Pediatric ACL Injuries

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Pediatric ACL Injuries

• A Amendola MD
• Professor , Orthopaedic Surgery
• Director , UI Sports Medicine
• University of Iowa

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ACL Injury Open Growth Plates

• Classification
• Non - traumatic
• - Congenital ACL absence
• Post - traumatic
• - Tibial eminence avulsion (common in agelt12)
• - Mid-substance tear ( common in agegt12 )
• - Femoral avulsion (rare, repair )

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ACL Injury Open Growth Plates
Children vs Adults

• Risk of operative Rx
• High activity level
• Patient compliance is difficult
• Consequences of recurrent episodes of giving way

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ACL Injury Open Growth Plates

• Mid-substance ACL Tears
• Juggling act

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ACL Injury Open Growth Plates

• Treatment Goals
• Protect menisci
• Prevent chronic instability, re - injury
• Address secondary articular, meniscal and
  ligamentous injuries

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ACL Injury Open Growth Plates

• Mechanism of Injury
• Quads active (as in adults)
• Fall from bike common
• Differential Diagnosis
• Growth plate injury
• Patellar dislocation
• ACL injury

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ACL Injury Open Growth Plates
Diagnosis

• H P
• haemarthrosis
• STS difference on ligamentous testing
• rule out physiological laxity

• Imaging
• AP, lateral, tunnel views
• Stress radiography ?
• MRI imaging of choice
• EUA

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Tibial Eminence Avulsions Classification

• Type I minimal / no displacement
• Type II anterior hinging (1/2 to 1/3 eminence)
• Type III avulsed fragment displaced
• Type IV avulsed and fragmented

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Tibial Eminence Avulsions Classification Rx

• Types II, III, IV
• Anatomical reduction essential
• Immobilize in extension

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Tibial Eminence Avulsions

• Recommendations
• Closed reduction with arthroscopic confirmation
• ORIF of irreducible fractures
• IMMOBILIZATION IN EXTENSION
• Prevent anterior tipping of fragment
• anterior tipping ? extension block

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Tibial Eminence Avulsions technique
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Tibial Eminence Avulsions
Results

• Good / excellent results if adequately reduced
• Meyers McKeever, 1970
• Molander et al., 1981
• Baxter Wiley, 1988
• Willis et al, 1993

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Tibial Eminence Avulsions Long Term Follow-up -
Willis et al.

• 50 patients, mean follow-up 4 yrs
• 30 closed reduction in extension
• 2 closed reduction _at_ 20 flexion
• 18 ORIF
• Results
• 84 returned to same level sports
• 10 complained of pain
• 98 no complaints of instability

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Tibial Eminence Avulsions Long Term Follow-up -
Willis et al.
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ACL Injury Open Growth Plates

• Mid - Substance ACL Tears
• Operative vs Non-Operative Rx ?

11 yo male 6 mos post injury
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ACL Injury Open Growth Plates

• Mid-substance Tears
• Non-Operative Treatment
• Rehabilitation
• Brace
• Adjust activities

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Conservative Treatment
• Chick Jackson 78
• Bradley et al. 79
• Clanton et al. 79
• Kannus Järvinen 88
• Angel Hall 89
• Mizuta et al 95
• Camanho et al 99
• Aicroth et al 2002

• Poor results (definitive or temporizing Rx)
• Low compliance with modified activity
• Poor prognosis for return to sport long term
  outcome
• High risk of associated meniscal tears
• Recurrent instability

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Conclusions

• Non Operative treatment may be best if
• Severely reduced activity and bracing
• Short duration
• Normal menisci and NO articular cartilage damage

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Conclusions

• Operative treatment indicated for
• Associated meniscal tears
• Symptomatic knee
• High risk activity level
• Long time to maturity

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Operative vs Non OP Treatment
• What is the evidence ?
• Managing Anterior Cruciate Ligament Deficiency
  in the Skeletally Immature Individual A
  Systematic Review of the Literature
• Nick Mohtadi, MD and John Grant, MD, PhD
  Clin J Sport Med 2006

• Included 63 / 615 cited studies
• No level I or II studies
• 4 level III
• 23 were level IV
• 35 were reviews or expert opinion ( level V )
• Evidence is weak

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ACL Injury Open Growth Plates

• Intraarticular ACLR evidence of risk

• Clinical studies suggest very low risk
• Laboratory studies confounding
• Significant risk
• Noule et al, 2001
• Edwards et al, 2001
• Some risk
• Guzzanti et al 1994
• Low Risk
• Stadelmeir et al 1995
• Janarv et al 1998
• Seil et al 2008

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Operative Treatment
• Herodicus and ACL Study Group Survey, 2003

• Numerous growth abnormalities, tibia and femur
• Various surgical techniques
• Variable response rate

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Intra-articular reconstruction
• Lipscomb Anderson, 1986
• McCarroll et al., 1994
• Parker et al 1994
• Andrews et al., 1994
• Lo et al., 1997
• Bisson et al 1998
• Gaulrapp Refior, 1999
• Edwards et al 2001
• Aicroth et al 2002
• GEbhardt et al 2006
• Macintosh et al 2007
• Kocher et al 2007
• No growth disturbance
• Variable techniques but transphyseal

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ACL Injury Open Growth Plates

• Differentiate between
• child with significant
• growth remaining and
• adolescent with little
• growth remaining.

BUT
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ACL Injury Open Growth Plates

• Dehaven et al, AOSSM 2003
• Significant growth remaining in adolescents
  close to maturity do not underestimate , and
  still treat as open physes

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ACL Injury Open Growth Plates

• McCarroll et al, AJSM 1994 PT Graft ACL
  Reconstruction in Junior High School Athletes
• mean age 14.2 yrs, tanner stage 4 or 5
• Standard ACL Reconstruction
• No growth disturbances
• 55/60 returned to sport

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Surgical Options
• Primary repair
• Extra-articular
• Intra-articular (transphyseal tunnels)
• Intra-articular without drill holes

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Primary Repair
• No better than in adults
• Gross instability
• ? activity level
• DeLee Curtis, 1983
• Engerbretsen et al., 1988
• Grontvedt et al., 1996

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Primary Repair
• A minimally invasive technique ("healing
  response") to treat proximal ACL injuries in
  skeletally immature athletes
• Steadman et al . JKS , 2006
• 13 cases over 6 years
• 3/13 revised to ACLR 2-4 years after
• 10/ 13 did well

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Extra-articular Reconstruction
• Physes are avoided
• Results deteriorate - ? instability
• - ? meniscal damage
• No role
• Graf et al., 1982 McCarroll et al.,
  1988

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ACL Injury Open Growth Plates
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ACL Injury Open Growth Plates

• From Kocher et al , JBJS 2005

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ACL Injury Open Growth Plates

• Literature review ACLR in wide open physes
• Andrews et al AJSM 1994 FL or Achilles
  allograft , 7mm tibial tunnel, OT femur
• Lo et al STG attached distally , small tibial
  tunnel, OT femur
• Graf et al Single or DSTG, tibial tunnel, OT
  femur
• No growth disturbance reported

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ACL Injury Open Growth Plates

• ACLR minimize the Risk
• Conclusions

• Avoid physes OR Smaller vertical tibial tunnel
• No bone, ie soft tissue grafts
• OT on the femur, do not groove the posterior
  aspect of roof
• Avoid fixation/hardware across physes, ie stay
  proximal and distal

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ACL Injury Open Growth Plates

• Mid-substance Tears
• Authors Preferred Treatment
• Intrarticular reconstruction/OTT
• Semi-T /- G
• Small (6mm) more vertical tibial tunnel
• Utilize the stump, no notchplasty

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ACL Injury Open Growth Plates
Meniscal debridement and repair
ACLR with semi-T through stump , over the top
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Technique
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Technique
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Technique
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Technique
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Technique
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Technique
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Technique
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Case no 1

• History
• 9 yo M, active and healthy
• 2 year history of recurrent R knee instability,
  several times per week
• No pain between episodes
• Diagnosis of congenital ACL deficiency

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Case no 1

• xrays

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Case no 1

• Treatment
• ACL recontruction
• ST doubled OTT
• Small drill hole on tibia, no violation of femur
• Meniscus, Articular cartilage N

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Case no 1
Post op
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Case 2 14 yo male
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Case 2 14 yo male
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Intra-articular Reconstruction Open Growth Plates

• Rehabilitation
• Functional
• Progressive
• As in adults

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ACL Injury Open Growth Plates
SUMMARY

• Operative vs non operative advantages and
  disadvantages
• Approach with caution, and try to protect the
  knee from further injury ( in my view a stable
  knee is required )
• Surgical technique should minimize trauma to
  growth plate, use soft tissue grafts