Pediatric ACL: A New Technique Koco Eaton, M.D.

Injuries in Younger Patients Why are kids tearing their ACLs at such a young age? Why are kids tearing their ACLs at such a young age? Increasing number of children playing organized sports at a younger age Increasing number of children playing organized sports at a younger age Correlates with the increasing number of ACL injuries Correlates with the increasing number of ACL injuries

Treatment Options Conservative treatment: Conservative treatment: Bracing Bracing Physical therapy to strengthen the quadriceps and hamstrings Physical therapy to strengthen the quadriceps and hamstrings Counseling Counseling Activity modification Activity modification

Treatment Options Conservative treatment: Conservative treatment: Various authors have reported poor outcomes with non-operative treatment Various authors have reported poor outcomes with non-operative treatment Bracing may not prevent instability Bracing may not prevent instability Further episodes of instability will most likely result in new meniscus tears and early arthritis Further episodes of instability will most likely result in new meniscus tears and early arthritis

Treatment Options Primary repair: Primary repair: May be attempted if ligament is avulsed from femoral or tibial insertions – may heal to provide temporary stability May be attempted if ligament is avulsed from femoral or tibial insertions – may heal to provide temporary stability Repair of midsubstance tears has resulted in persistent instability and decreased activity level Repair of midsubstance tears has resulted in persistent instability and decreased activity level

Treatment Options Extraarticular tenodesis: Extraarticular tenodesis: May provide anterior tibial stability and eliminate the pivot shift May provide anterior tibial stability and eliminate the pivot shift Not an anatomic reconstruction Not an anatomic reconstruction Overloaded lateral joint compartment may undergo premature degenerative changes Overloaded lateral joint compartment may undergo premature degenerative changes

Treatment Options Intra-articular reconstruction: Intra-articular reconstruction: Should be avoided in young patients with open growth plates Should be avoided in young patients with open growth plates Involves drilling through growth plates, which may cause physeal injury and growth arrest Involves drilling through growth plates, which may cause physeal injury and growth arrest

The Million $$$ Question: What is the best option for a patient with a torn ACL and open growth plates? What is the best option for a patient with a torn ACL and open growth plates? ACL Repair with Semitendinosus Augmentation ACL Repair with Semitendinosus Augmentation

The New Technique Semitendinosus is detached proximally, remains intact at the insertion Semitendinosus is detached proximally, remains intact at the insertion Passed under the intermeniscal ligament, running alongside the remaining stump of the ACL Passed under the intermeniscal ligament, running alongside the remaining stump of the ACL Passed over the top of the femur Passed over the top of the femur Held in place with screw and ligament washer proximal to physis Held in place with screw and ligament washer proximal to physis

The New Technique Clinical Orthopaedics, George A. Paletta, and Carl L. Stanitski; Ch. 63, p.779

The New Technique Three #1 PDS sutures are passed through the remaining stump of the ACL Three #1 PDS sutures are passed through the remaining stump of the ACL

The New Technique ACL stump is freed up from adhesions to PCL, to increase excursion ACL stump is freed up from adhesions to PCL, to increase excursion

The New Technique Gaffe is introduced into the lateral portal, passed intra-articularly to locate the over-the-top position Gaffe is introduced into the lateral portal, passed intra-articularly to locate the over-the-top position Skin incision made over the gaffe Skin incision made over the gaffe IT band is split IT band is split

The New Technique Double-looped passing suture is placed through the gaffe and brought out through the medial portal Double-looped passing suture is placed through the gaffe and brought out through the medial portal

The New Technique Sutures from the ACL are then brought out through a cannula placed in the medial portal Sutures from the ACL are then brought out through a cannula placed in the medial portal ACL sutures are then passed through the double-looped passing suture to the over-the-top position ACL sutures are then passed through the double-looped passing suture to the over-the-top position

The New Technique Incision is made over the hamstrings, semitendinosus is harvested Incision is made over the hamstrings, semitendinosus is harvested

The New Technique 2-0 Ticron is placed through the detached proximal end of the semitendinosus 2-0 Ticron is placed through the detached proximal end of the semitendinosus A 60° suture passer containing the Tycron is placed through the incision and under the intermeniscal ligament into the knee joint A 60° suture passer containing the Tycron is placed through the incision and under the intermeniscal ligament into the knee joint

The New Technique

The harvested semitendinosus is then pulled through the knee joint, also to the over-the-top position alongside the remaining stump of the ACL The harvested semitendinosus is then pulled through the knee joint, also to the over-the-top position alongside the remaining stump of the ACL

The New Technique The graft and sutures are tied down over a 6.5mm screw and spiked ligament washer The graft and sutures are tied down over a 6.5mm screw and spiked ligament washer

The New Technique Graft in full extension: Graft in full extension:

After Surgery Typically 3-5 days on crutches Typically 3-5 days on crutches Physical therapy is initiated as soon as possible after surgery Physical therapy is initiated as soon as possible after surgery Most patients report less pain after ACL repair with semitendinosus augmentation than with traditional intra-articular ACL reconstruction Most patients report less pain after ACL repair with semitendinosus augmentation than with traditional intra-articular ACL reconstruction

Results Since 1993, 13 patients have undergone this procedure Since 1993, 13 patients have undergone this procedure No growth arrest or angular deformity is present post-operatively No growth arrest or angular deformity is present post-operatively 100% of patients have returned to pre-injury activities 100% of patients have returned to pre-injury activities

X-rays Pre-op Pre-op Post-op

Graft at Later Arthroscopy Initial surgery Initial surgery 1 year later

Case Study 12-year old female gymnast falls off balance beam, tears her ACL 12-year old female gymnast falls off balance beam, tears her ACL Growth plates wide open on x-ray Growth plates wide open on x-ray Undergoes successful ACL repair with semitendinosus augmentation Undergoes successful ACL repair with semitendinosus augmentation

Case Study Same female, now age 14, tears her ACL in opposite knee running bases Same female, now age 14, tears her ACL in opposite knee running bases Growth plates are now closed Growth plates are now closed Undergoes traditional ACL reconstruction with bone-tendon- bone autograft Undergoes traditional ACL reconstruction with bone-tendon- bone autograft

Comparative X-rays 12 years old 12 years old 14 years old

Case Study Comparing knees, patient reports: Comparing knees, patient reports: Easier recovery and quicker return to activity with repair Easier recovery and quicker return to activity with repair Equal strength bilaterally Equal strength bilaterally Full range of motion bilaterally Full range of motion bilaterally Equal stability bilaterally Equal stability bilaterally

Summary ACL repair with semitendinosus augmentation is a safe and effective procedure in patients with a torn ACL and open growth plates ACL repair with semitendinosus augmentation is a safe and effective procedure in patients with a torn ACL and open growth plates QUESTIONS? QUESTIONS?