ACL, Meniscal, and Catilage Injuries in the Skeletally
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Transcript ACL, Meniscal, and Catilage Injuries in the Skeletally
ACL Injuries In the
Skeletally Immature
Jason W. Folk, MD
Steadman Hawkins Clinic of the Carolinas
February 2012
Disclosures
Consultant Smith & Nephew Endoscopy
Objectives
Describe the epidemiology,
pathophysiology, and treatment principles
of ACL injuries in skeletally immature
patients
ACL Injuries:
Introduction
Epidemiology:
– Intrasubstance tears once
considered rare in pediatric
population
– Tibial eminence fx considered
pediatric ACL equivalent
Typically under 12yo
– Increasing numbers over past
decade
– Increased attention
ACL Injuries:
Introduction
Reasons for increased
incidence:
– Increased participation in
sports
– Higher competitive levels
early on
– Increased awareness of
injury
– Decreased conditioning
5
ACL Injuries:
Introduction
ACL Injuries in Soccer Players 5-18 (Shea,
et al. JPO 2004.)
– Based on insurance data from 6 million
player-years
– 6.7% of total injury claims
– 30.8% of all knee injury claims
True incidence unknown
ACL Injuries:
Introduction
Differences in pediatric population
– Often lack fully developed complex motor
skills
– May have temporary decline in motor and
balance during puberty
– Open physes
– Higher strength of ligaments vs. boneligament interface
ACL Injuries:
Diagnosis
History:
– Patient describes a
characteristic “Pop”
– Effusion forms quickly after
injury
47% of patient’s aged 7-12
with traumatic effusion had
ACL disruption
65% in 13-18 year old group.
(Stanitski et al. 1993)
Approximately 60% partial
tears
ACL Injuries:
Diagnosis
Physical Exam
– Often more difficult in kids than adults
Acute pain
Frightened
Unable to relax
– Examine uninjured leg for baseline laxity or
congenital absence of ACL
ACL Injuries:
Imaging
Plain Radiographs (4 views)
– For anyone suspected of having
an ACL injury
Bony avulsions
Osteochondral fractures
Physeal fractures
Patellar dislocation/subluxation
Degree of physeal closure
– CT scan also used for evaluation
of physeal closure.
Tibial Eminence Fracture
In skeletally immature,
chondroepiphysis is
weaker than the ligament.
Mechanism of injury
typically hyperflexion
Most commonly 8-12yo
Present w/ pain and
limited ROM
Dx on x-ray and CT
Tibial Eminence Fracture
Type I: LLC x 3-6 weeks in 20degrees flexion
Type II/III: Attempted closed reduction,
+aspiration of hemarthrosis (may help
reduction), LLC in extension x 4-6 weeks
Irreducible Type II/III or IV: arthrocopic vs
open ORIF with suture, retrograde wire, or
screw fixation
Some argue all Types II-IV should be fixed
anatomically with countersinking of fragment
because of residual laxity
Results of fixation usually excellent
ACL Injuries:
Imaging
MRI
– Should not be used as replacement
for physical exam and routine
radiographs
– Look for ACL tear, meniscal injury,
chondral injury
– Indications
Failing to improve ROM
Persistent effusion
Physical exam difficult to interpret.
Help define anatomy of physis
ACL Injuries:
Etiology
Can occur with fractures
– Distal femoral physeal fractures
(25-45%)
– Salter-Harris III fxs at increased
risk because frequently exits
intra-articularly at notch
– Proximal tibial physeal fractures
The Physis
Concern about
iatrogenic injury to
physis is what drives
the debate about
treatment strategies
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The Physis
Distal femoral and
prox tibial physis
– Contribute more to
limb length than hip
and ankle
– DF 1.2 cm/yr
– PT 0.9 cm/yr
– Overall 65% of length
contributed to knee
– Closure typically occurs
M=16
F=14
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Anatomy of Physis
MRI closure of Physis
– 0% at 11 years
– 5% at 12 years
– 34% at 13 years
– 53% at 14 years
– 94% at 15 years
– 100% at 16 years
Central tibial physis closes prior to
peripheral physis
– ?More central tunnel
– ?Smaller tunnel
Sasaki et al., J Knee Surg 2002
ACL Injuries:
Treatment
Concern for possible growth abnormality fuels
debate on treatment
– Non-operative
– Operative
Direct Repair
Extra-articular
Intra-articular
Intra/Extra articular reconstructions
–
–
–
–
Physeal sparing
Partial Transphyseal
Complete transphyseal
Trans epiphyseal
ACL Injuries
Nonoperative Management
Avoids risk of physeal
damage
Sometimes used as a
temporizing measure until
skeletal maturity
Very difficult to reasonably
limit young patient’s
activities
ACL Injuries:
Nonoperative management
So what if we don’t treat
these injuries?
– Angel et al. Arthroscopy
1989
27 children with
arthroscopically documented
ACL tears
22 patients at 51mo f/u
None able to return to
sports at preinjury level
Non-op ACL Open Physis
40 pts under 14 y/o open physis
16 conservative
– 6 scope for meniscal tears
– Only 7 return to sports
All recur giving way, swelling, pain
McCarroll et al., AJSM 1988
Non-op ACL Open Physis
18 pts ACL injury open physis
Only one returned to preinjury
level of sports
Initial scope 13 meniscal tears
Later secondary meniscal tears
in 9
Degen changes 11 of 18 pts by
Xray
Mizuta et al., JBJS Br 1995
Non-op ACL Open Physis
60 children with ACL tear
23 nonop
• Nat Hx continued instability, further
meniscal and chondral damage
• 25 % secondary meniscal tears
• Few able to participate in sports
Aichroth et al., JBJS BR, 2002
Non-op ACL Open Physis
? Effect of delay in treatment
39 pt < 14 y/o
Sig increase in MMT with
delay in treatment > 6
weeks
• 36% chronic vs 11% in
acute
Rx
No diff in rate of LMT
Millett et al., Arthroscopy 2002
ACL Injuries
Nonoperative Management
Graf et al:
– 12 skeletally immature patients with ACL tears
– 8 patients underwent non-op and no restriction
management.
7 of the 8 had new meniscal tear at follow up
ACL Injury:
Long Term Results
Kannus et al. JBJS-B. 1988
• 8 year F/U – 4/7 Pediatric Patients that had
Untreated ACL Tears showed Advancing OA
radiographically
Nonoperative Rx in Children
Non-op treatment
has not resulted in
good outcomes
ACL Injuries:
Physeal Concerns
Fear disruption of open physes
Risk of epiphysiodesis, LLD,
angular deformity
Caused by crossing physis with
bone plug and/or fixation
devices
ACL Injuries:
Physeal Concerns
History
– Campbell et al. (1959)
Large holes drilled through the physis have maximal
retardation of growth plate
Insertion of cortical bone across physis causes arrest
– Makel et al (1988)
Destruction of >7% of physis causes growth arrest
Destruction of 3% or less…no arrest
– Stadelmeir et al (1995)
Soft tissue graft placed in drill hole did not cause physeal
bar.
Factors Influencing Physeal Arrest
Diameter of drill hole
Soft tissue graft within tunnel
Tension of graft across physis
Tunnel location? (Central and vertical)
ACL Injuries:
Operative Managment
Direct Repair:
– A historic treatment modality
– Inflammatory changes and degeneration
begins within 48 hours after injury
– Metalloproteases and cytokine inflammatory
factors affect healing potential of direct repair
– Poor results
Delee and Curtis, CORR 1983
Engebretsen, et al. Acta Orthop Scand 1988
ACL Injuries:
Operative Management
Extra-Articular repair
– Temporizing method
– Non-anatomic reconstruction
– Poor results
Dahlstedt , et al. Acta Orthop Scand 1988
McCarroll et al. AJSM 1998
Graf, et al. Arthrsocopy 1992
ACL Injuries:
Assessment of maturity
Tanner et al. :
– Adolescent growth spurt begins at
12.5 years in boys and 10.5 years in
girls.
– Peak Growth velocity 1 year later
Menarche is good indication of maturity
in girls
– In athletic girls, menarche may be
delayed.
Axillary and pubic hair appear in boys
after growth spurt
Bone age: Most accurate method to
determine skeletal maturity
General Guidelines
Think about physis if:
– Male
Tanner stage 1 or 2
Not shaving
Not reached growth spurt
14 y/o or less
– Female
Premenarchal
Tanner stage 1 or 2
Not reached growth spurt
12 y/o or less
ACL Reconstruction Techniques
ACL Injury:
Physeal Sparing Reconstruction
Intra-articular, non-anatomic, extra-physeal
Stanitski. JAAOS 1985
ACL Injury:
Kocher Technique
Physeal-Sparring Combined Intra- and Extra-articular Reconstruction
ACL Injury:
Partial Transphyseal
Hybrid of physeal
sparing and adult-type
reconstruction
Femoral physis left
intact
Graft: Hamstring or
patella
– Passed through 6-8mm
tunnel
<5% physeal X-sectional
area
– Fixed in over the top
position
ACL Injury:
Transepiphyseal
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ACL Injury:
Transphyseal
Thank You