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ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
ACL Reconstruction in the Adolescent Athlete
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ACL Reconstruction in the Adolescent Athlete

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Presented by Frank A. Cordasco, MD, MS, The Sports Medicine and Shoulder Service, Hospital for Special Surgery

Presented by Frank A. Cordasco, MD, MS, The Sports Medicine and Shoulder Service, Hospital for Special Surgery

Published in: Health & Medicine, Sports
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  • 1. HSS educational activities are carried out in a manner that serves the educational component of our Mission. <br />As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation.<br />{Frank A. Cordasco, MD, MS}<br />{HSS}<br />Disclosure: I {DO NOT} have a financial relationship with any commercial interest related to the content of this lecture. <br />
  • 2. ACLReconstruction in the Adolescent Athlete<br />Frank A. Cordasco, MD, MS<br />The Sports Medicine and Shoulder Service<br />Hospital for Special Surgery<br />New York, NY<br />
  • 3. ACL Tears - Epidemiology<br />1/2452 skier visits Johnson ‘91<br />College football 42:1000 players/yr = 16% risk in 4 year career Hewson ‘86<br />100,000-250,000 ACL injuries/yr Zarins ‘88, www.cdc.gov<br />Annual cost >$2 billion www.cdc.gov<br />Skeletally Immature?: Incidence is Rising, Kocher ‘05<br />AOSSM – STOP Program<br />
  • 4. Increasing Incidence of ACL Injury<br />Increase in Sports Participation and Level of Competition among younger age groups (Title IX doubled denominator) <br />Societal and Parental Pressures<br />D1 Scholarships<br />College “Hook”<br />“Professional” Aspirations <br />Improved Examination, Imaging and Diagnostic Methods: Increased Awareness and Index of Suspicion<br />
  • 5. Public Health Costs<br />Average Cost surgical treatment rehabilitation per Athlete = $30,000<br /> Loss of season<br /> Academic performance<br /> Scholarship funding<br /> Mental health<br />
  • 6. Gender Specific Differences<br />Females 4-6 X higher risk knee injury<br />Females 2-8 X higher risk of ACL tear<br />
  • 7. Female ACL Injury Rate<br />NCAA Soccer: 2.4 X higher <br />Basketball: 4-5 X higher<br />Volleyball: 4 X higher<br />US Naval midshipmen: ~4X higher <br />
  • 8. Female Intrinsic Factors: Anatomic<br />Wider Pelvis<br />Greater Hip Varus<br />Femoral Anteversion<br />Knee Valgus<br />Increased Q-Angle<br />Foot Pronation<br />Smaller Notch<br />Increased general laxity<br />
  • 9. Female Intrinsic Factors: Hormonal<br />Estrogen receptors ACL fibroblasts Liu ’96<br />Elevated estradiol: decreased fibroblast proliferation and collagen synthesis Liu ’97<br />ACL tears > ovulatory phase Wojtys ’98<br />Pregnancy: Elevated Estrogen & Relaxin<br />No Consensus – more study required<br />
  • 10. Female Extrinsic Factors: Biomechanical<br />Cutting/landing: more erect hip/trunk<br />Cutting/landing: less knee flexion<br />“Quadriceps dominant” (males fire their hamstrings 3 X the level of females when landing from a jump & cutting)<br />Muscle fatigue ~ dynamic stability<br />
  • 11. ACL Anatomy<br />Intraarticular and extrasynovial<br />Ave length 31 mm<br />Lg collagen bundles<br />Type I collagen, small % Type II<br />Mechanoreceptors<br />
  • 12. ACL Anatomy<br />Anteromedial: taut in flexion<br />Posterolateral: taut in extension<br />Different portions in tension or relaxed at various angles<br />
  • 13. ACL Anatomy<br />NWI: notch width/condyle width<br />NWI < 0.2<br /> 60 X higher risk of noncontact tear and bilateral tear<br />
  • 14. ACL Anatomy<br />Majority:<br /> disrupt femoral origin or intrasubstance<br />Tibial eminence fx in children<br />Bony avulsion rare in adults<br />
  • 15. Clinical History<br />Low velocity<br />Deceleration<br />Non-contact<br />Mechanism<br />Valgus/ER<br />Hyperextension<br />Snap or “pop”<br />Giving way<br />
  • 16. Clinical Presentation<br />Hemarthrosis<br />ACL tear (10-65%)<br />Patellar Dislocation<br />Fracture, Physis<br />Meniscal tear<br />PCL tear<br />Capsular tear<br />Stanitski et al, J Ped Ortho ‘93<br />Matelic et al, AJSM ‘95<br />Kocher et al AJSM ‘01<br />
  • 17. Physical exam<br />Palpation: Tenderness<br /><ul><li>Patellar retinaculum (dislocation)
  • 18. Posterolateral (translational contusion)
  • 19. Joint line (meniscus, chondral)
  • 20. Collateral ligament (physis)</li></li></ul><li>Physical Exam<br /><ul><li>Lachman: sensitive Torg’76
  • 21. Pivot Shift: Pathognomonic (test in AB/ER, Bach’88)</li></li></ul><li>Physical exam<br /><ul><li>Instrumented knee testing: KT-1000 Daniel’85</li></li></ul><li>Skeletally Immature: Imaging<br />Xrays: AP, lat, notch, merchant<br />MRI<br />Patellar dislocation?<br />Physeal Maturity<br /> Open, Narrowed, or Closed<br />Physeal injury: stress views?<br />
  • 22. Skeletal Growth<br />Peak velocity<br />girls at age 11.5,<br />boys at age 13.5<br />Determination of skeletal maturity<br />Tanner scale<br />Bone age <br /> (left hand PA view)<br />“Simple approach”: pubescent vs prepubescent<br />Average growth (Dorias, 2003)<br />Girls (11-15 years)<br />Distal femur 9.8 cm<br />Proximal tibia 5.9 cm<br />Boys (11-17 years)<br />Distal femur 18.5 cm<br />Proximal tibia 9.7 cm<br />
  • 23. Physiological Maturity &Projected Remaining Growth<br /><ul><li>Parental & Sibling heights
  • 24. Onset of menarche/axillary hair: preceded by growth phase of peak height velocity (M-13.5/F-11.5)
  • 25. Shoe size stability</li></li></ul><li>Skeletally ImmatureOperative treatment: Patient Factors <br />Age: Skeletal maturity<br />Degree of injury: Exam, KT1000<br />Activity level: Risk & Competition<br />Associated pathology<br />GOAL: prevent recurrent injury<br />
  • 26. Assessing Skeletal Maturity<br />Chronologic age<br />Physiologic age<br />Tanner I/Child < 10: wide open plates<br />Tanner II,III/Pre-pubescent 10-13: open plates<br />Tanner IV,V/Pubescent 13-16: narrowed plates<br />Skeletal age<br />Bone age (left hand PA view or MRI w Physeal windows)<br />
  • 27. Assessing Skeletal Maturity<br />Peak velocity<br />Females <br /> Age 11-13 (avg. 11.5)<br />Tanner III<br />Precedes menarche by 1 year<br />Males <br />Age 13-15 (avg. 13.5)<br />Tanner IV<br />Precedes mature axillary hair<br />Parental & Sibling heights<br />Shoe size stability<br />
  • 28. The Dilemma Historically<br />Operative Treatment<br />Nonoperative Treatment<br />Early Reconstruction Risks: <br /> Growth disturbance<br /> Angular deformity<br /> Non-Adult Type Reconstruction: <br /> Less “Anatomic”<br />Possible Revision in Future,<br />“Bridge to Adult Type <br /> Reconstruction” <br />Delayed Reconstruction Risks: <br /> Ongoing instability<br /> Meniscus injury<br /> Cartilage injury<br /> Restricted Activity until Skeletal Maturity: Compliance<br />
  • 29. Associated Pathology (ACL+)<br />Multiple ligaments<br />Repairable meniscus<br />Osteochondral lesions<br />
  • 30. Nonoperative Treatment<br />Goal: Prevent Recurrent Injury: Preserve Meniscii and Articular Cartilage<br />“Temporizing Measure” until patient can undergo an “adult type” transphyseal reconstruction<br />Physical therapy<br />Three Phase Program (Stanitski)<br />Functional ACL brace<br />Activity modification<br />
  • 31. Phase I<br />7-10 days<br />PWB, brace<br />Active flexion, Passive extension<br />Patient education re consequences of high risk activities<br />
  • 32. Phase II<br />6 weeks<br />Restore FROM<br />Normalize muscle balance: quad/hamstring ratio<br />Crutches discontinued<br />
  • 33. Phase III<br />Functional Bracing<br />Return to low or moderate demand activities when Isokinetc testing reveals strength equal to opposite side at functional speeds (>260 degrees/sec)<br />
  • 34. Activity Level<br />Level I <br /> (low risk)<br />Cycling<br />Swimming<br />Weight Training<br />Stairclimbing<br />
  • 35. Activity Level<br />Level II <br /> (med risk)<br />Skiing-intermediate<br />Tennis<br />
  • 36. Activity Level<br />Level III <br /> (high risk)<br />Skiing-expert<br />Basketball<br />Football<br />Soccer<br />Lacrosse<br />Volleyball<br />
  • 37. Outcomes of Nonoperative Treatment<br />
  • 38. ACL Deficiency: Natural HistoryNon-operative treatment<br />Instability 72%<br />Pain 48.5%<br />Swelling 34.7%<br />ACL reconstruction – late 56.9%<br />Xray OA 21-85%<br />Marzo & Warren ’91<br />
  • 39. Nonoperative Treatment Outcomes<br />Moksnes et al. KSSTA 2008<br />20 patients < age 12, 21 knees <br />Avg age 10 at time of injury<br />Evaluated 2 years after injury<br />Classified as copers if: resumed pre-injury level, performed >90% on all hop tests<br />65% had resumed preinjury activity, 50% classified as copers<br />9.5% with secondary meniscus injury <br />
  • 40. Nonoperative Treatment Outcomes<br />Woods GW, O’Connor DP AJSM 2004<br />13 adolescents delayed reconstructions until physeal bridging<br />Avg 70 weeks to reconstruction<br />Compared to 116 skeletally mature adolescents who underwent ACL reconstruction<br />Strict activity restriction from all cutting/jumping activities<br />Brace wear at all times<br />No difference in rates of:<br />Meniscal injury<br />Articular cartilage injury<br />Additional surgery<br />
  • 41. Nonoperative Treatment Outcomes<br />
  • 42. Skeletally ImmatureNon-operative treatment <br />Trends parallel Adult Natural History: Increased risk for further Instability Episodes, Meniscus and Chondral Injuries<br />Nonoperative Treatment Requires Strict Activity Limitations<br />Easy to Control Organized Sports<br />Difficult to Control Free Play<br />
  • 43. Skeletally ImmatureOperative treatment <br />
  • 44. Skeletally ImmatureOperative treatment <br />Primary concern is growth disturbance<br />Femoral tunnel<br />Angular (Valgus) deformity<br />Leg length discrepancy<br />Tibial Tunnel<br />Leg length discrepancy<br />Recurvatum deformity<br />
  • 45. Skeletally ImmatureOperative treatment <br />Kocher MS et al JPO 2002<br />Herodicus and ACL Study Group Survey<br />15 cases of growth disturbance<br />8 femoral valgus deformity with lateral distal femoral Physis arrest<br />3 tibial recurvatum<br />2 LLD<br />2 genu valgum without arrest<br />Observed potential factors:<br />Hardware across Physis<br />Bone plugs across Physis<br />Large tunnels<br />Hardware across Tibial Tubercle Apophysis<br />
  • 46. Transphyseal Surgical Principles from Animal Studies<br />Tunnels filled with soft tissue grafts may not result in transphyseal bone bridges (Stadelmaier et al. 1995, Seil et al. 2008)<br />Grafts placed under tension may cause physeal injury/growth arrest without a bar (Edwards et al. 2001)<br />The cross-sectional area of the drill hole should be minimized in transphyseal approaches <br />Safe zone 3-7% (Guzzanti et al 1994, Janarv et al 1998)<br />Limitation: In animal models remaining growth duration quite brief compared to adolescent boys<br />
  • 47. Reconstruction Techniques<br />Extraarticular Approaches<br />Intraarticular Approaches<br />Graft Options<br />
  • 48. Extraarticular Approaches<br />McIntosh Technique<br />Iliotibial Band Tenodesis<br />Largely historic techniques<br />Stretch out over time, poor rotational control<br />
  • 49. Intraarticular Approaches<br />Goal: <br />Provide Stability, Avoid Physeal Injury and Prevent Meniscus/Cartilage Injury <br />Physeal-Sparing Techniques<br />Partial Intra-articular/Extra-articular: Modified McIntosh (Kocher)<br />All-Epiphyseal: More Anatomic (Guzzanti/Stanitski, Anderson, Ganley)<br />Partial Transphyseal Techniques (Transtibial, Over-the-Top Femur)<br />Complete Transphyseal Techniques (Paletta)<br />
  • 50. Graft Options<br />Hamstring Autograft in most cases<br />BTB Autograft reserved for Adult-Type Reconstructions in Older Adolescents with closing physes<br />Allografts: High Failure Rates in the Adolescent population (Moon Consortium ‘10)<br />
  • 51. Physeal-Sparing: “Over-the-Top” on Tibia and Femur<br />No Bone Tunnels<br />Distally based ST/ G <br /> Over-the-Top on the <br /> Femur<br />Under meniscal <br /> coronary ligament <br />(Brief, Arthroscopy, 1991)<br />Groove anterior tibial<br /> epiphysis <br />(Parker et al, AJSM 1994)<br />
  • 52. Physeal-Sparing: Modified McIntosh<br />Kocher, Micheli JBJS Am 2005<br />ITB harvested proximally  over the top position  under meniscal coronary ligament<br />44 patients, Tanner I/II<br />2 revisions at 5, 8 years<br />98% normal/near normal Lachman<br />100% normal/near normal Pivot<br />Mean IKDC 96.7, mean Lysholm 95.7<br />No growth disturbances <br />? Over-Constrained<br />
  • 53. Physeal-Sparing: All-Epiphyseal<br />Guzzanti, Stanitski AJSM 2003<br />8 patients, Tanner I<br />Age 11.5<br />Bone age 10.9<br />ST/GR graft, left attached to tibia<br />Transphyseal tibial tunnel, looped around staple in shallow groove at femoral origin<br />No LLD or angular deformity <br />
  • 54. Physeal-Sparing: All Epiphyseal<br />Anderson JBJS Am 2005<br />12 patients <br />Average age 13.3<br />Mean f/u 4.1 years<br />Quad HS graft, femoral/tibial tunnels <br /> through epiphyses<br />Mean IKDC 96.5<br />KT-1000 mean side-to-side difference 1.5 mm<br />IKDC objective: 7 normal, 5 nearly <br /> normal<br />No LLD or angular deformities<br />Mean growth surgery to f/u 16.5 cm<br />
  • 55. Physeal-Sparing: All Epiphyseal<br />Lawrence, Ganley CORR 2010<br />3patients <br />Ages 10-12, All Male<br />F/U 1 year<br />Quad HS graft, femoral/tibial tunnels <br /> through epiphyses, Retro-drill on Tibia<br />Lachman and Pivot Normal<br />KT-1000 less than 1 mm side-to-side difference @ MMD<br />All returned to sport in functional brace <br />No LLD or angular deformities @<br /> minimum f/u 1 year<br />
  • 56. Physeal-Sparing: All Epiphyseal<br />Guzzanti, Stanitski AJSM 2003<br />Anderson JBJS Am 2005<br />Lawrence, Ganley CORR 2010<br />Quad HS graft, femoral/tibial tunnels <br /> through epiphyses<br />NormalLachman + Pivot<br />Mean IKDC > 95<br />KT-1000 mean side-to-side difference < 1.5 mm<br />IKDC objective: normalor nearly <br /> normal<br />No LLD or angular deformities<br />
  • 57. Partial Transphyseal<br />Transphyseal 6-8mm tibial tunnel, central & vertical<br />Femoral position<br />Over the top (Lo, Andrews)<br />Epiphyseal (Lipscomb & Anderson)<br />Avoids more common valgus deformity<br />Tanner Stage <br /> 2 or 3<br />
  • 58. Partial Transphyseal<br />Lipscomb and Anderson JBJS Am 1986<br />24 patients, age 12-15<br />Tibia transphyseal, femur epiphyseal<br />20/24 returned to same activity level, no objective instability<br />One LLD 2 cm <br />Andrews et al. AJSM 1994<br />8 patients, age 9-15<br />Tibia transphyseal, femur over the top, facia lata or achilles allograft<br />No objective instability<br />No significant LLD<br />Lo et al. Arthroscopy 1997<br />5 patients, age 8-14<br />Tibia transphyseal, femur over the top<br />No objective instability<br />No LLD/Angular deformity<br />
  • 59. Complete Transphyseal<br />Femoral & Tibial Transphyseal tunnels<br />Soft tissue grafts<br />Central, more vertical<br />Paletta, HSS Alumni meeting ‘09, AAOS ‘10<br />
  • 60. Complete Transphyseal<br />Liddle et al JBJS Am 2008<br />17 patients, Tanner I/II<br />Avg age 12 (9.5-14)<br />One failure<br />One valgus angular deformity<br />Kocher et al JBJS Am 2007<br />61 patients, Tanner III<br />Avg age 14.7 (11-16.9)<br />3% revision rate<br />Lachman/pivot shift all normal/ nearly normal<br />Mean height increase 8.2 cm<br />No angular deformity/LLD<br />Cohen et al Arthroscopy 2009<br />26 patients, 5 Tanner I/II, 21 II/IV<br />Avg age 13.3<br />3 failures<br />No angular deformity/LLD<br />
  • 61. ACL Reconstruction Failure in Children/Adolescents<br />Shelbourne et al AJSM 2009<br />Risk of retear 8.7% if <18<br />Risk of retear 1.7% if >18<br />Kaeding et al (MOON Cohort) AOSSM 2008<br />Highest re-tear rates in 10-19 yo<br />Risk of re-tear decreases by factor of 2 with each decade<br />Must Counsel Parents Regarding Higher Potential for Failure<br />
  • 62. Revision ACL Reconstruction in Adolescents<br />36 patients, Age 12-17, 22 Female, 14 Male<br />Interval between Primary and Revision: Average 18 months<br />Physeal Status @ Primary: Open 10, Partially Open 3, Closed 21 <br />Primary Graft: BTB 15, HS 13, Allograft 8<br />Reason for Failure: Non-Contact 23, Contact 7, Persistent Instability 5, Infection 1<br />Revision: Complete Transphyseal in all<br />F/U 2 years: Lachman Negative or 1A in 91%, Pivot Negative 96%<br />Mean IKDC subjective score: 89.1<br />Only 57% returned to the same or higher level of activity sport<br />8% required additional revision<br />Reinhardt et al ISAKOS 2011<br />
  • 63. Case: All Epiphyseal Technique<br />Age: 13y 10m<br />Bone Age: 13y<br />
  • 64. Case: All Epiphyseal Technique<br />Age: 11y 10m<br />Bone Age: 12y<br />
  • 65. Femur: Flip Cutter - 2.75 cm tunnel<br />Tibia: Retrodrill – 2cm Tunnel<br />
  • 66. Graft Passage: Femur Retrograde, Tibia Anterograde<br />Graft Fixation: Femur Tight-Rope, Tibia Retro-screw<br />
  • 67. Case: All Epiphyseal All Inside<br />
  • 68. Prepubescent<br />Tanner Stage 1 or 2<br />Males<12 Females<11<br /><ul><li>Temporize
  • 69. All-Epiphyseal, All Inside Technique
  • 70. Physeal-Sparing: Modified McIntosh
  • 71. Partial Transphyseal</li></ul>9 year old girl<br />
  • 72. Adolescent with Growth Remaining<br />Tanner Stage 2 or 3<br />Males 13-16<br />Females 12-14<br />Partial Transphyseal<br />Femoral Epiphyseal<br />Over-The-Top<br />Complete Transphyseal with Metaphyseal Fixation<br />13 year old girl<br />
  • 73. Older Adolescent with Closing Physes<br />Tanner Stage 4 or 5<br />Males > 16, Females > 14<br />BTB Autograft an option<br />Adult-Type Transphyseal<br />Reconstruction with Epiphyseal <br /> Fixation (Interference Screws) an <br /> option<br />
  • 74. Summary<br />ACL injuries on the rise (Adult, Adolescent and Pediatric)<br />Non-Operative Treatment possible but Requires strict activity limitation, Bracing: Compliance ?<br />Natural History: Non-Operative Treatment results in High Failure Rate and High rates of meniscus/cartilage injury with Delayed Reconstruction<br />Allografts Not Recommended<br /> (Higher Failure Rates)<br />
  • 75. Summary<br />Prepubescent, Tanner 1 or 2, M<12 F<11: <br />Physeal Sparing:All Epiphyseal, All-Inside<br />Physeal Sparing: Modified McIntosh (Kocher)<br />Partial/Complete Transphyseal (Paletta)<br />Adolescent with Growth Remaining, <br /> Tanner 2 or 3, M:13-16, F12-14<br />Partial Transphyseal Femur over the top or epiphyseal<br />Older Adolescent with Narrowed Physis, Tanner 4 or 5, M>16, F>14: <br />Complete Transphyseal, BTB Autograft<br />Younger age = Higher risk of Failure <br /> regardless of technique<br />
  • 76. Thank You<br />

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