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Pediatric ACL Injuries
- 1. Plano, Texas Pediatric ACLSurgery Management and Technical Considerations Dustin Loveland, MD Sports Medicine and Trauma Surgeon Children’s Health Andrews Institute Plano, TX 1 Privileged and Confidential
- 2. Plano, Texas Objectives • Discussthe epidemiology of ACL injuries in young athletes • Learn the differential diagnosis of ACL injuries • Identify risk factors for pediatric ACL injuries • Understand the surgical options for the young athlete with an ACL injury 2 Privileged and Confidential
- 3. Plano, Texas 3 Privilegedand Confidential
- 4. Plano, Texas On-Field Recognition •Often non-contact injuries (~70%) • Often inability to bear weight 4 Privileged and Confidential
- 5. Plano, Texas Knee Effusion •Especially in a skeletally immature patient, NO return to play • Needs Orthopedic referral and likely MRI • Swelling may be a marker of a more severe injury – 47% of preadolescent and 65% of adolescent athletes dx with ACL tear • Stanitski JPO 1993 5 Privileged and Confidential
- 6. Plano, Texas Diagnosis • AlwaysX-ray an athlete with a traumatic effusion – Physeal (growth plate) fracture – Patellar dislocation – Osteochondral fracture – Tibial spine avulsion • My options – Urgent care vs ED? – Saturday Morning Clinic – Monday clinic 6 Privileged and Confidential
- 7. Plano, Texas Diagnosis 7 Privileged andConfidential
- 8. Plano, Texas Pediatric ACLReconstruction 8 Privileged and Confidential
- 9. Plano, Texas ACL Tearsin the Growing Athlete • 38 million young athletes participate in sports annually in the US • 2 million high school students treated for sports-related injuries per year • Why this “new” epidemic of sports injuries? – Title IX – Year-round competition – Single sport concentration – More intense training – Awareness – Imaging 9 Privileged and Confidential
- 10. Plano, Texas ACL Tearsin the Growing Athlete • Female soccer players have the highest rate of injury – 14.08 per 100,000 exposures • Male football players second highest – 13.87 per 100,000 exposures • Comstock et al. 2012 10 Privileged and Confidential
- 11. Plano, Texas ACL Tearsin the Growing Athlete • Young athletes do poorly without a reconstruction – Persistent instability – Meniscus/Cartilage injuries – Early osteoarthritis 11 Privileged and Confidential
- 12. Plano, Texas Better Resultswith Reconstruction 12 Privileged and Confidential International Olympic Committee Pediatric ACL Injury Consensus Group, et al. Orthop J Sports Med. 2018 Kay J, et al. Knee Surg Sports Traumatol Arthrosc. 2018 Parikh SN, ed. Pediatric Anterior Cruciate Ligament: Evaluation and Management Strategies. New York, NY; Springer Publishing Co; 2018. Ramski DE, et al. Am J Sports Med. 2014 Saltzman BM, et al Am J Sports Med. 2016 Sommerfeldt M, et al. Orthop J Sports Med. 2018 Werner BC, et al. J Pediatr Orthop. 2016
- 13. Plano, Texas ACL Reconstruction •Surgical replacement of the torn ACL • Techniques – May be based on skeletal maturity of the patient • Graft Choices 13 Privileged and Confidential
- 14. Plano, Texas Skeletal Maturity 14 Privilegedand Confidential
- 15. Plano, Texas Skeletal Maturity •Knee Radiographs • Knee MRI • Bone Age (research/education) • Onset of menses 15 Privileged and Confidential
- 16. Plano, Texas Public ServiceAnnouncement • 50% of ACL reconstructions in the US are done by surgeons who do less than 10 per year • ATCs: – Know who is doing your kid’s ACL reconstruction – Second opinions are ok • Especially if treatment does not sound appropriate 16 Privileged and Confidential
- 17. Plano, Texas Public ServiceAnnouncement • Allograft ACLs are NOT OK in kids • Unacceptably high rate of failure • Multiligamentous knee injuries may be an exception 17 Privileged and Confidential
- 18. Plano, Texas Pediatric ACLReconstruction • Prepubescent • Males <12y • Females <11y 18 Privileged and Confidential
- 19. Plano, Texas Pediatric ACLReconstruction • AVOID Growth Plates!!! 19 Privileged and Confidential
- 20. Plano, Texas Pediatric ACLReconstruction • Phyeseal sparing with IT band • My preferred technique 20 Privileged and Confidential
- 21. Plano, Texas Pediatric ACLReconstruction • Another great option • All-epiphyseal ACLR 21 Privileged and Confidential
- 22. Plano, Texas Young AdolescentACLR • Males 13-15y • Females 12-14y • Soft Tissue Grafts – Autografts! – Hamstring – Quadriceps Tendon • Tunnel Placement • No bone across growth plate 22 Privileged and Confidential
- 23. Plano, Texas “Adult” ACLReconstruction • Males 15y+ • Females 14y+ • Anatomic Tunnel Placement • Graft Choices – Patellar Tendon – Hamstring – Quadriceps Tendon 23 Privileged and Confidential
- 24. Plano, Texas Future Trends •Biologics – Platelet-Rich Plasma – Autologous Stem Cells • Limited data to prove efficacy • Options for harvesting 24 Privileged and Confidential
- 25. Plano, Texas Future Trends 25 Privilegedand Confidential
- 26. Plano, Texas Future Trends •ACL Repair! – We reattach ligaments all the time, why not the ACL? – Historic Literature • Very little success and eventually abandoned • But… – Open repairs – Mid-substance – Up to 90% concomitant injuries (unable to address) – Casted for 4-6 weeks, little to no rehab 26 Privileged and Confidential
- 27. Plano, Texas Future Trends •ACL Repair! – Mackay Ortho Muscul Syst 2015 – 68 patients • 3 year follow-up • 1 re-reupture • 3 re-operations where ACL intact 27 Privileged and Confidential
- 28. Plano, Texas Future Trends •Backup suture fixation 28 Privileged and Confidential
- 29. Plano, Texas Future Trends 29 Privilegedand Confidential
- 30. Plano, Texas Thank You 30 Privilegedand Confidential