Options in the Young ACL Deficient Knee

Transcription

1 BOSTON SHOULDER AND SPORTS SYMPOSIUM 2013 Thomas M. DeBerardino, MD Disclosure Information Disclosure Information: The following relationships exist: Research Support from: 1. Musculoskeletal Transplant Foundation 2. Arthrex, Inc. 3. Histogenics Consultant 1. Arthrex, Inc. 2. ABMT Options in the Young ACL Deficient Knee Thomas M. DeBerardino, MD Associate Professor, Department of Orthopaedic Surgery UCONN Health Center Waltham Conference Center October 25-26, 2013 Adolescent Knee Injuries Adolescent ACL Injury Young adolescent s knee not simply a small adult knee Knee injuries can be the most perplexing problems to manage in the adolescent athlete Originally thought to be rare Now more widely recognized True prevalence and incidence is unknown Epidemiology: Adolescent ACL Injuries Hemarthrosis Due to ACL Injury Increased frequency Prevalence vs incidence Increased clinical awareness, MRI, arthroscopy Sport participation at younger ages Total ACL tear Vahasarja (1983) % Eiskjaar (1988) 40 45% Kloeppel-Wirth (1992) 35 26% Stanitski (1993) 65 47% Stanitski, Harvell, Fu. Observations on acute knee hemarthrosis in children and adolescents. JPO Jul-Aug;13(4):

2 ACL Tear Contraindications Prior Typical Treatment Non-surgical Current Typical Treatment Surgical (if clinically warranted) Congenital ACL absence Poor Rehab Compliance Systematic Review of Literature Concerns of Surgery Does early ACLR for skeletally immature patients result in improved outcome compared with nonsurgical treatment or delaying reconstruction until skeletal maturity? Only level I to III evidence - majority represented case series and reviews with expert opinion Only 7 of 615 compared surgical vs nonsurgical Study designs inadequate to answer question Premature physeal closure Growth arrest Leg length discrepancy Angular deformity Mohtadi N, Grant J. Clin J Sport Med Nov;16(6): Physeal Injury in the Literature 2 reports of physeal complications after ACLR Koman and Sanders (JBJS Am 81: ) 1 case of femoral valgus after HS ACLR Femoral fixation was transfixation pin, (crossed lateral aspect of femoral physis causing partial arrest of lateral physis) Lipscomb & Anderson (JBJS Am 68:19 28) Physeal complication related to staples Physeal arrest complication on femoral side only Expert Experience Questionnaire [unpublished rest of the story ] Identified 15 cases of growth disturbance Distal femoral valgus deformity with arrest of lateral aspect of distal femoral physis (n=3) Tibial recurvatum with an arrest of the tibial tubercle apophysis (n=3) Genu valgum without arrest due to a lateral extra-articular tether (n=2) LLD (shortening and overgrowth) (n=2) Kocher, et al. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. JPO, 2002;22:

3 Associated Factors Adolescent ACL Evaluaiton Hardware across lateral distal femoral physis (3) BTB bone plugs across distal femoral physis (3) Large (12-mm) tunnels (2) Lateral extra-articular tenodesis (2) Hardware across tibial tubercle apophysis (2) Creation of over-the-top femoral position (1) Suturing near the tibial tubercle apophysis (1) Kocher, et al. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. JPO, 2002;22:452-7 History Physical exam Imaging Studies Natural History Findings are essentially the same as per adults Natural Hx 58 skeletally immature patients 38 with Tanner stage 1-2 treated nonoperatively Majority with episodes of giving way 70% (27/38) developed meniscal tears ACL Injury History: 60% non-contact Common to feel snap or pop Unable to continue playing Near immediate swelling DX: Physical Positive Lachman with soft endpoint Positive pivot shift McCarroll et al, AJSM 1988, 1994 ACL Injury ACL Injury in Skeletally Immature MRI look for concomitant pathology Treatment and education of injured adolescent and family as to: risk of further instability skeletal maturation issues risk of physeal damage meniscus and articular cartilage injury Male- Tanner 1, 2, 3 Female- premenarche Trial of non-operative treatment consisting of brace, physical therapy and life style change Eventual surgical reconstruction when near musculoskeletal maturity Episodes of instability - not acceptable 3

4 Surgical Treatment Surgical Treatment Options Failure of non-surgical treatment Knowledge of growth and development in a 12 y/o average Tanner 2-3, consider the patient 1 yr from peak growth activity with 4 cm of distal femur and 3 cm of proximal tibia These ranges will vary depending on age and Tanner stage Primary repair Extra-articular reconstruction Intra-articular reconstruction Over-the-top on femur and/or tibia Trans-physeal on femur and/or tibia Trans-epiphyseal (physeal-sparing) on femur and/or tibia Surgical Treatment Surgical techniques remain controversial Small drill holes through central epiphysis more acceptable Newer described physeal-sparing methods provide anatomic intra-articular graft placement, yet spare physes Surgical Treatment Preoperative Evaluation Most common techniques: Transphyseal tibia and femur, small drill holes with STG (Paletta, Hinton) Transphyseal tibia, over the top femur, STG (Wickiewicz) Combined intra and extra-articular over the top femur, tibia epiphyseal groove using an IT band (Micheli) PE: Tanner staging, menarche history, growth plate prediction imaging X-rays: consisting of full length standing, hip to ankle wrist for bone age 4

5 Preoperative Evaluation Adolescent ACL Algorithm MRI Associated meniscal injury Repair with anterior cruciate ligament reconstruction gives best results Age 10, Tanner 1-2 consider repair of the meniscus and nonoperative ACL treatment Age 12, Tanner 3-4 repairable meniscus consider doing ACL reconstruction without the trial of conservative care Based upon physiologic age Group I: substantial growth remaining Tanner 2-3 At least a year of growth remaining Group II: minimal growth remaining Tanner 3-4 Less than a year of growth remaining Group I Plan Group II Plan Soft tissue graft Trans-epiphyseal or trans-physeal Fixation away from growth plate Femoral fixation: Endobutton or Transfix Tibial fixation: Interference screw (below growth plate) Screw post & washer Soft tissue graft or BTB Trans-physeal tunnels Femoral fixation Endobutton, Transfix, or Interference screw Tibial fixation Interference screw Screw post & washer Setup & Graft Harvest Independent Femoral Socket Same setup as per adult EUA Small vertical STG harvest incision Standard portals Auxiliary medial portal for independent femoral socket Hyper-flexed knee ( degrees) Consider physeal-only socket obtained with retrodrill device Transepiphyseal Femoral Socket 5

6 Tibial Side Summary- Early Adolescents Trans-epiphyseal approach with tibial tunnel or socket (retrodrill) Trans-physeal in adolescent near maturity Avoid fixation across physis Interference screw Screw post & washer Avoid transphyseal techniques in femur Over-the-top All epiphyseal Avoid transphyseal hardware in tibia Epiphyseal groove, socket, tunnel - OK Central transphyseal tunnel or socket - OK Summary- Later Adolescents Patient KB Transphyseal - OK Endobutton, Transfix Avoid hardware crossing the physis Avoid transphyseal hardware in tibia Transphyseal socket or tunnel - OK 14 y/o female soccer player DOI: 7/01 Partial PCL and MMT Initial surgery: 7/01 RF thermal shrinkage of PCL Subtotal MMT resection Reinjured playing soccer 11/01 KACH Evaluation 1/02 Game Plan Complete ACL/PCL deficiency Absent medial meniscus Gross instability Minimal joint line pain FAROM, NVI, Good muscle tone MRI correlation Allograft ACL and DFT PCL reconstructions with tibialis tendons Medial MAT Grafts from MTF 6

7 EUA Gross A-P instability 3+ Lachman/ADT 3+ PDT Gross pivot Hyperextension 7

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9 Rehabilitation TTWB 6-8 weeks Brace AROM Yr 2 nd Look Thank You 9