Pediatric ACL Injuries - American Osteopathic Academy of Sports

Corey R. Troxell, D.O. October 9, 2012 OMED 2012 Pediatric ACL Injuries   >100,000 ACL Reconstructions per year in US   Increased youth sports participation   Increased youth injuries   Youth Sports related injuries   Age 6-­‐12   63% increase in injuries over last decade   Knee most commonly injured joint Pediatric ACL Diagnosis History •  Twisting Injury/Valgus • 
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Force Audible pop Effusion Pain Weightbearing status Hemarthrosis •  ACL tear -­‐ 47% •  Meniscus tear •  Patellar dislocation •  Osteochondral injury Pediatric ACL Diagnosis Physical Exam •  Most Important tool •  Can be difficult •  Inspection •  Palpation •  Range of Motion •  Ligament Laxity Pediatric ACL Diagnosis Physical Exam   Assess ACL Stability   Anterior Drawer   Lachman   Pivot Shift  
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Extension Valgus stress Internal rotation Knee brought into flexion   IT band reduces subluxated tibia Pediatric ACL Diagnosis – Xrays   Important initial study   Physeal evaluation   4 view  
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AP Lateral Sunrise Notch/Tunnel   Osteochondritis dissecans   Loose bodies   Fracture   Tibial eminence fracture  
26% ACL injuries if physes wide open LaFrance et al Tibial eminence fractures   Contact and Noncontact injuries   Nondisplaced   Nonoperative treatment   Displaced   Surgical Repair   Most heal   Residual ACL laxity   Pre-­‐fracture ACL attenuation Tibial Eminence Fracture ClassificaCon Modified Myers and
McKeever
LaFrance et al
  Type I – Non-­‐displaced   Type II – Displaced anterior margin, intact posterior cortex   Type III – Completely Displaced   A – Footprint only   B – Entire Tibial Eminence   Type IV – Displaced and comminuted Tibial Eminence Fracture Treatment   Type I   Immobilization  
Cast or knee immobilizer   Type II   Closed Reduction and immobilization   Surgical Fixation   Type III and IV   Surgical Fixation   ORIF – screw or suture fixation   ARIF – suture fixation Tibial Eminence Fracture Treatment   ARIF   Arthroscopic Reduction and Internal Fixation   Suture Fixation   Drill tunnels through tibia   Suture passed through tunnel   Suture passed through ligament near attachment   Suture out through other tunnel   Tied over bony bridge Lafrance et al Pediatric ACL Diagnosis -­‐ MRI   Clinical statistics indicate physical exam more reliable   Useful as adjunct to physical exam   Import diagnostic tool   evaluation other intra-­‐
articular injuries Pediatric ACL Diagnosis -­‐ MRI   Characteristic Bone Bruise   Anterior or Mid Aspect Lateral Femoral Condyle   Posterior Tibial Plateau   ACL disrupted or stretched to create injury pattern   Indicative of acute injury Roberts CC et al Pediatric ACL Treatment Skeletal Maturity   Concern for physeal injury in ACL reconstruction   Growth Spurt initiation   12.5 years in boys   10.5 years in girls   Peak Growth Velocity   1 year later   Precedes menarche in girls   Tanner Staging   Bone Age   Hand Xray radiology.rsna.org Pediatric ACL ComplicaCons   Physeal Injury During Surgery   Distal femur   Proximal tibia   Growth Disturbance   Limb length discrepancy Femoral overgrowth   Valgus deformity   Genu recurvatum  
  Rare in properly performed reconstructions Pediatric ACL Treatment OpCons   Delayed Recontruction   Physeal Sparing Reconstruction   Partial Transphyseal Recontruction   Complete Transphyseal Reconstruction Delayed ACL ReconstrucCon   Most ACL tears 6-­‐12 months of skeletal maturity   Wait?   Restrict/Modify activities   Prohibit teams sports   Prohibit pivoting and jumping   Difficult!!!   Custom ACL Bracing   Strengthening and Rehabilitation   Wait for physes to close or for near closing Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Millet PJ, Willis AA, Warren RF: Arthroscopy. 2002 Nov-­‐Dec:18(9):955-­‐9  
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Retrospective review 39 patients 14 years old and younger Acute injury  
Surgery within 6 weeks  
17 patients  
11% medial meniscus tears Chronic injury  
Surgery after 6 weeks  
22 patients  
36% medial meniscus tears Lateral mensicus tears equal in both groups DegeneraCon of the knee joint in skeletally immature paCents with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Lawrence JT, Argawal N, Ganley TJ American Journal of Sports Medicine. 2011 Dec;39(12):2582-­‐7. Epub 2011 Sep 14.   70 Pediatric ACL Reconstructions   Increase time to reconstruction   Associated with medial meniscal tears   Associated with medial and lateral chondral injuries   29 late reconstructions   >12 weeks   Increased severity of medial meniscal tears   Higher grade lateral and patellar chondral injuries   Sense of instability also associated with meniscal injuries Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relaConship of treatment Cme and paCent-­‐specific factors. Dumont GD et al. American Journal of Sports Medicine 2012 Sep;40(9):
2128-­‐33. Epub 2012 Jun 22.   Retrospective Review   370 pediatric ACL reconstructions 2005-­‐2011   241 early (≤150 days)   37.8% meniscus tear   129 delayed (>150 days)   53.5% meniscus tear   Increased age and Increase Weight also associated with higher rate of meniscal tear   Presence of chondral injury significantly associated with meniscal tears ACL ReconstrucCon Physeal-­‐Sparing Techniques   Extra-­‐articular techniques   Non-­‐anatomic   Developed to avoid physes   Generally poor results   Avoid Drilling through bone   Trans-­‐epiphyseal drilling   Does not cross growth plate   New implants   Fluoroscopy aided  
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C-­‐arm O-­‐arm Klingele et al Physeal-­‐Sparing Techniques   Guzzanti et al 2003   5 patients   Tanner Stage I   Leave hamstring attached   Trans-­‐epiphyseal tibial tunnel  
Proximal to physis   Staple at femoral attachment   No growth disturbance   KT-­‐2000 1.8 mm side-­‐side difference Physeal Sparing Techniques   Anderson 2003   12 patients   Tanner stage I-­‐III   Fluoroscopic guided drilling  
Avoid physis   Femoral tunnel drilling distal to physis  
Endobutton fixation   Tibial tunnel drilling proximal to physis  
Post fixation distal to physis   No growth abnormalities, limb-­‐
length discrepancies or KT-­‐1000 differences   IKDC scores and objective ratings excellent Larsen et al ParCal Transphyseal Techniqe   Femoral physis left intact   Tibial physis drilled with small 6 to 8 mm tunnel   <5% physeal cross-­‐sectional area   Tibial tunnel more vertical than typical to decrease physeal damage Larsen et al Complete Transphyseal Technique   Conventional Adult-­‐Style Reconstruction   Potential option even in skeletally immature   Several studies have reported good results with few complications   Grafts with bone plugs?   SOFT TISSUE GRAFTS  
Avoid Physeal bar across physis Stanitiski Which ReconstrucCon Technique to Choose?   Tanner 0 and 1   Physeal Sparing   Tanner 2   Physeal Sparing   Partial Trans-­‐Physeal   Tanner 3 and greater   Physeal Sparing   Partial Trans-­‐Physeal   Transphyseal  
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All soft tissue graft Small tunnel Vertical tunnels   Physeal Sparing Technqique   Males less than 14 ½   Females with bone age less than 13 Pediatric ACL Injuries   Modern Reconstruction Techniques are Effective and Safe   What could be better???..............................  ACL INJURY PREVENTION!   What is it?   Does it work?   What are the limitations? ACL Injury PrevenCon RehabilitaCon Program   Strengthening   Secondary dynamic stabilizers   Hamstrings/Quadriceps   Plyometrics   Flexibility   Balance and Proprioception exercises   TEACH HOW TO LAND CORRECTLY   Slightly flexed knee   Body over knee Dynamic sagibal plane trunk control during anterior cruciate ligament injury. Sheehan FT, Sipprell WH 3rd, Boden BP: American Journal of Sports Medicine 2012 May; 40(5): 1068-­‐74. Epub 2012 Mar 1   Movie captures of 20 athletes performing 1-­‐legged landing resulting in ACL tear   Movie captures of 20 athletes performing similar maneuver not resulting in ACL tear   Evaluation   Center of Mass to Base of Trunk Distance   Trunk Angle   Limb Angle   Significant difference in ALL 3   Center of Mass average 38 cm more posterior in ACL tear   Potential modifiable risk factor by prevention program ACL Injury PrevenCon   Does it work ………….…Maybe, yes. …………….Still controversial.   Strong studies still lacking EffecCveness of anterior cruciate ligament injury prevenCon training programs Sadoghi P, von Keudell A, Vavken P: Journal of Bone and Joint Surgery 2012 May 2;94(9):769-­‐76   Systematic review of literature   Significant reduction in prevention group   P=0.003   Number needed to treat ranged from 5 to 187   52% reduction in female athletes   85% reduction in male athletes The 2012 ABJS Nicolas Andry Award: The Sequence of PrevenCon: A SystemaCc Approach to Prevent Anterior Cruciate Ligament Injury. Heweb TE, Myer GD, Ford KR, Paterno MV, Quatman CE: Clincial Orthopaedics and Related Research 2012 Oct:470(10):2930-­‐40. Epub 2012 Jun 29   Modifiable Risk factors in ACL injury   Biomechanical   Neuromuscular functionality   Implement in Childhood and Early adolescence Efficacy and Degree of Bias in Knee Injury PrevenCon Studies: A SystemaCc Review of RCTs Grimm NL, Sheas KG, Leaver RW, Aoki SK, Carel JL: Clincal Orthopaedic and Related Research 2012 Sep 8 Epub   Systematic search   Randomized Control Trials only   10 Level 1 Studies   2 reported reduction in knee injuries   8 showed no benefit   Literature to support ACL prevention is limited   Future research should more clearly describe methodology ACL PrevenCon Protocol   Difficult to implement   Who will teach/pay?   Athletic trainers  
Overworked/busy   Physical Therapists   Insurance coverage   Co-­‐Pays  
Time ACL Injury PrevenCon   Annual Free Clinic   Youth athlete and parents are educated   Instructed on Home Exercise Prevention Program   Given Theraband   Home Program Squat with RotaConal Jump   Feet shoulder width   Head up, eyes forward   Bend hips, knees   Knees over toes   Thighs parallel to ground   Return and repeat x 2   3rd squat – explode and turn 90 degrees   Land on balls of feet, knees slightly flexed Heel Bridging – Single Leg Bridge   Lay on back   Bend one knee and lift toes of same leg   Weight on heel   Lift straight leg to height of bent knee   Hold   Maintain level hips Broad Jump   2 footed jump forward   Land on balls of feet   Good balance with landing Single Leg Squat   Feet shoulder width   Arms forward   Lift one foot forward   Lean forward   Descend to chair/box   Return to starting position Test the Water   4 inch step   Flex ankle so toes higher than heel   Keep torso upright   Bend contralateral knee and lower body until heel touches ground   Push yourself back up Lunges – Forward, Lateral and RotaConal   Forward  
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Step forward Lower to lunge position Front and back knee 90° Keep weight on heels Push back up   Lateral  
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Step to side Bend knee of step leg Knee tracks over shin Push back up   Rotational  
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Feet at right angles Bend back knee Front leg straight Toes of front foot up Push back up Russian Hamstring Curl   Knees bent 90°   Lean forward lowering body   Contract hamstrings to return Single Leg Romanian Dead Lij   Feet shoulder width   Bend knees   Pick one leg behind, slightly bent   Reach down to shin level with opposite hand of leg on ground   Hold and return Single Leg Hop to Step   Stand on one foot   Hop onto box/step with same foot   Keep knee bent for landing   Do NOT land with leg straight   Change directions 3-­‐way Hip with Band   Stretch band around ankles   Keep legs straight   Stand on one leg   Move other leg forward, out to side, back at angle   Maintain balance ACL PrevenCon Protocol   Easy to learn   Minimal assistance required   Done at home   Minimal equipment required   Block/step   Theraband   Large, Multi-­‐Center, Randomized, Prospective Study Still Needed to Determine True Efficacy Pediatric ACL Injury Summary  2 TAKE HOME POINTS!!!!   Delayed Reconstruction Leads to Increased Medial Meniscus Tears and Chondral Injuries  
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Particularly with recurrent sense of instability Early Reconstruction with Appropriate Technique is Superior   ACL injuries may be decreased with Prevention Rehabilitation Programs   www.stopsportsinjuries.org  Thank You! References   Larsen MW, Garret WE, DeLee JC, Moorman CT: Surgical Management of Anterior Cruciate  
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Ligament Injuries in Patients With Open Physes. J Am Acad Orthop Surg 2006;14:736-­‐44 Stanitski CL, Harvell JC, Fu F: Observations on acture knee hemarthrosis in children and adolescents. J Pediatr Orthop 1993;13:506-­‐510 DeLee JC: ACL insufficiency in children, in Feagin JA (ed): The Crucial Ligaments, ed 2, New York, NY: Chruchill-­‐Livingstone, 1994, pp 649-­‐76 Tanner JM, Davies PS: Clinical longitudinal standards for height and height velocity for North American children. J Pediatr 1985;107:317-­‐329 Lawrence JT, Argawal N, Ganley TJ : Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? American Journal of Sports Medicine. 2011 Dec;39(12):2582-­‐7. Epub 2011 Sep 14. Millet PJ, Willis AA, Warren RF: Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Arthroscopy. 2002 Nov-­‐
Dec18(9):955-­‐9 Dumont GD et al. : Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relationship of treatment time and patient-­‐specific factors. American Journal of Sports Medicine 2012 Sep;40(9):2128-­‐33. Epub 2012 Jun 22. References (cont)   Roberts CC, Towers JD, Spangehl MJ, Carrino JA, Morrison WB. Advanced MR Imaging of the  
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Cruciate Ligaments Radiologic Clinics of North America, Volume 45, Issue 6, Pages 1003-­‐1016 Sheehan FT, Sipprell WH 3rd, Boden BP. Dynamic sagittal plane trunk control during anterior cruciate ligament injury. Am J Sports Med 2012 May:40(5): 1068-­‐74. Epub 2012 Mar 1. Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injry prevention training programs. J Bone Joint Surg Am. 2012 May 2;94(9):769-­‐76 Hewett TE, Myer GD, Ford KR, Paterno MV, Quatman CE. The 2012 ABJS Nicolas Andry Award: The Sequence of Prevention: A Systematic Approach to Prevent Anterior Cruciate Ligament Injury. Clin Orthop Relat Res. 2012 Oct:470(10):2930-­‐40. Epub 2012 Jun 29. Grimm NL, Shea KG, Leaver RW, Aoki SK, Carey JL. Efficacy and Degreee of Bias in Knee Injury Prevention Studies: A Systematic Review of RCTs. Clin Orthop Relat Res. 2012 Sep 8 Epub. Frank JB, Jarit GJ, Bravman JT, Rosen JE. Lower Extremity Injuries in the Skeletally Immature Athelet. J Am Acad Orthop Surg 2007;15:356-­‐66 Wall EJ, Myer GD, May MM. Anterior Cruciate Ligament Reconstruction Timing in Children with Open Growth Plates: New Surgical Techniques Including All-­‐Epiphyseal. Clin Sports Med 2011 30 789-­‐800 Stanitski CL. Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosis and Treatment. J Am Acad Orthop Surg 1995;3:146-­‐158 http://radiology.rsna.org/content/261/3/719/F9.expansion.html Guzzanti V, FalcigliaF, Sanitiski CL: Physeal-­‐sparing intraarticular anterior cruciate ligament reconstruction in preadolescents. Am J Sports Med 2003;31:949-­‐953 Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Am 2003;85;1255-­‐1263. Klingele KE, Stephens S. Management of ACL elongation in the Surgical Treatment in Chronic Knee Dislocaton. Orthopedics 2012;35;(7)e1094-­‐e1098 LaFrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric Tibial Eminece Fractures: Evaluation and Management. J Am Acad Orthop Surg 2010;18:395-­‐405