Present DISCLOSURES. youth sports. Skeletally Immature ACL. Skeletally Immature ACL Reconstruction: Update Less free play. - More competition

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1 Reconstruction: Update 2017 March 25 th, 2017 Philip L. Wilson, MD Associate Professor of Orthopedics Univ. of Texas Southwestern Medical Center -Royalties and Stock Options Elsevier -Consulting income None -Research and Education support DISCLOSURES ROCK Study Group Unrestricted Grants: Ossur, Breg, Allosource -Other support None youth sports Present - Less free play - More competition Injuries in youth soccer. Koutures CG, Gregory AJ; American Academy of Pediatrics. Council on Sports Medicine and Fitness. Pediatrics Feb;125(2): Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. Shea KG, Pfeiffer R, Wang JH, Curtin M, Apel PJ. J Pediatr Orthop Nov-Dec;24(6): Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents. Kocher MS, DiCanzio J, Zurakowski D, Micheli LJ. Am J Sports Med May-Jun;29(3):

2 Non-Operative or delayed Management in Young Patients Change in Incidence 400% increase in Pediatric ACL injuries between % did not return to same level of activity Meniscal damage Damage to articular cartilage Worsening instability Compromised knee function Earlier evidence of degeneration in the knee Ganley 2010 Henry 2009 Millett 2002 Achroth 2000 Mizuta 1995 McCarroll 1993 Kannus 1988 Treat It Delay of 150 days Increased Incidence of Medial Meniscus Tear (37.8% vs. 53.5%, OR 1.8, p=0.014) Algorithm Based upon Growth Remaining < years growth remaining - Through Physis > years growth remaining - Avoid Physis Dimeglio 2

3 Immature ACL > 6 years Growth Remaining > 3 Years Growth Remaining < 3 years Growth remaining At Maturity (Closing Tubercle / Bone Age < 6 mos remaining ) ITB Extra-Osseous All-Epiphyseal Tunnels and Fixation Trans-physeal Tunnels and Fixation Patellar Autograft SPORTS MEDICINE Immature ACL > 6 years Growth Remaining > 3 Years Growth Remaining < 3 years Growth remaining At Maturity (Closing Tubercle / Bone Age < 6 mos remaining ) Extra-physeal ACL Reconstruction ITB Extra-Osseous All-Epiphyseal Tunnels and Fixation Trans-physeal Tunnels and Fixation Patellar Autograft > 5 years of Growth Remaining Extra-Articular IT Band - Losee / Insall - MacIntosh Central slip of Ilio-tibial band tissue used for graft An Illustrated History of ACL Surgery. McCulloch et al. J of Knee Surg Apr Lateral and intra-articular control points 3

4 - Micheli - MacIntosh Modification Orthopedic Literature Evaluation of Pediatric Anterior Cruciate Ligament ITB Graft Reconstruction Techniques Safe with minimal risk of growth complication Anterior Cruciate Ligament Reconstruction in the Skeletally Immature with Extra-physeal Iliotibial Band Reconstruction Kocher, Micheli et al Bone Joint Surg Am % or greater liklihood of graft function without the need for further surgery for at least 5 years following reconstruction Kocher M, Garg S, Micheli L. Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents. JBJS 2005, 87A:11, Orthopedic Literature Evaluation of Pediatric Anterior Cruciate Ligament ITB Graft Reconstruction Techniques Excellent control of knee stability Kennedy A, Coughlin DG, Metzger MF, Tang R, Pearle AD, Lotz JC, Feeley BT. Biomechanical Evaluation of Pediatric Anterior Cruciate Ligament Reconstruction Techniques Am J Sports Med May;39(5): ITB ACL Reconstruction The Role of the iliotibial band during the pivot shift Serial section of Six frozen hip to toe cadaveric specimens. Mm of translation ACL intact 0 mm, ACL deficient 8.1 mm, ACL + IT 10.8 mm Increase in pivot shift and lachman was observed as constraint of the IT band removed Suero EM Knee Surg Sports Traumatol Arth 2012 Oct 27 (Epub) Growth disturbances without growth arrest after ACL reconstruction children Growth disturbances w/ an autologous iliotibial band graft. symmetrical overgrowth tibial valgus deformity Chotel Knee Surg Sports Traum Arth 2010; 18(11): View of Knee from the side Attachment points of ACL Graft 4

5 MRI VIEW OF RECONSTRUCTED ACL 5

6 LEG APPEARANCE FOLLOWING ITB RECONSTRUCTED ACL > 3 Years Growth Remaining All Epiphyseal ACL Reconstruction Trans-Epipyseal Reconstruction Anderson (2004) JBJS Lawrence (2010) CORR 6

7 Transepiphyseal anterior cruciate ligament reconstruction in pediatric patients surgical techniques: Anderson 2009 Ganley/Lawrence CORR 2010; 468: Hamstrings -All Epiphyseal tunnels / All Epiphyseal Fixation - Antegrade femoral drilling outside in - Retrograde tibial drilling docking procedure - Intra-op CT Scan/Computer navigation Anatomic Landmarks utilized for physeal-sparing anatomic ACL Reconstruction: An MRI Study The center of the ACL femoral footprint and the popliteus insertion are easily identifiable landmarks - will allow safe, reproducible, anatomic ACL reconstruction the skeletally immature. Xerogeanes J, JBJS Feb 2010;94(3): All-epiphyseal ACL reconstruction improves tibiofemoral contact: an in vitro study Sonestreet J Pediatr Orthop 2012 Jan-Feb; 32(1):

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9 < 3 Years Growth Remaining Trans-physeal ACL Reconstruction Trans-Physeal Reconstruction EB y/o F 1/13/

10 Outcomes Extraosseous (IT Band) IKDC (94-96) Lysholm ( ) < 5% Re-rupture Rate All-epiphyseal IKDC ( ) Re-rupture??? Transphyseal IKDC ( ) Re-rupture ( %) Why Are The Grafts Failing? General literature on ACL Failures Tunnel position Allografts Conditioning/Biomechanics Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Conditioning/Biomechanics Optimizing Graft Survival and Functional Outcome GRAFT POSITION Transtibial Versus Anteromedial Portal Reaming in Anterior Cruciate Ligament Reconstruction: An Evaluation of Distal Femoral Physeal Defect and Cortical Fixation Position Charles J. Osier M.D., Christopher Espinoza-Ervin M.D., Albert Diaz de Leon M.D., Gina Cho Sims M.D, Henry Bone Ellis, M.D., Philip Wilson M.D, Gold Standard 10

11 Optimizing Graft Survival and Functional Outcome GRAFT SIZE > 8 mm Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Arthroscopy Apr;28(4): Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level. Barrett AM, Craft JA, Replogle WH, Hydrick JM, Barrett GR. Am J Sports Med Oct;39(10): Optimizing Graft Survival and Functional Outcome Reconstruction TYPE Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques. Kennedy A, Coughlin DG, Metzger MF, Tang R, Pearle AD, Lotz JC, Feeley BT. Am J Sports Med May;39(5): Epub 2011 Jan 21. All-epiphyseal ACL reconstruction improves tibiofemoral contact: an in vitro study. Stonestreet MJ, Jones KC, Kirkpatrick MS, Shah KS, Frampton CE, Morscher MA, Elias JJ. J Pediatr Orthop Jan-Feb;32(1):15-20 Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Conditioning/Biomechanics Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Conditioning/Biomechanics Possible options Challenges to treatment in Pediatric ACL Reconstruction Musculoskeletal Immaturity Compliance Physiological Laxity- high translation on Lachman and pivot Arthrometry normal values higher in young patients Flynn JM, Mackenzie W, Kolstad K, Sandifer E, Jawad AF, Galinat B. Objective evaluation of knee laxity in children. J Pediatr Orthop. Mar-Apr; 20(2)259-63, Graft source Add points of control 11

12 Possible option Possible option Transphyseal + ITB Transphyseal + ITB Increase footprint Increase graft size Add additional rotational control ARGUMENT FOR ITB CONTROL Argument for ITB Control ALL The Role of the iliotibial band during the pivot shift Increase in pivot shift and lachman was observed as constraint of the IT band removed Suero EM Knee Surg Sports Traumatol Arth 2012 Oct 27 (Epub) Antero-lateral ligament Cadaveric and sectioning studies Segond Fragment Excellent control of knee stability Kennedy A, Coughlin DG, Metzger MF, Tang R, Pearle AD, Lotz JC, Feeley BT. Biomechanical Evaluation of Pediatric Anterior Cruciate Ligament Reconstruction Techniques Am J Sports Med May;39(5): Argument for ITB Control Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents Frosch Arthroscopy 2010 Nov. 26 (11); Transphyseal + ITB Medline, the Chochrane Controlled Trial Database, Embase, and Medipilot. This meta-analysis showed overall low rates of leglength differences or axis deviations and graft failures after ACL reconstruction in skeletally immature patients. Transphyseal reconstruction significantly lower risk of leg-length differences or axis deviations compared with physeal-sparing techniques but had a higher risk of rerupture. 12

13 Transphyseal + ITB Transphyseal + ITB Transphyseal + ITB Transphyseal + ITB Transphyseal + ITB Transphyseal + ITB 13

14 Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Conditioning/Biomechanics Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Conditioning/Biomechanics Prevent It Knee Injury Prevention strategies Body Core positioning and Jumping / Landing Techniques Knee Injury Prevention strategies PREVENT KNEE VALGUS COLLAPSE 14

15 Injury Prevention strategies Biomechanics laboratory-based prediction algorithm to identify female athletes with high knee loads that increase risk of ACL injury. Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Br J Sports Med Apr;45(4): Epub 2010 Jun 17. Integrated injury prevention program improves balance and vertical jump height in children. DiStefano LJ, Padua DA, Blackburn JT, Garrett WE, Guskiewicz KM, Marshall SW. J Strength Cond Res Feb;24(2): Injury Prevention strategies Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Arch Pediatr Adolesc Med Nov;165(11): Erratum in: Arch Pediatr Adolesc Med Jan;166(1):73. Effects of an age-specific anterior cruciate ligament injury prevention program on lower extremity biomechanics in children. DiStefano LJ, Blackburn JT, Marshall SW, Guskiewicz KM, Garrett WE, Padua DA. Am J Sports Med May;39(5): Epub 2011 Feb 1. 15

16 A decision-analysis model (1) no training or screening (2) universal neuromuscular training (3) universal screening :: neuromuscular training for identified high-risk athletes only Results: Universal training of all athletes was the dominant strategy, with better outcomes and lower costs compared with screening universal training program would save $100 per player per season would reduce the incidence of ACL injury from 3% to 1.1% per season. Screening was not cost effective Challenges to treatment in Pediatric ACL Reconstruction Non Anatomic Tunnels Musculoskeletal Immaturity Compliance They are Kids Return to Play Pressures Parents Thank You Phil Wilson Cell: Conditioning/Biomechanics scottishritehospital.org/sports 16