Prof. Romain Seil, MD, PhD

Centre Hospitalier

de Luxembourg Orthopaedic

Surgery

Sports Medicine

Research Laboratory

Centre de Recherche

Public – Santé,

Luxembourg

Management of ACL injuries in

the skeletally immature patient

5th course of advanced surgery of the knee

Val d’Isère, 02-2014

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Disclosures

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None !

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Types of pediatric ACL lesions

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0 8 14

Bony

avulsions

years

Midsubstance

tears

Cartilaginous

avulsions

Chotel, KSSTA 2013

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In-house ACL registry: 2011-2012

: 32%

: 68%

Frobell RB, Scand J Med Sci Sports 2007

Granan LP, Am J Sports Med 2009

Renstrom P, Br J Sports Med 2012

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Few precise epidemiological data

4-5%

30%

rerupture

risk

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Boys

Girls

Gro

wth

sp

ee

d

1

2

3

4

5

6K

ne

e la

xity (

mm

)

0

20

40

60

80

100

120

140

9 10 11 12 13 14 15 16 17 18 19 20 21

Nu

mb

er

of

surg

erie

s /

yea

r

Age (years)

Baxter MP, 1998

Gicquel P, 2007

Swedish ACL registry 2010

Growth speed

lower extremity

Knee laxity

(mm)

No. of surgeries

per year

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Growth and maturation of knee joint

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Treatment

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Surgery Nonoperative

Growth changes Meniscal tears

Signs of OA

MFC

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Treatment

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Low treatment evidence

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Nonoperative treatment debate

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• children < 12 years, no surgery

• 65% returned to pre-injury level of sport

Streich NA, KSSTA 2010

• Tanner I or II (median 11 years)

• 42 % of conservatively treated children

did not need surgery over a 5-years period

• 58 % developed instability and received

an ACL-reconstruction

Moksnes H, KSSTA 2008

• children < 14 years, surgery

• more medial meniscus & cartilage lesions

if surgery > 3 months after injury

Henry J, KSSTA 2009

• higher MMT rate in late surgery group

Lawrence J, AJSM 2011

Hypothesis:

The earlier the surgery,

the lower secondary meniscus

and cartilage lesions.

Hypothesis:

> 40 % of children do not

need surgery !

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Nonoperative treatment debate

Patients’ & families’ adherence to:

• Less active lifestyle

• Damocles sword of later surgery and

subsequent meniscus tear / cartilage

lesions

• Level II sports

• Brace

Functional tests

Reliability ?

Sensibility ?

Limited option for some patients & their family

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Growth arrest 3 pathophysiological types of growth changes

Chotel F, KSSTA 2010

Arrest Boost deCeleration

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Operative treatment debate

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4 types of gross complications

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Arrest distal lateral

femur physis:

valgus knee

Arrest tibial

tuberosity:

recurvatum

Arrest medial

proximal tibial

physis:

Varus knee

NO transphyseal

hardware

placement or

synthetic graft

Complications probably underreported

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Evolution since 2000

1. Evaluate remaining growth

2. Know specific anatomy

3. Fill the tunnels with soft tissues

4. Small tunnels (< 9mm)

5. Perpendicular to physis

6. Graft tension not too high

7. No physeal-crossing fixation

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TREATMENT UNSTABLE KNEES (%)

Nonoperative 91

Sutures 73

Extraarticular reconstructions 64

Intraarticular reconstructions 14

17 studies

(1983– 1999),

458 knees

Seil R, 2000

2000

2013

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Treatment algorithm

Isolated ACL tear:

NO early reconstruction !

• Explanations +++

• Rehabilitation for 3-6 mo.

• Limitation of physical activity

• Close FU

• (Brace)

Indication for surgery:

1. If primary meniscal tear

2. @ skeletal maturity

3. If secondary meniscus tear

4. If functional instability

5. High sports demand (?)

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No international consensus,

expert-opinion level discussions

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Preoperative evaluation: diagnostic pitfalls

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Pivot-shift test:

Hefti F, Muller W 1993

Frequently pathologic

in healthy children

Lachman test:

High physiologic laxity in children !

Baxter MP, J Ped Orthop, 1998

Haemarthrosis:

• 1/3 ligamentous tears (♂>♀)

• 1/3 patella dislocations (♀>♂)

• 1/3 meniscal tears

Luhmann SJ, 2003

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Kocher MS, 2001

sensitivity specificity

< 12 y.: 62 % 90 %

12-16 y.: 78 % 96 %

BEWARE false positive

(up to 25 % !) ♂, 9 y.

Lee K, 1999

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Preoperative evaluation: diagnostic pitfalls

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Preoperative evaluation: functional testing

Moksnes H 2008

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Current hop tests not specific enough

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Height of joint line

Growth plate proximal tibia

Height of Epiphysis (+1 cm)

Tibia

Left knee, specimen of 10 yrs old girl

2 x 2 cm

Small tibial tunnel

entrance area

Preoperative planning: anatomy

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3 mm

ACL

Femur

Preoperative planning: anatomy

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Preoperative planning

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• Remaining knee growth

• Leg length

• Alignment

• Skeletal age

• Tanner staging non reliable

Slough JM MedSciSportsExerc 2013

Greulich & Pyle Atlas

Anderson M, JBJS 1963

No international consensus

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5 cm 1 cm 0 cm

• Skeletal age: 12,9 y.

• ♂ ACL tear @ 12

• Chronological age: 14,9 y.

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3 physiological stages

Growth and maturation of knee joint

Preoperative evaluation: growth assessment

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Surgical techniques

Transphyseal Extraphyseal Epiphyseal

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Physeal sparing

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Quadriceps

tendon

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Graft selection

Hamstrings Patellar tendon

without bone blocks

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HJ *1994 OP 2005

• Transphyseal 4-fold-Semi-

tendinosus/Gracilis graft

• 6-8 mm (< 9 mm!!)

• distal fixation

• femoral tunnel over

anteromedial portal

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Surgical technique

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Surgical technique

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Tibial tuberosity apophysis

Anatomy

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central

Tibial drill injury

♂ 10 y

+ 1 cm

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posterolateral

Femoral drill injury

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♂ 11 y

♂ 11 y

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Transtibial

Anteromedial

9 mm tunnel : 70 mm2 245 mm2

7 mm tunnel : 42 mm2 148 mm2

Femoral drill injury

x 3,5 = x 3,5 =

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Ford & Key, JBJS-A, 1956

Peripheral damage

Axial deviation

Principles of physeal injuries

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3-4% of surface

Seil R, 2008

Masson-Goldner, 25 x

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Isolated ACL replacement:

- 6 weeks brace

- FWB

- Free ROM

- Return to pivoting sports 9-12 months

Meniscal repair:

- 6 weeks brace

- 6 w. 0-0-90°

- 6 w. FWB in extension

Rehabilitation

1 y. postop.

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Bonnard C, Chotel F, RCO 2007

Results

• IKDC A&B: 84 %

• Retears: 5 %

• Return to sports: 91 %

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JBJS 2012

Results less predictable than in adults

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Summary

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Topic Problem Need for further

investigation

Epidemiology No register Yes

Growth / maturation /

evolution of laxity

Little investigations Yes

Prevention No studies for children Yes

Injury risk factors No studies for children Yes

Treatment indications /

algorithms

No consensus Yes

Surgical techniques / (No)

Surgical risk factors Types of complications

Reported complications

(No)

Yes

Outcome Graft evolution

Knee function

Reoperations

Return to sports

Long term outcome

Yes

Yes

Yes

Yes

Yes

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Conclusions

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Pediatric ACL reconstructions are safe if technically correct

But

Complications may occur

Some children do not need an immediate ACL reconstruction

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Conclusions

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The art of pediatric ACL management is to choose:

The right child & family

The right indication

The right moment for reconstruction

The right technique

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Pediatric ACL Monitoring Initiative (PAMI)

Håvard Moksnes

Lars Engebretsen

Romain Seil

• Online survey on the current treatment of pediatric ACL injuries

• Planned submitted to ESSKA members and affiliates

• 2500 recipients, 500 answers

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16th ESSKA Congress

May 14-17, 2014

AMSTERDAM / THE NETHERLANDS

CONGRESS PRESIDENT

C. Niek van Dijk

ESSKA PRESIDENT

João Espregueira-Mendes

SCIENTIFIC CHAIRMEN

Stefano Zaffagnini

Roland Becker

Gino Kerkhoffs

ORGANISER

esska@intercongress.de

www.esska-congress.org