pediatric acl: a new technique koco eaton, m.d.. injuries in younger patients why are kids tearing...
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Pediatric ACL: A New Pediatric ACL: A New TechniqueTechnique
Koco Eaton, M.D.Koco Eaton, M.D.
Injuries in Younger Injuries in Younger PatientsPatients
Why are kids tearing their ACLs Why are kids tearing their ACLs at such a young age?at such a young age?
Increasing number of children Increasing number of children playing organized sports at a playing organized sports at a younger ageyounger age
Correlates with the increasing Correlates with the increasing number of ACL injuriesnumber of ACL injuries
Treatment OptionsTreatment Options
Conservative treatment:Conservative treatment:
BracingBracing Physical therapy to strengthen the Physical therapy to strengthen the
quadriceps and hamstringsquadriceps and hamstrings CounselingCounseling Activity modificationActivity modification
Treatment OptionsTreatment Options
Conservative treatment:Conservative treatment:
Various authors have reported poor Various authors have reported poor outcomes with non-operative outcomes with non-operative treatmenttreatment
Bracing may not prevent instabilityBracing may not prevent instability Further episodes of instability will Further episodes of instability will
most likely result in new meniscus most likely result in new meniscus tears and early arthritistears and early arthritis
Treatment OptionsTreatment Options
Primary repair:Primary repair:
May be attempted if ligament is May be attempted if ligament is avulsed from femoral or tibial avulsed from femoral or tibial insertions – may heal to provide insertions – may heal to provide temporary stabilitytemporary stability
Repair of midsubstance tears has Repair of midsubstance tears has resulted in persistent instability and resulted in persistent instability and decreased activity leveldecreased activity level
Treatment OptionsTreatment Options
Extraarticular tenodesis:Extraarticular tenodesis:
May provide anterior tibial stability May provide anterior tibial stability and eliminate the pivot shiftand eliminate the pivot shift
Not an anatomic reconstructionNot an anatomic reconstruction Overloaded lateral joint Overloaded lateral joint
compartment may undergo compartment may undergo premature degenerative changespremature degenerative changes
Treatment OptionsTreatment Options
Intra-articular reconstruction:Intra-articular reconstruction:
Should be avoided in young Should be avoided in young patients with open growth platespatients with open growth plates
Involves drilling through growth Involves drilling through growth plates, which may cause physeal plates, which may cause physeal injury and growth arrestinjury and growth arrest
The Million $$$ Question:The Million $$$ Question:
What is the best option for a What is the best option for a patient with a torn ACL and patient with a torn ACL and open growth plates?open growth plates?
ACL Repair with ACL Repair with Semitendinosus Semitendinosus AugmentationAugmentation
The New TechniqueThe New Technique
Semitendinosus is detached Semitendinosus is detached proximally, remains intact at the proximally, remains intact at the insertioninsertion
Passed under the intermeniscal Passed under the intermeniscal ligament, running alongside the ligament, running alongside the remaining stump of the ACLremaining stump of the ACL
Passed over the top of the femurPassed over the top of the femur Held in place with screw and Held in place with screw and
ligament washer proximal to ligament washer proximal to physisphysis
The New TechniqueThe New Technique
Clinical Orthopaedics, George A. Paletta, and Carl L. Stanitski; Ch. 63, Clinical Orthopaedics, George A. Paletta, and Carl L. Stanitski; Ch. 63, p.779p.779
The New TechniqueThe New Technique
Three #1 Three #1 PDS sutures PDS sutures are passed are passed through the through the remaining remaining stump of the stump of the ACLACL
The New TechniqueThe New Technique
ACL stump is freed up from ACL stump is freed up from adhesions to PCL, to increase adhesions to PCL, to increase excursionexcursion
The New TechniqueThe New Technique
Gaffe is introduced into the lateral Gaffe is introduced into the lateral portal, passed intra-articularly to portal, passed intra-articularly to locate the over-the-top positionlocate the over-the-top position
Skin incision made over the gaffeSkin incision made over the gaffe
IT band is splitIT band is split
The New TechniqueThe New Technique
Double-looped passing suture is Double-looped passing suture is placed through the gaffe and placed through the gaffe and brought out through the medial brought out through the medial portalportal
The New TechniqueThe New Technique
Sutures from the ACL are then Sutures from the ACL are then brought out through a cannula brought out through a cannula placed in the medial portalplaced in the medial portal
ACL sutures are then passed ACL sutures are then passed through the double-looped through the double-looped passing suture to the over-the-passing suture to the over-the-top position top position
The New TechniqueThe New Technique
Incision is made over the Incision is made over the hamstrings, semitendinosus is hamstrings, semitendinosus is harvestedharvested
The New TechniqueThe New Technique
2-0 Ticron is placed through the 2-0 Ticron is placed through the detached proximal end of the detached proximal end of the semitendinosussemitendinosus
A 60A 60° suture passer containing ° suture passer containing the Tycron is placed through the the Tycron is placed through the incision and under the incision and under the intermeniscal ligament into the intermeniscal ligament into the knee jointknee joint
The New TechniqueThe New Technique
The New TechniqueThe New Technique
The harvested semitendinosus is then The harvested semitendinosus is then pulled through the knee joint, also to pulled through the knee joint, also to the over-the-top position alongside the over-the-top position alongside the remaining stump of the ACLthe remaining stump of the ACL
The New TechniqueThe New Technique
The graft and sutures are tied The graft and sutures are tied down over a 6.5mm screw and down over a 6.5mm screw and spiked ligament washerspiked ligament washer
The New TechniqueThe New Technique
Graft in full extension:Graft in full extension:
After SurgeryAfter Surgery
Typically 3-5 days on crutchesTypically 3-5 days on crutches
Physical therapy is initiated as Physical therapy is initiated as soon as possible after surgerysoon as possible after surgery
Most patients report less pain Most patients report less pain after ACL repair with after ACL repair with semitendinosus augmentation semitendinosus augmentation than with traditional intra-than with traditional intra-articular ACL reconstructionarticular ACL reconstruction
ResultsResults
Since 1993, 13 patients have Since 1993, 13 patients have undergone this procedureundergone this procedure
No growth arrest or angular No growth arrest or angular deformity is present post-deformity is present post-operativelyoperatively
100% of patients have returned 100% of patients have returned to pre-injury activitiesto pre-injury activities
X-raysX-rays
Pre-opPre-op Post-opPost-op
Graft at Later Graft at Later ArthroscopyArthroscopy
Initial surgeryInitial surgery 1 year later1 year later
Case StudyCase Study
12-year old female gymnast falls 12-year old female gymnast falls off balance beam, tears her ACLoff balance beam, tears her ACL
Growth plates wide open on x-Growth plates wide open on x-rayray
Undergoes successful ACL repair Undergoes successful ACL repair with semitendinosus with semitendinosus augmentationaugmentation
Case StudyCase Study
Same female, now age 14, tears Same female, now age 14, tears her ACL in opposite knee running her ACL in opposite knee running basesbases
Growth plates are now closedGrowth plates are now closed
Undergoes traditional ACL Undergoes traditional ACL reconstruction with bone-tendon-reconstruction with bone-tendon-bone autograftbone autograft
Comparative X-raysComparative X-rays
12 years old12 years old 14 years old14 years old
Case StudyCase Study
Comparing knees, patient Comparing knees, patient reports:reports:
Easier recovery and quicker return Easier recovery and quicker return to activity with repairto activity with repair
Equal strength bilaterallyEqual strength bilaterally Full range of motion bilaterallyFull range of motion bilaterally Equal stability bilaterallyEqual stability bilaterally
SummarySummary
ACL repair with semitendinosus ACL repair with semitendinosus augmentation is a safe and augmentation is a safe and effective procedure in patients effective procedure in patients with a torn ACL and open growth with a torn ACL and open growth platesplates
QUESTIONS?QUESTIONS?