1. ACL INJURIES IN YOUNG FOOTBALL PLAYERS
Tsoukas D , Simos C, Vissarakis G. Mediterraneo Hospital Athens Greece, Filoktitis Rehabilitation Center Athens Greece

2. Raise of children and adolescents injuries in sports

3. The knee is the most frequent site of musculoskeletal injury in the pediatric athlete.
Children and adolescents account for 0,5- 3% of all ACL injuries.
Shea et all found that ACL injuries accounted for 31% of all knee injuries in soccer players aged 5 to 18 years in United States
Management of pediatric ACL injuries requires understanding of bone growth, mechanisms of physeal injury and the natural history of delayed versus acute surgical management.

4. Treatment options Non surgical treatment:
Concern for meniscal and cartilage injury.
Surgical treatment:
Concern for growth disturbance

9. SO about ACL non surgical treatment:
Non surgical treatment of ACL injury in skeletally immature patients is disappointing.
There is a high incidence of repeated instability events and subsequent meniscal and gartilage damage.

10. GOAL of ACL Reconstruction:
To provide long term stability to the knee.
To minimize the risk of growth disturbance.

11. Most commonly used techniques for pediatric ACL reconstruction

13. MRI study by Sasaki,2002:physes are open 100% at 11 years of age but 94% closed at 15

15. From 2004 to 2013 we treated 36 young (mean age 14
From 2004 to 2013 we treated 36 young (mean age 14.3±2,2 years) athletes, 22 male and 14 female, with ACL intrasubstance tear.
Mean Tanner score was 2.3±0,7 and bone age more than 12.
Lachmann and pivot-shift test was the clinical test of choice and we used radiographs for patient sexual-skeletal maturation (criteria Greulich and Pyle) and Magnetic Resonance Imaging (MRI) for determining meniscal injuries.
Surgical repair as soon as possible was the favorite treatment using transphyseal technique with small centrally located tunnels and quadruple hamstrings graft.
11 had associated meniscal tears.

18. Post-op evaluation (min. 2 years).
Sublective IKDC and Lysholm knee scores.
Clinical examination,evaluation of leg length.
KT-1000 arthrometer.
Routine radiographs were taken at 6 weeks and 6 months for tunnel position and expansion,asymmetric or premature physeal closure ,or angular deformity.

21. Operative technique
Arthroscopically assisted transphyseal reconstruction with quadrupled hamstring graft.
Transtibial technique.10-or 2- o’clock position of the femoral tunel.No use of the medial portal in order to avoid exiting in the perichondral ring.
Very slowly drilled tunnels to minimize the thermal damage to the growth plate( mean diameter:8mm)
Endobutton for femoral fixation.
20 knee cycles to pretension the graft.
4,5 screw with washer below the tibial tunnel as a post for tension and tying of graft sutures.

24. Rehabilitation

25. Full weight bearing on the first day.
Hinged knee brace for one month locked in extension for the first two weeks.
Knee range of motion exercises, patellar mobilization, electrical stimulation, propioception and closed-chain strengthening exercices.
Straight line jogging, plyometrics and eventually sport specific exercices.

26. Results
No evidence of growth disturbance, all patients had knee extension equal to the non operated side, mean side to side difference in anterior displacement was 1.6±0.22 mm as measured by the KT 1000 at 134 N, and mean IKDC subjective knee score was 95.7± 2.1 out of 100.Return to sport without restriction at months after surgery.

27. Three dimensional studies based on CT and MRI scans have shown that a tunnel that is 8mm in diameter affects less than 3% of the area of the growth plate.
A 9mm tunnel also affects a smaller area than that required to cause arrest, which is 7% of the growth plate (Shea et all, Arthroscopy,2009 Dec;25(12).

29. Key points
The tibial tuberosity must be avoided to prevent genu recurvatum.
The drill holes must be in the center of the growth plate.
Damage to the growth plate can be minimized by drilling very slowly.
Only a soft tissue graft such as hamstrings should be used and fixed well away from the growth plate.
No excessive tensioning of the graft.
Follow the patient till skeletal maturity