ACL Reconstruction in Skeletally Immature Patients

ACL Reconstruction in Skeletally
Immature Patients: Treatment
Options
Dr Michael J Priola, DO
Quick Overview
• Increased involvement in
organized sports
• Dodwell, et al reported a 20 fold
increased from 1996-2009 in the
rate of ACL reconstruction per
100,000 population aged 2-20 in
New York state (1)
• A 2012 study showed ACL injuries
represent nearly 25% of all high
school knee injuries (12)
Intrinsic Risk Factors
• Female sex
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– Females 2-9 times higher rate of non-contact
ACL injury
Decreased femoral notch width
Decreased ACL volume
Increased posterior slope
Increased Q angle
Increased anteversion
Greater generalized ligamentous laxity
Quadriceps dominant musculature
Weak core and hip strength
Extrinsic Risk Factors
• Pivoting and cutting sports
• Footwear
• Weather conditions
• Playing surfaces
The History and Physical
• Events surrounding the injury
• Mechanism of injury
• Knee effusion
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– 65% correlation rate (2)
Other injuries
Lachman test
Anterior drawer test
Pivot-shift
Other routine exam maneuvers to
check for other injuries
• Assess for possible limb-length
discrepancy (don’t want to get
blamed for it)
Radiography
• AP, lateral, merchant are all necessary to
rule out a possible fracture or
osteochondral fragment
• Hip to ankle for comparison of limblengths during follow up
• Bone age radiograph
• MRI
Historical Treatment
• Maintain comfort
• Functional knee brace
• Directed knee rehabilitation to
regain normal range of motion
in knee
• Should have normal ROM and
knee strength by 6-8 weeks
and can return to activity
– Non-contact sports and
resrticted in those that require
rapid directional changes
• Transphyseal surgery after
skeletal maturity reached
Should We Operate?...
• Risks for surgery
– Complication rates
for infection,
neurovascular
damage, etc all very
low
– Growth plate arrest
• Historical concern
• Has led to varying
techniques
Should we Operate?...
• If we stabilize the knee earlier, what effect does that have of other aspects
of the child’s life?
•
– Boykin et al (6)
• Used the Child Health Questionnaire and the International Knee Documentation
Committee Score
• Self-esteem, mental health, emotional role, and social limitations categories all
significantly correlated with knee function
– Non-operative treatment associated with up to 50% sports drop out rate (8)
– Quality of Life is affected
Should we Operate?...
• Ramski, DE et al (5)
– Meta-analysis of non-operative and operative treatment
– “Trends” favoring early surgery
– Patients after non-operative and delayed treatment had more
knee instability and inability to return to previous activity levels
– Quality analysis revealed the majority of the studies were
inconsistent with reporting outcomes
Should we Operate?...
• Millet et al (3)
– 26 patients
• 10 medial meniscus injuries
(longer wait time statistically
significant)
• 15 lateral meniscus tears
• 3 medial collateral ligament
tears
• 1 femur fracture
Should we Operate?...
• Dumont, Guillaume D et al (5)
– 370 pediatric patients
– >150 days to treatment statistically significant for increase
in medial meniscus tears (37.8% vs 53.5%)
– Lateral meniscus tear rates similar in two groups
– Presence of chondral injury significantly associated with
presence of meniscal tear in the same knee compartment
– Increased age and weight independently associated with
higher rate of MMT.
Should we Operate?...
• Concomitant Procedures
are on the Rise
– Nationwide database
query between 2007-2011
(12)
• Meniscetomy (27.6%
increase in 10-14 year olds)
• Meniscus Repair (54.8%
increase in 10-14 year olds)
• Shaving Chondroplasty
(81.3% increase in 10-14
year olds)
So What About the Physes?...
• More and more studies showing that those with open physes were
not at increased risk for early revision or early reoperation
compared to those with closed physes
– Scintalin RP, et al (9)
– Guzzanti, et al (10)
– Meller, et al (11)
• Multiple studies correlate no surgery and delayed surgery with
worse outcomes
• Current surgical techniques minimize physeal involvement or avoid
them altogether (not including some surgeries that show a
tethering effect can occur)
So What We Know…
• Multiple studies correlate no
surgery and delayed surgery
with worse outcomes
• Current surgical techniques
minimize physeal
involvement or avoid them
altogether (not including
some surgeries that show a
tethering effect can occur)
OPERATE
Unless..
• No concomitant
injuries
• Limited goals for
participation in athletic
activities
• No symptoms of
instability
Surgical Options
• Extraphyseal
• Partial Transphyseal
• Transphyseal (wont discuss except for
indications)
• All-Epiphyseal
Graft Options
• Hamstring tendon
autograft
• Allograft
• Patella tendon or
bone-tendon-bone
autograft
• Quadriceps tendon
autograft
• Tensor Lata Autograft
• Allograft
Extraphyseal
• When neither the
femoral or tibial
physis is directly
violated
Modified MacIntosh
• Combined extra-articular and intra-articular physealsparing
• Uses the iliotibial band
• Proximally harvest the central 1/3 and leave it attached
at its insertion site (Gerdy’s tubercle)
• Bring free end through the knee joint in an over the
top position, under the intermeniscal ligament, then
sutured onto the periosteum anteriorly
Modified MacIntosh
• Kocher, et al (13) in 2005 reported:
– 4.5% failure rate
– No incidences of growth disturbance
– IKDC score of 96.7
• Chudik, et al (14) in 2007 showed how as you
grow, the graft migrates
– (in a canine model)
Modified MacIntosh
• Long term follow up from Johnson in 2003(15)
– Excellent Lysholom scores on 52 of 84 knees at 9.8
years
– Poor outcome in 13/48
– 58% had reduced level of activity
Partial Transphyseal
• When either one of the femoral and tibial
physis are transversed
• In skeletally immature patients you try to drill
more vertically to minimize area of physis
that is transversed
Insall Technique
• Release distal IT band from Gerdy’s tubercle
and mobilize proximally
• Tubularize tendon
• Reroute “over the top” of the lateral femoral
condyle and through intercondylar notch
• Can drill vertical tunnel through tibial physis
OR entirely within physis
Insall Technique
• Benefits
– For tibial insufficiency
– IT band deforming force in certain instances
(arthrogryposis) and rerouting it can be beneficial
– Active transfer, not just static constraint
– Can avoid physis completely if choose to
• Drawbacks
– Not anatomic when child gets older
Insall Technique
• Scott WN, et al (16)
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111 ACL insufficient knees
Followed 2-7 years
90 knees had negative Lachman (81%)
93 knees had anterior drawer of +1 or
less (84%)
– 104 knees had negative pivot shift
(94%)
– Subjective rating
• 82 knees excellent (74%)
• 23 knees good (21%)
• 6 knees poor (5%)
Insall Technique
• Windsor R, et al (17)
– 5-10 year follow-up
– All patients (62 knees) had buckling pre-operatively
– 35 excellent, 21 good, 4 fair, and 4 poor results
• Pain major reason for fair or poor results
• No fair or poor result had intact menisci
– Buckling absent in 93% of post op
All Epiphyseal
• Avoids both the femoral and tibial physis
• Proponents claim the more anatomic graft
placement improves rotational stablity
Anderson Technique
• Drills outside-in
transepiphyseal bone
tunnels
• Secures hamstring
autograft with suspensory
cortical fixation on
femoral side
• Secures autograft to tibia
with a suture over a post
(screw)
Anderson Technique
• Anderson, AF (25)
– 4 year follow up (mean 4.1 years)
– 12 patients, average age of 13.3 years
– Mean IKDC score of 96 + 4.4 points
– KT difference of 1.5 + 1.1 mm
– No incidence of LLD
Ganley-Lawrence Technique
• Utilizes a quadrupled
hamstring autograft
• Utilizes intraoperative
comptued CT (O arm) to
confirm tunnel placement
• Secures in the all tunnels
with interference screws
Ganley-Lawrence Technique
• Lawrence et al (26)
– Only three patients
– None had growth disturbance
– All returned to pre-injury level
Cordasco-Green Technique
• “all-epiphyseal and all-inside”
• Modification of Lawrence
Technique
• Employs the cortical button on
the femur and the tibia
• Involves inside-out drilling of
proximal tibial and distal
femoral epiphyseal sockets,
leaving cortically based bone
bridges
• Avoids the use of screws
Comparison of Techniques
• Kaeding CC, et al (27)
– 10 studies of ACL reconstruction in skeletally
immature patients
– Tanner II and Tanner III
• Both all-epiphyseal and transphyseal all showed
favorable outcomes
– Tanner 1
• “Insufficient evidence from physeal-sparing techniques
to conclude it was a well tolerated technique”
Hamstring
• Advantages
– Less donor site morbidity
– Less patellar pain
– Material properties similar to ACL
• Disadvantages
– Some laxity results overtime
– Must have tunnel <12mm or growth arrest
CompleteTransphyseal
• Guzzanit et al found lower rates of physeal
bridge formation with soft tissue in tunnels
(10)
• Kumar, et al (18) used hamstring autograft and
had growth arrest in only 1/72 patients
Bone-Patellar Tendon-Bone
• Advantages
– Greater strength
– Better fixation in
femur and tibia
• Disadvantages
– More likely to
interrupt physeal
growth
Others
• Quadriceps
• Fascia Lata
– In extra-physeal surgeries
• Allograft
– Preserves tendons for future surgery
– Use in those with generalized ligamentous laxity
or collagen disease
– Does have higher failure rate in children but may
not apply in those with disorders
So Which Graft?
• Kennedy A, et al (7)
– Biomechanical study subjected cadaveric knees to AP,
varus and internal rotation forces
– Each knee subjected to the forces with intact ACL,
after disruption, and after reconstruction
• All-epiphyseal, transtibial over-the-top, and IT band physeal
sparing techinques
– IT band reconstruction best restored AP stability and
rotational control
• Overconstrained the knee to rotational control at some
forces
– All physeal-sparing reconstruction techniques restored
some stability
Graft Failure
• Kaeding, et al (20) in 2011
reported on graft failure
rates
– 8.2% in patients 10-19 yoa
– 4% in patients 20-29
– 1.8% in patients 30-39 yoa
– Allograft and autograft
failures* activity related?
Graft Failure
• Gebhard et al (21)
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68 patients with short term follow up (32 months)
Mean age 12.5 years
Transphyseal
Compared hamstring autograft, bone-patella-bone
autograft, quadriceps graft, and fascia alta graft
– No significant difference in outcomes and no growth
disturbance
So Which Surgery and Which
Graft?...
• Patient Specific
• Must take Skeletal Age into account
• Surgeon Specific
My Algorithm
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Confirm on exam and MRI
Brace and start rehab
Skeletal age
Are they unstable?
Associated intra-articular disease?
Assess current activity level and anticipated
future activity level
• Number of years left for growth
My Algorithm
• If I proceed with surgery…
– < 2 years growth remaining
• Transphyseal with hamstring autograft
– 2-5 more years of growth remaining
• All epiphyseal with hamstring autograft
– > 5 years growth and no other intra-articular
pathology
• Serious discussion with family concerning future
surgery
• If I proceed, all epiphyseal with hamstring autograft
Prevention
• Increasing evidence that suggests neruomuscular
control and relative knee position during jumping and
landing are the most important biomechanical factors
• Swartz, et al (23)
– Increased knee valgus and decreased hip flexion in
prepubescent subjects versus adult controls
• Noyes, et al (24)
– Improvments in knee separation and neutral
landing after neuromuscular training
– Most noteworthy in females
Prevention
• Females
– Tend to be one leg dominant
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Valgus with landing
One knee relatively straight
Most weight on one leg
Trunk tilted so center of mass
is shifted outside of feet
THANK YOU
References
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