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ACL Injuries In the Skeletally Immature

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Presentation on theme: "ACL Injuries In the Skeletally Immature"— Presentation transcript:

1 ACL Injuries In the Skeletally Immature
Jason W. Folk, MD Steadman Hawkins Clinic of the Carolinas February 2012

2 Consultant Smith & Nephew Endoscopy
Disclosures Consultant Smith & Nephew Endoscopy

3 Objectives Describe the epidemiology, pathophysiology, and treatment principles of ACL injuries in skeletally immature patients

4 ACL Injuries: Introduction
Epidemiology: Intrasubstance tears once considered rare in pediatric population Tibial eminence fx considered pediatric ACL equivalent Typically under 12yo Increasing numbers over past decade Increased attention ACL Injuries in children were previously considered a rare event. However, the number has been increasing over the past few decades. This is mostly because kids are more active in sports and are adhering to more vigorous training regiments and schedules.

5 ACL Injuries: Introduction
Reasons for increased incidence: Increased participation in sports Higher competitive levels early on Increased awareness of injury Decreased conditioning

6 ACL Injuries: Introduction
ACL Injuries in Soccer Players 5-18 (Shea, et al. JPO 2004.) Based on insurance data from 6 million player-years 6.7% of total injury claims 30.8% of all knee injury claims True incidence unknown

7 ACL Injuries: Introduction
Differences in pediatric population Often lack fully developed complex motor skills May have temporary decline in motor and balance during puberty Open physes Higher strength of ligaments vs. bone- ligament interface

8 ACL Injuries: Diagnosis
History: Patient describes a characteristic “Pop” Effusion forms quickly after injury 47% of patient’s aged with traumatic effusion had ACL disruption 65% in year old group. (Stanitski et al. 1993) Approximately 60% partial tears

9 ACL Injuries: Diagnosis
Physical Exam Often more difficult in kids than adults Acute pain Frightened Unable to relax Examine uninjured leg for baseline laxity or congenital absence of ACL

10 ACL Injuries: Imaging Plain Radiographs (4 views)
For anyone suspected of having an ACL injury Bony avulsions Osteochondral fractures Physeal fractures Patellar dislocation/subluxation Degree of physeal closure CT scan also used for evaluation of physeal closure.

11 Tibial Eminence Fracture
In skeletally immature, chondroepiphysis is weaker than the ligament. Mechanism of injury typically hyperflexion Most commonly 8-12yo Present w/ pain and limited ROM Dx on x-ray and CT

12 Tibial Eminence Fracture
Type I: LLC x 3-6 weeks in 20degrees flexion Type II/III: Attempted closed reduction, +aspiration of hemarthrosis (may help reduction), LLC in extension x 4-6 weeks Irreducible Type II/III or IV: arthrocopic vs open ORIF with suture, retrograde wire, or screw fixation Some argue all Types II-IV should be fixed anatomically with countersinking of fragment because of residual laxity Results of fixation usually excellent

13 ACL Injuries: Imaging MRI
Should not be used as replacement for physical exam and routine radiographs Look for ACL tear, meniscal injury, chondral injury Indications Failing to improve ROM Persistent effusion Physical exam difficult to interpret. Help define anatomy of physis

14 ACL Injuries: Etiology
Can occur with fractures Distal femoral physeal fractures (25-45%) Salter-Harris III fxs at increased risk because frequently exits intra-articularly at notch Proximal tibial physeal fractures

15 The Physis Concern about iatrogenic injury to physis is what drives the debate about treatment strategies

16 The Physis Distal femoral and prox tibial physis
Contribute more to limb length than hip and ankle DF 1.2 cm/yr PT 0.9 cm/yr Overall 65% of length contributed to knee Closure typically occurs M=16 F=14

17 Anatomy of Physis MRI closure of Physis 0% at 11 years 5% at 12 years
Central tibial physis closes prior to peripheral physis ?More central tunnel ?Smaller tunnel Sasaki et al., J Knee Surg 2002

18 ACL Injuries: Treatment
Concern for possible growth abnormality fuels debate on treatment Non-operative Operative Direct Repair Extra-articular Intra-articular Intra/Extra articular reconstructions Physeal sparing Partial Transphyseal Complete transphyseal Trans epiphyseal

19 ACL Injuries Nonoperative Management
Avoids risk of physeal damage Sometimes used as a temporizing measure until skeletal maturity Very difficult to reasonably limit young patient’s activities

20 ACL Injuries: Nonoperative management
So what if we don’t treat these injuries? Angel et al. Arthroscopy 1989 27 children with arthroscopically documented ACL tears 22 patients at 51mo f/u None able to return to sports at preinjury level

21 Non-op ACL Open Physis 40 pts under 14 y/o open physis 16 conservative
6 scope for meniscal tears Only 7 return to sports All recur giving way, swelling, pain McCarroll et al., AJSM 1988

22 Non-op ACL Open Physis 18 pts ACL injury open physis
Only one returned to preinjury level of sports Initial scope 13 meniscal tears Later secondary meniscal tears in 9 Degen changes 11 of 18 pts by Xray Mizuta et al., JBJS Br 1995

23 Non-op ACL Open Physis 60 children with ACL tear 23 nonop
Nat Hx continued instability, further meniscal and chondral damage 25 % secondary meniscal tears Few able to participate in sports Aichroth et al., JBJS BR, 2002

24 Non-op ACL Open Physis ? Effect of delay in treatment
39 pt < 14 y/o Sig increase in MMT with delay in treatment > 6 weeks 36% chronic vs 11% in acute Rx No diff in rate of LMT Millett et al., Arthroscopy 2002

25 ACL Injuries Nonoperative Management
Graf et al: 12 skeletally immature patients with ACL tears 8 patients underwent non-op and no restriction management. 7 of the 8 had new meniscal tear at follow up

26 ACL Injury: Long Term Results
Kannus et al. JBJS-B. 1988 8 year F/U – 4/7 Pediatric Patients that had Untreated ACL Tears showed Advancing OA radiographically

27 Nonoperative Rx in Children
Non-op treatment has not resulted in good outcomes

28 ACL Injuries: Physeal Concerns
Fear disruption of open physes Risk of epiphysiodesis, LLD, angular deformity Caused by crossing physis with bone plug and/or fixation devices

29 ACL Injuries: Physeal Concerns
History Campbell et al. (1959) Large holes drilled through the physis have maximal retardation of growth plate Insertion of cortical bone across physis causes arrest Makel et al (1988) Destruction of >7% of physis causes growth arrest Destruction of 3% or less…no arrest Stadelmeir et al (1995) Soft tissue graft placed in drill hole did not cause physeal bar.

30 Factors Influencing Physeal Arrest
Diameter of drill hole Soft tissue graft within tunnel Tension of graft across physis Tunnel location? (Central and vertical)

31 ACL Injuries: Operative Managment
Direct Repair: A historic treatment modality Inflammatory changes and degeneration begins within 48 hours after injury Metalloproteases and cytokine inflammatory factors affect healing potential of direct repair Poor results Delee and Curtis, CORR 1983 Engebretsen, et al. Acta Orthop Scand 1988

32 ACL Injuries: Operative Management
Extra-Articular repair Temporizing method Non-anatomic reconstruction Poor results Dahlstedt , et al. Acta Orthop Scand 1988 McCarroll et al. AJSM 1998 Graf, et al. Arthrsocopy 1992

33 ACL Injuries: Assessment of maturity
Tanner et al. : Adolescent growth spurt begins at years in boys and 10.5 years in girls. Peak Growth velocity 1 year later Menarche is good indication of maturity in girls In athletic girls, menarche may be delayed. Axillary and pubic hair appear in boys after growth spurt Bone age: Most accurate method to determine skeletal maturity

34 General Guidelines Think about physis if: Male Female
Tanner stage 1 or 2 Not shaving Not reached growth spurt 14 y/o or less Female Premenarchal 12 y/o or less

35 ACL Reconstruction Techniques

36 ACL Injury: Physeal Sparing Reconstruction
Intra-articular, non-anatomic, extra-physeal Stanitski. JAAOS 1985

37 ACL Injury: Kocher Technique
Physeal-Sparring Combined Intra- and Extra-articular Reconstruction

38 ACL Injury: Partial Transphyseal
Hybrid of physeal sparing and adult-type reconstruction Femoral physis left intact Graft: Hamstring or patella Passed through 6-8mm tunnel <5% physeal X-sectional area Fixed in over the top position

39 ACL Injury: Transepiphyseal

40 ACL Injury: Transphyseal

41 Thank You

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