Pediatric ACL Reconstruction: Current Status and

---

ORTHOPEDICS TODAY HAWAII 2014

Pediatric ACL Reconstruction: Current Status and Considerations for Surgical Repair Dr. Freddie H. Fu Distinguished Service Professor David Silver Professor and Chairman Department of Orthopaedic Surgery University of Pittsburgh Head Team Physician University of Pittsburgh Athletic Department

Disclosures Freddie H. Fu, MD, DSc (Hon), DPs (Hon) No disclosures

University of Pittsburgh Department of Orthopaedic Surgery Royalties and Stock Options: None Consulting Income: None Research and Educational Support: Smith & Nephew

Other Support: Department of Orthopaedic Surgery of the University of Pittsburgh receives funding from Arthrocare, Synthes, Stryker, Johnson & Johnson, DePuy, DonJoy, Breg, Omeros, Biomet, Mitek

Torn ACLs in Children Are More Common than We Think  80’s: Children Hospital in Pittsburgh  285 diagnostic arthroscopies in pre adolescents and children (pre MRI)  15% of ACL injuries Stanitski , Fu et al. 1989 Orthopedics Stanitski, Fu et al. 1993 Journal of Pediatric Orthopaedics

Growth Remaining?      

Age: chronological and bony Gender and Tanner Stage Menarche Increasing Shoe Size Height of Parents/Older Siblings Width and Appearance of the Growth Plate

Diagnosis     





Pop Effusion History of giving way Lachman Pivot shift Difficult Clinical Exam MRI

Pediatric Bone Bruise Stops at the Growth Plate Adult

Pediatric

Results of Non-Operative Treatment Poor Compliance

Instability High Incidence of Meniscal Tears Joint Degeneration

ACL: Surgical Treatment Options  Differentiate wide open from closing physes  Physeal sparring reconstruction  “Adult” reconstruction – transphyseal  Conservative rehabilitation

How To Reconstruct an ACL with Open Physes???  Wide open physes Spare growth plates  Closing physes Vertical and central tibial tunnel  Over the top  Transepiphyseal femoral tunnel (complex)  Soft tissue grafts

Graft Choices Soft Tissue Only  Hamstrings  Iliotibial band  Allograft ‒ Achilles, anterior or posterior tibial tendons

 Quadriceps tendon

Hamstrings

‒ Soft tissue only



No bone plug

Tibialis anterior allograft

Anatomic Physeal Sparring (APS) ACL Reconstruction 

Anatomic position of the Graft



Avoiding growth problems



APS ACL fulfills All Goals, BUT

Complex Surgery

Over the Top: Anatomical!! No femoral tunnel Over the Top

More than 300 “over the top” cases in open physes patients in Pittsburgh Vertical Tibial Tunnel

No growth plate disturbance

Over the Top (OTT)

OTT

Cases

Case 1 Growth Plate Injury Risk  14 y/o male. Transphyseal ACL reconstruction with BTB and metal interference screws.  Referred to Pittsburgh at 16 y/o with – 18º of valgus – Unstable knee  In 2 years, submitted to: 1. Medial epiphysiodeses 2. Distal Femur Osteotomy 3. ACL revision surgery.  2 inches of discrepancy

Case 2  10 y/o male sustained ACL injury playing soccer  Transphyseal ACL reconstruction with hamstrings

Patient referred to us 3 years post-op 17º valgus

17º

6 months post op

2 cm limb discrepancy Immediate Post op

Case 3  15 y/o male

 Previous physeal sparring ACL reconstruction  Developed a complex, multi-planar deformity  Multiple operations to correct

Case 4

 14 y/o female  Torn ACL  Open physes

MRI

OTT w/ HS Autograft

1 Year PO MRI Oblique sagittal view

Oblique coronal view

Excellent Healing

Comparison to Anatomic SB

Anatomic SB

OTT

3D-CT Scan

AM Area

Anatomic SB

OTT

Second Look Arthroscopy 1 year PO PCL

ACL

Healed Graft

Graft

Vascularization Healed to Femoral Insertion Site

Take Home Message Wide Open Physes:  Use only soft tissue as graft  Spare the physes  Do not leave fixation devices crossing the physes Insall procedure with iliotibial band Younger patients

Take Home Message Patients with Closing Physes:  Consider remaining growth potential  Vertical and central tibial tunnel  Avoid transphyseal tunnel in femur  Go over the top

Conclusion  Differentiate wide open from closing physes  Avoid growth plate problems  Over the top – a simple and good solution  Conservative rehabilitation

Thank You!

University of Pittsburgh Cathedral of Learning