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

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ACL Reconstruction in the Adolescent Athlete

  1. 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. 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. 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,<br />Annual cost >$2 billion<br />Skeletally Immature?: Incidence is Rising, Kocher ‘05<br />AOSSM – STOP Program<br />
  4. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 17. Physical exam<br />Palpation: Tenderness<br /><ul><li>Patellar retinaculum (dislocation)
  18. 18. Posterolateral (translational contusion)
  19. 19. Joint line (meniscus, chondral)
  20. 20. Collateral ligament (physis)</li></li></ul><li>Physical Exam<br /><ul><li>Lachman: sensitive Torg’76
  21. 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. 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. 23. Physiological Maturity &Projected Remaining Growth<br /><ul><li>Parental & Sibling heights
  24. 24. Onset of menarche/axillary hair: preceded by growth phase of peak height velocity (M-13.5/F-11.5)
  25. 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. 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. 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. 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. 29. Associated Pathology (ACL+)<br />Multiple ligaments<br />Repairable meniscus<br />Osteochondral lesions<br />
  30. 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. 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. 32. Phase II<br />6 weeks<br />Restore FROM<br />Normalize muscle balance: quad/hamstring ratio<br />Crutches discontinued<br />
  33. 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. 34. Activity Level<br />Level I <br /> (low risk)<br />Cycling<br />Swimming<br />Weight Training<br />Stairclimbing<br />
  35. 35. Activity Level<br />Level II <br /> (med risk)<br />Skiing-intermediate<br />Tennis<br />
  36. 36. Activity Level<br />Level III <br /> (high risk)<br />Skiing-expert<br />Basketball<br />Football<br />Soccer<br />Lacrosse<br />Volleyball<br />
  37. 37. Outcomes of Nonoperative Treatment<br />
  38. 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. 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. 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. 41. Nonoperative Treatment Outcomes<br />
  42. 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. 43. Skeletally ImmatureOperative treatment <br />
  44. 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. 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. 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. 47. Reconstruction Techniques<br />Extraarticular Approaches<br />Intraarticular Approaches<br />Graft Options<br />
  48. 48. Extraarticular Approaches<br />McIntosh Technique<br />Iliotibial Band Tenodesis<br />Largely historic techniques<br />Stretch out over time, poor rotational control<br />
  49. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 63. Case: All Epiphyseal Technique<br />Age: 13y 10m<br />Bone Age: 13y<br />
  64. 64. Case: All Epiphyseal Technique<br />Age: 11y 10m<br />Bone Age: 12y<br />
  65. 65. Femur: Flip Cutter - 2.75 cm tunnel<br />Tibia: Retrodrill – 2cm Tunnel<br />
  66. 66. Graft Passage: Femur Retrograde, Tibia Anterograde<br />Graft Fixation: Femur Tight-Rope, Tibia Retro-screw<br />
  67. 67. Case: All Epiphyseal All Inside<br />
  68. 68. Prepubescent<br />Tanner Stage 1 or 2<br />Males<12 Females<11<br /><ul><li>Temporize
  69. 69. All-Epiphyseal, All Inside Technique
  70. 70. Physeal-Sparing: Modified McIntosh
  71. 71. Partial Transphyseal</li></ul>9 year old girl<br />
  72. 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. 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. 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. 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. 76. Thank You<br />