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6/9/13
1
HSS educational activities are carried out in a manner that serves the educational
component of our Mission. As faculty we are committed to providing transparency in any/all external
relationships prior to giving an academic presentation.
Frank A. Cordasco, MD,MS Hospital for Special Surgery
Disclosure: I DO have a financial relationship with a commercial
interest. Types of financial relationships and the companies with whom I have
relationships are as follows:
ConMed/Linvatec: Royalties from intellectual property Arthrex: Consultant
Pediatric ACL Debate All Epiphyseal
Frank A. Cordasco, MD, MS Associate Professor of Orthopaedic Surgery The Sports Medicine and Shoulder Service
Hospital for Special Surgery Weill Cornell Medical College
New York, NY
Outline • Skeletally Immature Athletes: Increasing
Incidence of Injury (ACL, Shoulder Dislocation, “Tommy John”, Hip Labrum, etc.)
• Early Diagnosis Important • Non-operative Treatment Often
Unsuccessful • Surgical Treatment: Higher Failure Rates
than Adults • Return to Sport Assessment Critical
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ACL Injury in the Child and Young Adolescent with Significant Growth
Remaining
Increasing Incidence of ACL Injury •! Increase in Sports
Participation and Level of Competition (Title IX doubled denominator)
•! Societal and Parental Pressures
•! D1 Scholarships and D3 “College Hook”
•! Improved Examination, Imaging and Diagnostic Methods: Increased Awareness and Index of Suspicion
Shea JPO 04, Kocher JBJS 05
Gender Specific Differences
•! Females 4-6 X higher risk knee injury •! Females 2-8 X higher risk of ACL tear
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Public Health Costs > $2 Billion Annually
• High Cost surgical treatment and rehabilitation per Athlete
• Loss of season • Academic performance Trentacosta et al AJSM ‘09 • Scholarship funding • Mental health
Physeal Anatomy
• Distal Femoral Physis – Contributes ~70% of total
length of the femur and 37% of total length of the leg
– 0.375 inches (1.0 cm) of growth/yr
– The distance from ACL (femoral origin) to femoral physis remains unchanged from gestational age
Physeal Anatomy
• Proximal Tibial Physis – Contributes ~55% of total
length of the tibia and 25% of total length of the leg
– 0.25 inches (0.64 cm) of growth/yr
– The medial border of the ACL insertion closely defines the medial extent of the tibial apophysis
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Skeletally Immature: Imaging
The Dilemma Historically
Early Reconstruction Risks: Growth disturbance Angular deformity
Non-Adult Type Reconstruction: Less Anatomic Possible Revision in Future,
Bridge to Adult Type Reconstruction
Delayed Reconstruction Risks: Ongoing instability Meniscus injury Cartilage injury
Restricted Activity until Skeletal Maturity: Compliance
Nonoperative Treatment
Operative Treatment
Early Reconstruction Risks: Growth disturbance Angular deformity
Non-Adult Type Reconstruction: Less AnatomicPossible Revision in Future,
Bridge to Adult Type Reconstruction
Delayed Reconstruction Risks: Ongoing instability Meniscus injury Cartilage injury
Restricted Activity until Skeletal Maturity: Compliance
Risk of Growth Disturbance •! Herodicus Society and the ACL study Group, 15 cases of
postoperative deformity were reported (Kocher, JPO 2002)
•! Distal femoral valgus deformity (8 cases) •! Tibial recurvatum (3 cases) •! Genu valgum (2 cases) •! Leg length discrepancy (2 cases)
•! Associated risk factors
•! Hardware placed across the lateral distal femoral physis
•! Bone plug (BPTB) placed across distal femoral physis
•! Large (12mm) tunnels •! Hardware across tibial tubercle apophysis •! Lateral extra-articular tenodesis •! Over-the-top femoral position
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Nonoperative Treatment Outcomes
Graf BK et al Arthroscopy 1992
12 patients treated with brace, return to sports
60% further meniscal injury 12/12 recurrent instability
Mizuta et al. JBJS Br 1995 18 treated nonoperatively 16/18 fair/poor function 11/18 degenerative changes
Millett et al. Arthroscopy 2002 39 patients early vs delayed Higher rate of medial meniscus tears in chronic: 36% vs 11%
Aichroth et al. JBJS Br 2002 23 treated nonoperatively All unable to return to sport/activity level 10/23 OA changes
Henry et al. KSSTA 2009 Early vs Delayed reconstruction
Early group with: -Lower rate of medial meniscus tear (16% vs 41%)
60% further meniscal injury 12/12 recurrent instability
meniscus tears in chronic: Higher rate of medial meniscus tears in chronic: 36% vs 11%
Early group with: -Lower rate of medial meniscus tear (16% vs 41%)
16/18 fair/poor function 11/18 degenerative changes
All unable to return to sport/activity level 10/23 OA changes
Nonoperative Treatment Outcomes •! 70 pts < 14 yo: Delay in Treatment >
12 weeks •! Results in Increased Risk of
Irreparable Medial Meniscus Tears and Lateral Compartment Chondral Injury
Lawrence et al AJSM ‘11
Surgery is the Conservative Treatment
Determination of Skeletal Age Skeletal Age Does Not = Chronologic Age
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Physiological Maturity & Projected Remaining Growth
•! Parental & Sibling heights •! Shoe size stability •! Onset of menarche/axillary
hair: preceded by growth phase of peak height velocity (M-13.5/F-11.5)
Skeletal Growth •! Determination of skeletal maturity
–! Tanner scale –! Bone age (Based on PA Left Hand xray)
•! Greulich-Pyle Atlas –! Most Common –! Predictable Pattern of Ossification: Estimate Skeletal
Age •! HSS Shorthand Bone Age Measurement Scale
–! Prediction of Bone Age Without Use of Atlas –! Relies on Recognition/Memorization of X-ray findings –! Equivalent Accuracy to GP atlas (Heyworth et al AAOS,
2011)
–! Simple approach : Pubescent vs Prepubescent
Skeletal Growth
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Physiological Maturity & Projected Remaining Growth
Green-Anderson Growth Chart Guide to estimate remaining growth. Skeletal age is
determined using GP Atlas or Short-Hand method.
ACL Reconstruction Techniques in the Skeletally Immature
•! Physeal-Sparing Techniques
-!Combined Intra-articular/Extra-articular: Modified McIntosh Kocher JBJS 05
-!All-Epiphyseal (AE): Guzzanti/Stanitski AJSM 03,
Anderson JBJS 05, Ganley CORR 10, Cordasco/Green Arthroscopy Tech 12
•! Partial Transphyseal Techniques - Over-the-Top Femur and Transphyseal Tibia
- AE Femur and Transphyseal Tibial •! Complete Transphyseal Techniques
Paletta Clin Sports Med 11
ACL Tear (Clinical and MRI confirmation)
HSS PREFERRED SURGICAL TREATMENT ALGORITHM
Activity Modification Bracing
Closed chain rehabilitation
Symptomatic
Determination of Skeletal Age
1yr of remaining skeletal growth
Transphyseal
(Hamstring vs. BPTB)
2-3yrs of remaining skeletal growth
All-Inside
Partial Transphyseal (Hamstring)
3-6 yrs of remaining skeletal
growth
All-inside All-Epiphyseal
(Hamstring)
>6 yrs of remaining skeletal growth
All-Epiphyseal vs.
Physeal sparing ITB reconstruction
Determination of Skeletal Age
Transphyseal (Hamstring vs. BPTB)
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Kocher, Micheli JBJS Am 2005 •! ITB harvested proximally ! over
the top position ! under meniscal coronary ligament (Intra/Extra)
•! 44 patients, Tanner I/II •! 2 revisions at 5, 8 years •! 98% normal/near normal Lachman •! 100% normal/near normal Pivot •! Mean IKDC 96.7, mean Lysholm
95.7 •! No growth disturbances •! Kinematic Study: Over-Constrained
(Kennedy et al AJSM 2011)
Physeal-Sparing: Modified McIntosh
Skeletally Immature: Imaging •! Xrays: AP, lateral, notch,
merchant views •! Standing AP alignment
(bilateral hip to ankle) –! LLD –! LE alignment
•! If Suspicious for LLD, CT Scanogram to measure Magnitude and Source (Tibia vs. Femur)
Graft Options
•! Hamstring Autograft in most cases •! BTB Autograft reserved for Adult-Type
Reconstructions in Older Adolescents with closing physes
•! Allografts: High Failure Rates in the Adolescent population (Moon Consortium ‘10, Kappa Delta Award ‘12)
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GraftLink Hamstring Auotgraft
• ST +/or Gracilis • Short Thick Graft • 65-70mm Long • 9-12mm Diameter • Biomechanically
Stiffer
Effect of Drill Tunnel Size • Incidence of Physeal Arrest increases: Tunnel Drilling >7% of
Total Physeal Volume (Guzzanti, JBJS Br 1994) • Graft radius may be the most important variable affecting the
volume of physeal injury Variation of graft diameter from 6mm to 11mm will increase volume % removed from 2.3% to 7.8%
• Increasing tunnel Drill Angle from 45° to 70° will decrease volume % removed from 4.1% to 3.1% (mean 0.2% decrease in physeal damage for each 5° increase in drill angle)
• Volume % of physis removed decreases linearly with age • Double-bundle techniques substantially increase the volumetric
injury to the physis (Shea, JBJS Am 2011)
Effect of Soft Tissue Tensioning
• Excessive soft-tissue graft tension across an open physis may induce premature physeal closure
• In a canine model, fascia lata autograft tensioned to 80N across femoral and tibial tunnels led to significant valgus deformity in the distal femur and significant varus deformity in the proximal tibia (Edwards, JBJS Am 2001)
!"#
TH E JO U R NA L OF BONE & JOINT SURGER Y · JBJS .ORG
VO LU M E 83-A · NU M B ER 5 · MAY 2001TH E EF F E C T OF PLA CING A TEN S ION E D GR AF T ACROSS OP E N GROW TH PL A TE S
the tibia and femur) were pooled and compared with use ofpaired t tests.
Resultsknee infection requiring irrigation and débridement andantibiotics developed at six weeks postoperatively in one
dog (Specimen 10). Postinfectious arthropathy developed rap-idly, as demonstrated on radiographic and clinical exami-nation, and the dog was excluded from the study. Of theremaining eleven dogs, six had the left hindlimb operated onand five had the right hindlimb operated on. No complica-tions developed in any of these eleven dogs. All dogs limpedfor approximately two weeks postoperatively and had a nor-mal gait pattern thereafter.
The osseous tunnels crossed both physes in each op-erative specimen as seen on the immediate postoperative ra-diographs (Fig. 1). All grafted specimens demonstratedlongitudinal growth in both the tibia and the femur, as evi-denced by migration of the fixation screws away from thephyses when immediate postoperative radiographs were com-pared with postmortem radiographs. No specimens showedany radiographic evidence of physeal bar formation. There wasno qualitative difference in the physes between any graftedextremity and its contralateral control.
When inspected grossly, all fascia lata autografts werenoted to be in continuity. All grafts with the exception ofSpecimen 1 appeared to be under tension. All grafted speci-mens appeared to have some procurvatum of the distal part of
the femur when compared with the contralateral control. Thisdeformity was most notable in Specimens 11 and 12 (Fig. 2).No gross recurvatum or procurvatum was noted in any of thetibiae. In addition to length discrepancies, valgus deformity ofthe distal part of the femur was obvious in several of the speci-mens (Fig. 3). In general, minimal deformities were apparenton gross inspection of the tibiae.
The medial and lateral femoral and tibial measure-ments of the experimental and control limbs are summarizedin Table I. With the numbers available, no significant differ-ences could be detected between the grafted and control limbswith regard to mean medial femoral length (p = 0.13) or meanmedial tibial length (p = 0.67). The mean lateral femorallength in the control limbs was significantly greater than thatin the grafted limbs (p < 0.01). The mean lateral tibial lengthin the grafted limbs was significantly greater than that in thecontrol limbs (p = 0.009).
Furthermore, significant valgus femoral angulation waspresent in the grafted extremities (p < 0.001). Coupled withthe results of length measurements, this valgus reflects the rel-ative shortening of the lateral part of the femur. The tibiae ofthe grafted extremities demonstrated significant varus angu-lation (p = 0.03). This deformity reflects the relative lengthen-ing of the lateral part of the tibia. Data on varus and valgusangulation are summarized in Table II.
Histologic evaluation demonstrated no osseous bar for-mation in any specimen. Bone was seen in the tunnel at thelevel of the physis in all grafted specimens in which the graft
A
Fig. 3
Posterior photograph of the right (grafted) and left (control) femora of Specimen 12, demonstrating marked valgus angulation and shortening of the distal part of the right femur.
Control canine femur on right, femur that underwent ACL reconstruction with excessive graft tensioning on left
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Animal Models: Summary •! Tunnels filled with soft tissue grafts may not
result in transphyseal bone bridges •! Grafts placed under tension may cause physeal
injury •! The cross-sectional area of the drill hole should
be minimized in transphyseal approaches •! More Central and Vertical Tunnels (Non-Adult
Approach) •! Issue: In animal models remaining growth
duration quite brief compared to adolescent boys in particular
Transepiphyseal ACLR
Anderson JBJS Am 2004 •! Quad Hamstring •! Femoral and Tibial Tunnels •! Outside-In Technique •! Intraoperative Fluoroscopy •! Endobutton-Washer Femoral
Fixation •! Screw and Post Tibial Fixation
Distal to Tibial Physis
All-Inside Techniques in Adults
Routine and Easy
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All-Inside All Epiphyseal ACL Arthroscopy Techniques 12
McCarthy et al •! Sockets Not Tunnels Created
Inside-Out •! Quad Hamstring Autograft
using a GraftLink Technique with Tensioning Buttons
•! No Hardware Distal to Tibial Physis
Tibia: Flipcutter – 2cm Socket
Femur: Flip Cutter - 2.75 cm Socket 70 Degree Lens
Cannulas
Useful for Suture and Instrument Management Graft Passage
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All-Epiphyseal Advantages • Graft placed within Native ACL
Footprints as performed in Adult ACLR
• Avoids Potential Growth Disturbance Related to Transphyseal Drilling
• Graft should not be effected by Growth as it is All-Epiphyseal
• Avoids Lateral Arthrotomy necessary for OT and Modified McIntosh
All-Inside Sockets versus Outside-In Tunnels
• Avoids Graft Fixation distal to the Tibial Physis or Proximal to the Femoral Physis and Potential for Tethering/Growth Disturbance and the need for associated HWR
• Shorter Graft 60-70mm • Thicker Graft 9-12mm • Biomechanically Stiffer • Theoretically: “Blind Sockets”
may provide improved Biologic Milieu for Healing of Tendon-Bone Interface
All-Inside AE ACLR
EFFECTIVE Biomechanical Contact Stress &
Kinematic Analysis Study • Kinematics: Restored Anterior
and Rotational Stability • Contact Stress: Decrease
Posterior Joint Contact Stresses Compared to the ACL Deficient Knee.
McCarthy, Tucker, Green, Imhauser, Cordasco
AOSSM 12 (Nominated: Herodicus Award) AJSM 13
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MRI @ 6 month
MRI @ 6 Month
All-Inside AE ACLR: SAFE Physeal-Sensitive SPGR MRI
3 Joint Standing X-Ray •! First 25 pts: AE & PTP ACLR @ 12
months Post-op •! Tibial Physeal Compromise: AE 1.7%
PTP = 7.3% •! Femoral Physeal Compromise 1.5% (1
in each group) •! Neither technique resulted in Growth
Disturbance •! Both All-Inside ACLRs: Safe and
Effective @ Early Follow-up in Skeletally Immature Patients.
Nawabi, Potter, Green, Cordasco AOSSM13
!
!
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Versatility: All-Inside Partial Transphyseal
Versatility: All-Inside Complete Transphyseal
Hospital for Special Surgery Rehabilitation Protocol
•! Post-Operative Phase 1 (Weeks 0-4) –! Full knee extension –! Maximum 90° passive flexion –! Patella mobility –! Improve quadriceps contraction –! Home exercise program (HEP)
•! Post-Operative Phase 2 (Weeks 4-8) –! ROM 0-125° –! Normalize WBAT gait –! Single-leg stance without pain and with
neuromuscular control
•! Post-Operative Phase 3 (Weeks 8-16) –! Full ROM –! Improve quadriceps and core strength –! Eccentric quadriceps control
•! Post-Operative Phase 4 (Weeks 16-20) –! Maximize strength and flexibility –! Demonstrate athletic-ready position stance –! HSS ACL Prevention Assessment at Week
16
•! Post-Operative Phase 5 (Weeks 20-28) –! Symptom-free running and flexibility –! Proper dynamic control with jumping and
landing –! Independent gym program
•! Post-Operative Phase 6 (Weeks 28-Return to Sport)
–! Hop Test ! 85% limb symmetry –! Lack of apprehension with sport specific
movements –! Dynamic control with sport specific
movements –! Flexibility appropriate for sport –! Patient/caregiver compliance with
functional bracing
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ACL Reconstruction Failure in Adolescent Athletes
•! Shelbourne et al AJSM 2009 •!Risk of Retear 8.7% if <18 •!Risk of Retear 1.7% if >18
•! Kaeding et al (MOON Cohort) Sports Health 2011
•!Highest re-tear rates in 10-19 yo •!Risk of re-tear decreases by factor of 2
with each decade Must Counsel Parents Regarding Higher Potential for Failure
Shelbourne et al AJSM 2009 Risk of Retear 8.7% if <18 Retear 8.7% if <18 RetearRisk of 1.7% if >18
• Highest re-tear rates in 10-19 yo • Risk of re-tear decreases by factor of 2
Re-Injury
•! These Young Athletes have Unacceptable Failure Rates with Non-Operative Treatment
•! Ipsilateral Failure Rates are Relatively High with Surgical Treatment (5-12%)
•! Contralateral ACL Injury Rates are Higher (7-15%)
•! What Can we do to Diminish these Numbers both on the Prevention Side and Post-Operatively?
Return to Sport (RTS)
•! Less than 50% of Athletes RTS within the First Year
•! Post ACLR: 20-25% of Young Athletes will sustain a second Knee Injury Hewett AJSM 12 ePub
•! 63% HS and 69% C FB RTS and only 43% RTS at previous level McCullough (Moon) AJSM 12
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Revision ACL Reconstruction in Adolescents
• 36 patients, Age 12-17, 22 Female, 14 Male • Interval between Primary and Revision: Average 18 months • Physeal Status @ Primary: Open 10, Partially Open 3, Closed 21 • Primary Graft: BTB 15, HS 13, Allograft 8 • Reason for Failure: Non-Contact 23, Contact 7, Persistent
Instability 5, Infection 1 • Revision: Complete Transphyseal in all • F/U 2 years: Lachman Negative or 1A in 91%, Pivot Negative 96% • Mean IKDC subjective score: 89.1 • Only 57% returned to the same or higher level of activity sport • 8% required additional revision
Reinhardt et al ISAKOS 2011, CORR 2011
HSS Program • Postoperative Guideline
Moksnes J Orhtop Sports PT 12, McCarthy et al Arthroscopy Techniques 2012
• ACL Prevention Program Sadoghi JBJS 12, Mandelbaum AJSM 05, Logerstedt AJSM 12
• Back to Sport: Independent of Time Myer, Hewett AJSM 12
References • McCarthy M, Graziano J, Green DW, Cordasco FA: All-Epiphyseal, All-
Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients. Arthroscopy Techniques 1(2):e231-e239, 2012.
• Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al: Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts. J Bone Joint Surg,95:e28(1-13), 2013.
• Fabricant PD, McCarthy MM, Cordasco FA, Green DW: All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete. J Bone Joint Surg Mar 6;95(5): e28,2013
• McCarthy MM, Tucker S, Nguyen J, Green DW, Imhauser CW, Cordasco FA: Contact Stress and Kinematic Analysis of All-Epiphyseal and Over-the-Top Pediatric Reconstruction Techniques for the Anterior Cruciate Ligament. Am J Sports Med 41:1330-09, 2013.
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Thank You