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1 ACL Rupture in the Skeletally Immature Athlete the End of the Career? Edward M. Wojtys, M.D. University of Michigan Conflicts of Interest None Disclosures NIH/NIAMS R01 AR Coulter Foundation Grant KIA Research Consultant Center for Organogenesis NFL Injury and Safety Panel Sports Health Editor Age Distribution Incidence Rates Danish registry Lind Acta Orthop 2009 Adolescent females Scandanavian registry: Median age ~25 Range= 5-70 years Granan Acta Orthop ,472 adolescents, 14-18yo 9 year period 60.9 per 100,000 person years Hazard ratio Organized sports >4x/wk Males 4.0 Females 8.5 Parkkari Br J Sports Med 2008 Inconclusive Results Øiestad AJSM 2009 Systematic review: 615 articles 7 compared Question unanswered! Future? Follow similar cohorts over time Systematic Review 7 prospective, 24 retrospective studies 3069 ACL patients 10 year follow-up with X-rays Mohtadi Clin J Sport Med 2006 Evidence Level II - Cohort 1

2 Øiestad AJSM 2009 Primary Risk Factors Isolated ACL Injury 0-13% OA (3 prospective studies) ACL & Meniscal Injury % OA Best rated studies show lowest rate of OA Coleman Methodology Mean 52(90) Meniscal Injury with ACL High level sports with cutting, pivoting and twisting Evidence Level II - Cohort Øiestad AJSM 2009 Knee Function & OA After ACL-R Knee Function & OA After ACL-R 181 pts. (82% follow-up) at years No significant knee function difference between Isolated and Combined Injuries 106 (221) pts 127 partial Meniscectomies 8 Meniscal repairs Mean time from injury to ACL-R, 28 months (0-278) Evidence Level II - Cohort Øiestad AJSM 2010 Øiestad AJSM 2010 ACL with meniscectomy OA Meniscal Status and ACL-R Prospective cohort years follow-up 63/103 pts (61%) Evidence Level II Wu AJSM % pts with Intact menisci had normal X-rays (22 repairs, 21 stable tears, 38 normal) Any meniscal resection led to more complaints, limitations, lower IKDC and Lysholm All 9 complete meniscectomies OA Wu AJSM 2002 Evidence Level II - ProspectiveCohort 2

3 Predictive Factors for OA after ACL Rupture 56 patients follow-up 6 years (Consecutive series of PT & STG grafts) No Meniscal Repairs Predictive Factors for OA after ACL Rupture Discriminant Analysis (Tibiofemoral OA) Meniscectomy.72 Weak Quadriceps.39 Chondral Damage.41 Pat. Tendon Graft.37 Low Q/H ratio.06 Keays AJSM 2010 Evidence Level I - Cohort Keays AJSM 2010 Evidence Level I - Cohort Meniscus Repair with ACL-R 448 pts Sample size still too small to provide a detailed analysis of meniscal injuries... Spindler AJSM 2011 Evidence Level II - Cohort 24 Medial repairs 12 Lateral repairs Meniscal Pathology w/acl Tears in Patients w/open Growth Plates Samora JPO Males (ave. 14.3) 44 Females (ave. 14.1) Meniscus Tears (Within 3 Months of Injury) 51 Lateral 17 Medial 19 Medial and lateral 69.3% Meniscal tears? Repair? ACL Injury Successful athletic career Good functional, lifelong outcome Preserving menisci 1. Early ACL-R 2. Menscus repair Samora JPO

4 ACL Injury in Children 56 ACL Injury Cons. Rx. or Delayed Surgery (>12 weeks) 69 pts 14 y.o. Children s hosp. 29 (early surgery) Mean 13.5 m Adult hosp. 27 (delayed surgery) Mean 30 m Med. mensical tears (3) 16% Med. mensical tears (11) 41% 40 pts (< 12 weeks) 7% irreparable menisci Henry KSSTA 2009 Lawrence AJSM 2011 Delay ACL Treatment? Balancing Risk Lawrence AJSM pts (> 12 weeks) 1. Delay Increases risk of medial meniscal tear 4 fold. 2. severity of med men tears (24% irreparable) 3. lateral chondral injuries Early Surgery Growth plate trauma Limb length discrepancy Angular deformity? Unnecessary Delayed Surgery (or cons. Rx) Meniscal tears (loss) Chondral lesions? OA ACL Reconstruction Pitfalls 1. Central growth plate injury from tunnels. 2. Peripheral growth plate injury from periosteal elevation. 3. Pressure generation across growth plate from tight graft fixation. Stoked the Controversy (21) 8 week old rabbits 1. Femoral tunnel -- 11% frontal plane, 3% crosssectional area -- no growth or angular deformities 2. Tibial tunnel 12% frontal plane, 4% crosssectional area 2 valgus tibias, 1 shortened tibia Guzzanti JBJS-B

5 Stoked the Controversy Stoked the Controversy (12) immature dogs 4 mm tunnels fascia lata grafts Tensioned at 80N (fascia lata ACL graft) Significant femoral valgus and tibial varus developed in all limbs. (44) 5 week old rabbits Distal Femoral physis 1. 2 mm drill hole (3% cross-sectional area) No problems mm drill hole (7% cross-sectional area) permanent growth disturbance and limb shortening Edwards JBJS 2001 Makela JBJS-B 1988 Calmed the Controversy Physeal Injury (8) immature dogs 5/32 transphyseal tibial and femoral tunnels (4) dogs fascia lata grafts (4) dogs no graft NO tension on graft Bony bridges formed in non-grafted tunnels only. Stadelmaier AJSM 1995 Tunnel diameter / physeal CSA Guzzanti AJSM 2003 Excessive graft tensioning Edwards JBJS 2001 Incomplete tunnel fill Stadelmaier AJSM 1995 Graft fixation across physis Chudik Arthroscopy 2007 Vavken Arthroscopy 2011 Transphyseal ACL 26 pts (physis > 2 mm) 65% - meniscal tears F/U 45 ± 18.3 months LL discrepancy ± 7 mm Angular 0.46 ± 1.1 AP translation 2.0 ± 1.0 mm ACL Outcome ( ) Isolated ACL s (14) cons. rx. Combined ACL s (17) surgical rx. Tanner Slage I or II (median 11 y.o.) F/U 70 m, mean growth 20.3 cm *** Surgical group did better! * 58% cons. group subsequent surgery Cohen Arthroscopy 2009 Streich KSSTA

6 Transphyseal ACL - Hamstrings 18 pts (mean age 14.2, 1(11), 1(12)) F/U months All stable, no ROM loss (>5 ) No growth s or angular deformities No re-ruptures 3 contralateral Pediatric ACL Biomechanics 6 cadaver knees (time 0) 0-90 AP, varus, 0-90 ACL intact 2.8 ± 1.4 mm ACL def. 7.2 ± 2.7 All epiphyseal 5.1 ± 2.3 Trans tib (over) 4.8 ± 1.8 ITB (Micheli) 1.7 ± 1.1 Redler Arthroscopy 2012 Kennedy AJSM 2011 ACL Meta-Analysis 55 studies (935 pts., median age 13) F/U 40 months (median) LLD or deformity risk 1.8% (95% C.I. 0 to 3.9%) Re-rupture 3.8% (95% C.I %) Frosch Arthroscopy 2010 ACL Tears in Skeletally Immature Systematic review 47 studies Conservative rx. Poor clinical outcomes Secondary meniscal, chondral injury Surgical rx. Weak evidence for growth Good stability and function Vavken Arthroscopy 2011 ACL Systematic Review Youngest patients (10-12 y.o.) 4 studies (Tanner I or II) Significantly better results w/ surgery. No significant deformities. Vavken Arthroscopy 2011 Recommendations Be Careful! 1. Teenagers with less than 6 months of growth remaining may be treated as adults if growth spurt has occurred. 2. Make every attempt to salvage the menisci. Examine Tibial Apophysis closely! 6

7 Recommendations Children, Adolescents, Teenagers (unstable knees and/or physically active) 1. Pediatric Age ACL injuries should be reconstructed 2. Bracing, physical therapy, and activity modification alone is inadequate. Rehabilitation 55 patients Avg age 15.9 yrs Time from surgery 85% normal quad. Strength 5.42 ± 2.27 months Ability to return to sport after 6 months rehab. 50% of patients (strength) vascularity and fiber pattern Wells J Pediatr Orthop 2009 Kids - Sports Unique dependent relationship Separating Kids-Sports Can Be Catastrophic Loss of identity Depression drugs, alcohol Challenging Cases Thank You 13 yr. old football player 6 foot, 340 lbs 7

8 9 yearold Bilateral ACL Def Children and Adolescents Intra-articular Trans-tibial Physis If the growth plate is drilled, try to stay central. Start tunnel lower on tibia. Aim for posterior intraarticular placement. (Andrews and Noyes, 1994) Intra-Articular Extraphyseal ITB graft 44 immature prepubescent patients Michelli Modification Results: 32 Normal exam 18 Nearly Normal 1 Abnormal Mean growth (height) cm Kocher JBJS Year Follow-up Technical Points only soft tissue should cross growth plate in bone tunnels. avoid excess tension (10 lbs) keep tunnels small (6-7mm) 8

9 Summary ACL-R for children and adolescents for jumping, pivoting sports Repair essentially ALL menisci in kids Thank You Balance risks for return to sport! Nonoperative ACL Treatment (Retrospective Cohort) OA Nonoperative ACL Treatment (Retrospective Cohort) OA 12-year follow-up of 84 female soccer players (82%) No difference between reconstructed and nonoperative group for symptoms or OA Evidence Level II 14-year follow-up of 205 male soccer players (94%) No difference between reconstructed and nonoperative group for symptoms or OA 41% of uninjured knees showed Rad OA Evidence Level II Lohmander AJSM 2007 Von Porat Ann Rheum Dis 2004 Nonoperative ACL Treatment OA Post Injury Activity Level Contact Sports 15-year follow-up Rx Physical Therapy/Activity Modification (Tegner decreased 7 to 4) 44% (35/79) had meniscectomies 16% (13/79) Rad OA, all had meniscectomies None of the knees with normal menisci developed Rad OA (p 0.001) Neuman AJSM 2008 Evidence Level II - Cohort 12-year followup in female Swedish soccer players. Reconstructive or Conservative Rx Lohmander AJSM % - Rad OA 42% - Sx OA 8% - Rad OA uninjured knee 9

10 Injury reports 5-18yo Soccer 6 million athlete-years Knee: 30.8% ACL tears: 6.7% Dilemma Kids do worse than adults with conservative ACL injury treatment resulting in meniscal tears and chondral injuries. Shea Sports Med 2003 Graf Arthroscopy 1992 McCarroll AJSM 1988 Part of the Problem Rehabilitation Difficult to restrict physical activity in children, adolescents, and teenagers. Age-specific components altering treatment course? Moksens Knee Surg Sports Traumatol Arthrosc 2008 Conservative promising rehab. Results Roos Curr Opin Rheumatol 2005 Significant risk for OA with injury Prognosis for children and adolescents? Rehabilitation potential MRI 96% Sensitivity (ACL) 59% (Meniscus) 91% (Specificity) Author Journal Year Samora JPO

11 Knee Function & OA After ACL-R Combined Injuries had more Rad OA than Isolated Injuries 80% vs. 62% (p=0.008) (Contralateral, uninjured knee 15% Rad OA) No significant difference in Sx OA 46% vs. 32% (p=0.053) Lohmander AJSM 2007 (Clinical Review) 50% of ACL injuries with meniscectomies have Rad OA at years (odds ratio 10) Worst outcome obese women with ACL and lateral meniscectomy Øiestad AJSM 2010 Transphyseal ACL 26 pts ( >2 mm femoral & tibial physis) Quad hamstring 3 re-ruptures Early Surgery Balancing Risk Delayed Surgery (or cons. Rx) 89% returned to same level Growth plate trauma Limb length discrepancy Angular deformity Meniscal tears (loss) Chondral lesions Cohen Arthroscopy 2009 Balancing Risk Stoked the Controversy Early Surgery Delayed Surgery (or cons. Rx) Theoretical computations based on assumption that a bony bar will form at physis. Assumes drill holes in the most peripheral locations in femur and tibia. Growth plate trauma Limb length discrepancy Angular deformity Meniscal tears (loss) Chondral lesions 1. Trigonometric principals to determine shortening and angulation. 2. If physis drilled in boys <15.5 years old and girls < 13.4 year old, Expect: 5 increased valgus 1 cm shortening Wester J Ped Ortho

12 Multicenter ACL Study 68 pts. mean 12.5 y 4 surgical techniques ( ) F/U 32 months No angular deformity or LLD 6 recurrent instability Only 2 pts. Returned to same sports level Growth Plate Disturbance After Transphyseal ACL-R in Skeletally Immature Patients 43 pts, mean 14.8 years ( ) F/U MR, mean 16m (6 36m) Bone tunnel / growth plate < 3% (femoral & tibial) Gebhard KSSTA 2006 Yoon, Kocher, Micheli JPO 2011 Growth Plate Disturbance After Transphyseal ACL-R in Skeletally Immature Patients 5 focal bone bridges (12%) 4 tibial, 1 femoral 2 early physeal closures (tibia) No growth disturbances Yoon, Kocher, Micheli JPO