Diagnosis Assessment of Skeletal Maturity Tibial Eminence Fractures Nonsurgical Management Surgical Management Introduction Diagnosis Assessment of Skeletal Maturity Tibial Eminence Fractures Nonsurgical Management Surgical Management

3 ACL Injuries in the Skeletally Immature Introduction ACL injuries in young patients are being diagnosed with increasing frequency –Higher clinical suspicion of ACL tears –More modalities to diagnose ACL tears (MRI) –More preadolescents participating in sports ACL injuries in young patients are being diagnosed with increasing frequency –Higher clinical suspicion of ACL tears –More modalities to diagnose ACL tears (MRI) –More preadolescents participating in sports

4 ACL Injuries in the Skeletally Immature Introduction Poor prognosis associated with nonsurgical management of ACL injuries with respect to sports and long term sequelae –High incidence of repetitive instability episodes (leading to early DJD?), meniscal tears and inability to return to sports Poor prognosis associated with nonsurgical management of ACL injuries with respect to sports and long term sequelae –High incidence of repetitive instability episodes (leading to early DJD?), meniscal tears and inability to return to sports

5 ACL Injuries in the Skeletally Immature Introduction However: Efficacy and risks of surgical management are not well documented –Growth Arrest –Early graft failure –Early arthrosis However: Efficacy and risks of surgical management are not well documented –Growth Arrest –Early graft failure –Early arthrosis

6 ACL Injuries in the Skeletally Immature Diagnosis Differential diagnosis of anterior knee instability in the young patient –Tibial eminence fractures –Periarticular fractures –Constitutional laxity –Congenital absence of the ACL Differential diagnosis of anterior knee instability in the young patient –Tibial eminence fractures –Periarticular fractures –Constitutional laxity –Congenital absence of the ACL

7 ACL Injuries in the Skeletally Immature Diagnosis Hx/Physical Exam –History of acute injury –Acutely swollen knee (50% incidence of ACL injury) –Mechanism of injury –Examination of contralateral knee Hx/Physical Exam –History of acute injury –Acutely swollen knee (50% incidence of ACL injury) –Mechanism of injury –Examination of contralateral knee

8 ACL Injuries in the Skeletally Immature Diagnosis MRI –High level of specificity and sensitivity –Detects other pathology (meniscal tears, osteochondral injuries, etc.) MRI –High level of specificity and sensitivity –Detects other pathology (meniscal tears, osteochondral injuries, etc.)

9 ACL Injuries in the Skeletally Immature Assessment of Skeletal Maturity Important in considering reconstructive options –Patients with significant growth remaining are at increased risk for deformity and leg length discrepancy with surgical procedures performed at or near the physis Important in considering reconstructive options –Patients with significant growth remaining are at increased risk for deformity and leg length discrepancy with surgical procedures performed at or near the physis

10 ACL Injuries in the Skeletally Immature Assessment of Skeletal Maturity Physiologic Age (menarche, Tanner stage, cessation of change in shoe size)

11 Classification of Sexual Maturity Stages in Girls Pubic Hair 1.Preadolescent 2.Sparse, lightly pigmented, straight, medial border of labia 3.Darker, beginning to curl, increased amount 4.Course, curly, abundant, but amount less than adult 5.Adult femenine triangle, spread to medial surface of thighs Pubic Hair 1.Preadolescent 2.Sparse, lightly pigmented, straight, medial border of labia 3.Darker, beginning to curl, increased amount 4.Course, curly, abundant, but amount less than adult 5.Adult femenine triangle, spread to medial surface of thighs Breasts 1.Preadolescent 2.Breast Papilla elevated and small mound; areolar diameter increased 3.Breast areola enlarged, no contour seperation 4.Areola and papilla form secondary mound 5.Mature; nipple projects, areola part of general breast

12 Classification of Sexual Maturity Stages in Boys Pubic hair 1.None 2.Scanty, long. Slightly pigmented 3.Darker, starts to curl, small amount 4.Resembles adult type, but less in quantity, course curly 5.Adult distribution, spread to medial surface of thighs Pubic hair 1.None 2.Scanty, long. Slightly pigmented 3.Darker, starts to curl, small amount 4.Resembles adult type, but less in quantity, course curly 5.Adult distribution, spread to medial surface of thighs Penis/Testes 1.Preadolescent 2.Slightly enlarged/enlarged scrotum, pin texture altered 3.Longer/larger 4.Larger; glans and breadth increase in size; scrotum dark 5.Adult size

13 ACL Injuries in the Skeletally Immature Assessment of Skeletal Maturity Chronologic Age Bone Age (Risser sign, Wrist film) Family Height Plain films of the knee (wide open growth plates vs. fused growth plates) Chronologic Age Bone Age (Risser sign, Wrist film) Family Height Plain films of the knee (wide open growth plates vs. fused growth plates)

14 ACL Injuries in the Skeletally Immature Tibial Eminence Fractures Unique pediatric variant of ACL injury –Tibial spine offers less resistance to traction forces than the substance of the ACL –Bony insertion of the ACL on the intercondylar eminence is avulsed Unique pediatric variant of ACL injury –Tibial spine offers less resistance to traction forces than the substance of the ACL –Bony insertion of the ACL on the intercondylar eminence is avulsed

15 ACL Injuries in the Skeletally Immature Tibial Eminence Fractures: Classification Meyers and McKeever) Type I: Nondisplaced Type II: Hinged fragment Type III: Displaced fragment Type I: Nondisplaced Type II: Hinged fragment Type III: Displaced fragment

16 ACL Injuries in the Skeletally Immature Tibial Eminence Fractures: Treatment Nonoperative management for nondisplaced or reducible fragments (Types I and II) Arthroscopic reduction and fixation for displaced and irreducible fragments (Type III) Nonoperative management for nondisplaced or reducible fragments (Types I and II) Arthroscopic reduction and fixation for displaced and irreducible fragments (Type III)

17 ACL Injuries in the Skeletally Immature Nonsurgical Management Risk of iatrogenic physeal damage with reconstructive surgery Some authors advocate activity modification rehabilitation and bracing until patient reaches skeletal maturity Risk of iatrogenic physeal damage with reconstructive surgery Some authors advocate activity modification rehabilitation and bracing until patient reaches skeletal maturity

18 ACL Injuries in the Skeletally Immature Nonsurgical Management However: uniformly poor results reported with conservative management in the active pediatric population –Subsequent meniscal tears, instability episodes, early arthrosis However: uniformly poor results reported with conservative management in the active pediatric population –Subsequent meniscal tears, instability episodes, early arthrosis

19 ACL Injuries in the Skeletally Immature Surgical Management Reconstructive techniques focused on avoiding the growth plate –Primary ACL repair (Poor results) –Extraarticular reconstructions (non- anatomic, poor results) Reconstructive techniques focused on avoiding the growth plate –Primary ACL repair (Poor results) –Extraarticular reconstructions (non- anatomic, poor results)

20 ACL Injuries in the Skeletally Immature Surgical Management In considering ACL reconstruction in the skeletally immature patient, need to assess how much growth is remaining

21 ACL Injuries in the Skeletally Immature Surgical Management Little growth remaining Safe to treat as adults and offer them a reconstruction with transphyseal drill holes and graft of choice (B- T-B, etc.) Little growth remaining Safe to treat as adults and offer them a reconstruction with transphyseal drill holes and graft of choice (B- T-B, etc.) Patients close to skeletal maturity

22 ACL Injuries in the Skeletally Immature Surgical Management Wide open growth plates/significant growth remaining Alter reconstructive technique (graft choice, femoral tunnel) to minimize risk of physeal arrest/deformity Wide open growth plates/significant growth remaining Alter reconstructive technique (graft choice, femoral tunnel) to minimize risk of physeal arrest/deformity Skeletally immature patients

23 ACL Injuries in the Skeletally Immature Surgical Management Smaller grafts (6-7 mm) to accommodate size of knee as well as to minimize assault to tibial physis Soft tissue grafts to avoid placing a bone block across the physis Over the top fixation on the femoral side to avoid drilling across the femoral physis Smaller grafts (6-7 mm) to accommodate size of knee as well as to minimize assault to tibial physis Soft tissue grafts to avoid placing a bone block across the physis Over the top fixation on the femoral side to avoid drilling across the femoral physis Skeletally immature patients

24 Hamstring ACL Reconstruction Harvest

25 Hamstring ACL Graft preparation

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30 ACL Injuries in the Skeletally Immature Summary ACL injuries are being diagnosed with increasing frequency in the younger population Results of nonoperative management in patients with symptomatic anterior instability are poor Assessment of skeletal maturity is key in choosing reconstructive technique ACL injuries are being diagnosed with increasing frequency in the younger population Results of nonoperative management in patients with symptomatic anterior instability are poor Assessment of skeletal maturity is key in choosing reconstructive technique


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