Sports Injuries: Lower Extremity

Transcription

1 Sports Injuries: Lower Extremity September 29, 2018 WOJCIECH L CZOCH, MD COHEN CHILDREN S MEDICAL CENTER LONG ISLAND, NY

2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation

3 Learning Objectives Learn to identify common pediatric sports injuries of the lower extremity Learn techniques on how to examine an injured athlete Understand treatment principles of these injuries Learn when to refer an athlete to an orthopaedic surgeon

4 15 yof sustained a twisting injury to L knee while trying to stop a ball

5 Pediatric Sports Injuries Dramatic rise in pediatric sports injuries over past 2 decades 38 million children participate in organized sports in US Approx 2 million high school students treated for sports inury each year Surge in sports injuries Increased number of athletes year-round competition More intense training

6 ACL Injuries Approximately 400,000 ACL reconstructions per year Most common mechanism of injury Non-contact pivoting Knee partially flexed, foot planted Historically, thought to be a rare occurrence in children Incidence grown considerably Sports involving pivoting, cutting, collisions More common in females (F:M ratio 4.5:1) Anatomy Landing biomechanics Neuromuscular differences

7 ACL Injuries National High School Sport Related Injury Surveillance Study Female soccer players Highest rate of ACL injury 14 per 100,000 exposures Male football players Second highest rate of ACL injury per 100,000 exposures

8 Anatomy Knee is a hinge joint Also allows for gliding/rolling Stability enhanced by complex interplay of ligaments Cruciates A to P stability Collaterals Varus/valgus stability

9 Anterior Cruciate Ligament 85% of A to P stability Secondary restraint to tibial rotation Composed of 2 distinct bundles Anteromedial bundle Anterior Drawer Test Posterolateral bundle Pivot Shift Test Femoral Attachment Lateral femoral condyle Tibial Attachment Between intercondylar eminences

10 Anterior Cruciate Ligament Strength 2200 Newtons Composition 90% Type I collagen Blood Supply Middle geniculate artery Innervation Posterior articular nerve

11 ACL Tear Obtain a thorough focused history Mechanism of injury Often report a pop Difficulty with weightbearing Hemarthrosis Within 6-12 hours Physical exam Anxious/guarding Start with uninjured knee Examine visually Palpate

12 Physical Exam Pearls ROM Will often be limited by guarding and effusion Lachman s test Flex knee degrees (use a pillow) Tibia is pulled forward to assess translation on femur Firm/soft end-point Pivot Shift Very challenging in office setting Leg is internally rotated 20 degrees Valgus force applied and knee slowly flexed Tibia s position on femur will reduce with flexion

13 Imaging Radiographs Mainstay of initial evaluation Complete knee series Often unremarkable (Segond fracture) Help to assess skeletal maturity MRI Standard for assessing/confirming ACL tear Partial vs complete Associated ligamentous pathology Integrity of menisci 95% Sensitivity for detecting ACL tears in pediatric patients (Lee et al. Radiology, 1999)

14 Treatment Non-operative Historically standard approach Bracing, activity modification, physical therapy satisfactory short term results Allow time for skeletal maturity Recent Literature (Miuzta et al, Janarv et al, etc.) Progressive degenerative changes Secondary meniscal tears Low return to pre-injury level of athletics Low satisfaction scores Reserved for highly compliant, low demand patients Partial tears <50% Near normal Lachman and Pivot shift tests Kocher et al, Am J Sports Med

15 Treatment Operative Widely agreed approach Timing Pre-op restoration of knee ROM Can delay up to 12 weeks Lawrence et al, 2011 Level of skeletal maturity Guides technique choice Majority of ACL tears occur in adolescents with limited growth remaining Transphyseal reconstruction leads to minimal risk of growth disturbance Preadolescent patients are the subject of much debate

16 Graft Selection Multicenter Orthopaedic Outcomes Network patient database Patients between ages 10 and 19 years were found to have the highest percentage of graft failures regardless of graft type. Allograft reconstruction failure rate was 4 times higher than autograft

17 Operative Treatment Combined Intra-articular/Extra-articular Uses autogenous iliotibial band ITB harvested proximally, left intact distally Looped through knee in overtop position Sutured to lateral femoral condyle/proximal tibia Kocher, M et al JBJS 2018 clinical outcomes of a large cohort of prepubescent children over a 23 year period 237 patients (240 knees) Mean age 11.2 Average follow-up >6 years Excellent functional outcomes, minimal risk of growth disturbance, and a low graft rupture rate

18 Operative Treatment Intra-articular All intra-epiphyseal Anderson, JBJS, 2003 Autograft hamstring tendon No functional instability, no evidence of growth disturbance or limb-length discrepancy at 2- to 8-year follow-up Partial transphyseal Hamstring or bone-patellar tendon-bone grafts Either the distal femoral or the proximal tibial physis is left undisturbed Transphyseal Resembles adult ACL reconstruction Adolescents with very limited remaining growth No hardware/bone at level of physis Fixation in metaphysis Smaller and more vertical tunnels Excellent functional outcome with a low revision rate and minimal risk of growth disturbance

19 Post-op Recovery ROM bracing is recommended (Wright and Fetzer, CORR 2007) Equivalent in adults Behavior in children is more haphazard Bracing duration at surgeon discretion Physical Therapy Cornerstone of recovery ROM, progressively increasing activities Compliance can be problematic Can expect return to cutting sports in approx. 6 months

20 8 year old male s/p fall from bicycle

21 Tibial Spine Fractures Relatively uncommon Most frequently seen in children 8-14 years old Considered pediatric equivalent of ACL rupture Mechanism of Injury Rapid deceleration or hyperextension of knee ACL placed under traction Tibial spine is weaker than ACL Avulsion of tibial spine by intact ACL

22 Tibial Spine Fractures Physical Exam Immediate hemarthrosis ROM limited due to pain/effusion Positive maneuvers for anterior tibial translation Associated conditions Meniscal derangement Collateral ligament injury Osteochondral fracture

23 Tibial Spine Fractures Imaging Radiographs MRI CT Identify bony injury Lateral most helpful Assess for concomitant soft tissue injury For pre-operative planning in complex fracture morphology

24 Treatment Goal of treatment is appropriate fracture reduction with preservation of knee motion Based on severity of fragment displacement +/- additional injuries Myers and McKeever classification helps guide treatment

25 Treatment Non-displaced/Minimally displaced Casting/bracing in near full extension 6 weeks Type II fractures Casting if reducible in extension (<3-5mm of displacement) Close follow-up Type III/IV Operative Open vs arthroscopic No difference in outcomes (Edmonds, JPO 2015) Removes blocks to reduction Provides internal fixation Suture vs screw

26 12 yom with vague activity related R knee pain

27 Knee Osteochondritis Dissecans Distinct pathologic lesion Subchondral bone and overlying cartilage Cause Occult trauma Hereditary Most commonly in adolescents Age Younger age correlates with better outcomes Open distal femoral physis Best predictor of successful outcome

28 Knee Osteochondritis Dissecans >70% of lesions localized to lateral aspect of medial femoral condyle 15-20% of lesions involve lateral condyle Worse prognosis Patella rarely involved Injury progression Softening of articular cartilage Cartilage separation from bone Partial intra-articular detachment Loose body formation

29 Knee Osteochondritis Dissecans Presentation Vague activity related knee pain Recurrent effusions Localized tenderness Stiffness/Swelling Catching/Locking Indicative of loose bodies Worse prognosis

30 Knee Osteochondritis Dissecans Imaging Radiographs MRI Standard knee series (AP/Lat/Notch) Weightbearing Excellent for characterizing lesion Size Status of subchondral bone/separation Loose bodies

31 Treatment Nonoperative All stable lesions in skeletally immature children Restricted weightbearing, crutches, +/- bracing ~ 6 weeks Up to 75% success rate

32 Treatment Operative Indicated for unstable lesions, loose bodies, or failed non-op management Subchondral drilling Transchondral/Retrograde Improved outcomes with open physes Internal fixation Cannulated screws Absorbable screws Bone pegs Osteochondral grafting Large lesions (>3cm) OATS vs allograft plugs Similar recover periods and functional results

33 Talus Osteochondritis Dissecans Similar mechanism to Knee OCD Repetitive microtrauma 10-15% bilateral Medial talar dome More common No history of trauma Lateral talar dome Less common Usually have a history of trauma

34 Talus OCD Presentation Similar to knee OCD Pain with activity Intermittent swelling Joint effusion Mechanical symptoms Loose bodies

35 OCD Talus Imaging Radiographs CT First line modality Often unremarkable Subtle findings Used for detailed architectural assessment Pre-operative planning MRI Persistent pain/swelling Negative radiographs

36 Treatment Non-operative Stable/Non-displaced fragments CAM boot or SLC Crutches, NWB x 6-8 weeks Operative Indications Loose bodies Unstable fragment Failure of non-operative treatment Techniques Arthroscopy vs open Loose body removal Antegrade vs retrograde drilling Fragment ORIF

37 17 yom presents with locked knee sustained during a basketball game

38 Traumatic Patellar Dislocation Common in the adolescent/young adult population year olds account for greatest percentage (Khormaee, 2015) Mechanism of injury Non-contact Most common (~75%) Forced internal rotation of femur and valgus force on knee Contact Direct blow to knee >60% occur during sporting events Almost always patella displaced laterally

39 Traumatic Patellar Dislocation Risk Factors Femoral Anteversion Female Gender Trochlear Dysplasia Patella Alta Increased Q angle Increased TT-TG distance Generalized Hyperlaxity

40 Traumatic Patellar Dislocation Presentation Spontaneous reduction common Osteochondral injury most common during reduction Large hemarthrosis Medial >> Lateral tenderness MPFL Must always perform a full ligamentous exam Collateral/Cruciate injury Patellar apprehension test Apprehension to lateral displacement degrees of knee flexion

41 Traumatic Patellar Dislocation Imaging Plain Radiographs Standard knee series Assess for persistent subluxation Osteochondral fracture MRI Routinely performed Osteochondral Injury Up to 50% of cases Loose bodies MPFL Injury >85% sensitive

42 Treatment Non-operative First line treatment for acute dislocations Aspiration for large effusion Immobilization for 3-6 weeks Allow soft tissue recovery Physical therapy Quad strengthening

43 Treatment Operative Acute Osteochondral fracture Loose body removal Delayed Recurrent Instability Must address bony and soft tissue factors MPFL reconstruction Reconstruction superior to repair Multiple zones of ligament injury Lateral release In combination with other procedures Proximal/Distal realignment Tibial tubercle osteotomy (skeletally mature) Femoral/tibial derotation osteotomy

44 Risk of Recurrence 266 knees, 250 patients 83.5% treated non-operatively 34% of non-op patients sustained a recurrent dislocation Most significant risk factors Trochlear dysplasia and skeletal immaturity

45 Thank You!

46 References Comstock RD, Collins CL, McIlvain NM: Summary Report: National High School Sports-related Injury Surveillance Study School Year. Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthrosis in children and adolescents. J Pediatr Orthop1993;13(4): Tjoumakaris FP, Donegan DJ, Sekiya JK. Partial tears of the anterior cruciate ligament: diagnosis and treatment. Am J Orthop. 2011;40:92 7. Lee K, Siegel MJ, Lau DM, Hildebolt CF, Matava MJ: Anterior cruciate ligament tears: MR imaging-based diagnosis in a pediatric population. Radiology 1999;213(3): Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62: Mizuta H, Kubota K, Shiraishi M, Otsuka Y, Nagamoto N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995;77: Janarv PM, Nyström A, Werner S, Hirsch G. Anterior cruciate ligament injuries in skeletally immature patients. J Pediatr Orthop. 1996;16: Kocher MS, Micheli LJ, Zurakowski D, Luke A: Partial tears of the anterior cruciate ligament in children and adolescents. Am J Sports Med 2002; 30(5): Lawrence JTR, 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? Am J Sports Med. 2011;39: Vavken P, Murray MM: Treating anterior cruciate ligament tears in skeletally immature patients. Arthroscopy2011;27(5): Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ. Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. JBJS Jul 5;100(13): Kocher MS, Smith JT, Zoric BJ, Lee B, Micheli LJ: Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am 2007; 89(12): Wright RW, Fetzer GB: Bracing after ACL reconstruction: A systematic review. Clin Orthop Relat Res 2007;455: Kaeding CC, Aros B, Pedroza A, et al: Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort. Sports Health 2011;3(1):73-81.

47 References II Edmonds EW, Fornari ED, Dashe J, Roocroft JH: Results of displaced pediatric tibial spine fractures: A comparison between open, arthroscopic and closed management. J Pediatr Orthop 35(7): , Khormaee S, Kramer DE, Yen Y-M, Heyworth BE. Evaluation and Management of Patellar Instability in Pediatric and Adolescent Athletes. Sport Heal A Multidiscip Approach. 2015;7(2): Willis RB, Firth G. Traumatic patellar dislocation: loose bodies and the MPFL. J Pediatr Orthop. 2012;32 Suppl 1(1):S47-S51 Seeley M a, Knesek M, Vanderhave KL. Osteochondral injury after acute patellar dislocation in children and adolescents. J Pediatr Orthop. 2013;33(5): Jaquith BP, Parikh SN. Predictors of Recurrent Patellar Instability in Children and Adolescents After First-time Dislocation. J Pediatr Orthop. 2015