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ACL Rupture in the
Skeletally Immature Athlete – the End of
the Career?
Edward M. Wojtys, M.D.
University of Michigan
Conflicts of InterestNone
DisclosuresNIH/NIAMS—R01 AR054821
Coulter Foundation Grant
KIA Research—Consultant
Center for Organogenesis
NFL—Injury and Safety Panel
Sports Health—Editor
Age Distribution
Scandanavianregistry:
•Median age ~25
•Range= 5-70 years
Danish registry
Adolescent females
Lind Acta Orthop 2009
Granan Acta Orthop 2009
• 46,472 adolescents, 14-18yo
• 9 year period
• 60.9 per 100,000 person years
• Hazard ratio—Organized sports >4x/wk
•Males� 4.0
•Females� 8.5
Incidence Rates
Parkkari Br J Sports Med 2008
Inconclusive Results
• Systematic review: 615 articles — 7 compared
• Question unanswered!
•Future?
•Follow similar cohorts over time
Mohtadi Clin J Sport Med 2006
Øiestad AJSM 2009
Systematic Review
7 prospective, 24 retrospective studies
Evidence Level II - Cohort
3069 ACL patients
10 year follow-up with X-rays
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Øiestad AJSM 2009
• Isolated ACL Injury – 0-13% OA(3 prospective studies)
• ACL & Meniscal Injury – 21-100% OA
Best rated studies show lowest rate of OA
Coleman Methodology – Mean 52(90)
Evidence Level II - Cohort
Primary Risk Factors
• Meniscal Injury with ACL
• High level sports with cutting, pivoting and twisting
Øiestad AJSM 2009
Knee Function & OA After ACL-R
• 181 pts. (82% follow-up) at 10-15 years
• No significant knee function difference between Isolated and Combined Injuries
Evidence Level II - Cohort
Øiestad AJSM 2010
Knee Function & OA After ACL-R
• 106 (221) pts – 127 partial Meniscectomies
• 8 Meniscal repairs
• Mean time from injury to ACL-R,
28 months (0-278)
Øiestad AJSM 2010
ACL with meniscectomy OA
Prospective cohort - 10.4 years follow-up
63/103 pts (61%)
Evidence Level II
Wu AJSM 2002
Meniscal Status and ACL-R
• 92% pts with “Intact” menisci had normal X-rays
(22 repairs, 21 stable tears, 38 normal)
• Any meniscal resection led to more complaints, limitations, lower IKDC and Lysholm
• All 9 complete meniscectomies → OA
Evidence Level II - ProspectiveCohort
Wu AJSM 2002
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Predictive Factors for OA after ACL
Rupture
• 56 patients follow-up – 6 years(Consecutive series of PT & STG grafts)
• No Meniscal Repairs
Evidence Level I - Cohort
Keays AJSM 2010
Predictive Factors for OA after
ACL Rupture
Evidence Level I - Cohort
Discriminant Analysis(Tibiofemoral OA)
Meniscectomy .72
Weak Quadriceps .39
Chondral Damage .41
Pat. Tendon Graft .37
Low Q/H ratio .06
Keays AJSM 2010
Meniscus Repair with ACL-R
Sample size still too small to provide a detailed analysis of meniscal injuries...”
Evidence Level II - Cohort
448 pts
24 Medial repairs
12 Lateral repairs
“
Spindler AJSM 2011
Meniscal Pathology w/ACL
Tears in Patients w/Open Growth Plates
80 Males (ave. 14.3)
44 Females (ave. 14.1)
Samora JPO 2011
Meniscus Tears
(Within 3 Months of Injury)
• 51 Lateral
• 17 Medial
• 19 Medial and lateral
69.3% Meniscal tears
? Repair ?
Samora JPO 2011
Successful athletic career
Good functional, lifelong outcome
1. Early ACL-R
2. Menscus repair
ACL Injury
Preserving menisci
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ACL Injury in Children
Henry KSSTA 2009
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Children’s hosp.29 (early surgery)
Mean 13.5 m
Adult hosp.27 (delayed surgery)
Mean 30 m
Med. mensical tears(3) 16%
Med. mensical tears(11) 41%
69 pts ≤ 14 y.o.
40 pts (< 12 weeks) � 7% irreparable menisci
Lawrence AJSM 2011
ACL InjuryCons. Rx. or Delayed Surgery (>12 weeks)
Delay ACL Treatment?
29 pts (> 12 weeks)
1. Delay Increases risk of medial meniscal tear 4 fold.
2. severity of med men tears
(24% irreparable)
3. lateral chondral injuries
Lawrence AJSM 2011
Early
Surgery
Growth plate trauma
Limb length discrepancy
Angular deformity
? Unnecessary
Delayed Surgery
(or cons. Rx)
↑ Meniscal tears (loss)
↑ Chondral lesions
? OA
Balancing Risk
1. Central growth plate injury from tunnels.
2. Peripheral growth plate injury from periosteal elevation.
3. Pressure generation across growth plate from tight graft fixation.
ACL Reconstruction Pitfalls
(21) 8 week old rabbits 1. Femoral tunnel -- 11% frontal plane, 3% cross-
sectional area -- no growth or angular deformities
2. Tibial tunnel – 12%
frontal plane, 4% cross-
sectional area
2 valgus tibias ,
1 shortened tibia
Stoked the Controversy
Guzzanti JBJS-B 1994
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Stoked the Controversy
(12) immature dogs
4 mm tunnels
fascia lata grafts
Tensioned at 80N (fascia lata
ACL graft)
Significant femoral valgus and tibial varus
developed in all limbs.
Edwards JBJS 2001
Stoked the Controversy
(44) 5 week old rabbits
Distal Femoral physis
1. 2 mm drill hole (3% cross-sectional area)
No problems
2. 3.5 mm drill hole (7% cross-sectional area)
permanent growth disturbance and limb shortening
Makela JBJS-B 1988
Calmed the Controversy
(8) immature dogs
5/32 transphyseal tibial and femoral tunnels
(4) dogs – fascia lata grafts
(4) dogs – no graft
NO tension on graft
Bony bridges formed in non-grafted
tunnels only.
Stadelmaier AJSM 1995
Physeal Injury
• Tunnel diameter / physeal CSAGuzzanti AJSM 2003
• Excessive graft tensioningEdwards JBJS 2001
• Incomplete tunnel fillStadelmaier AJSM 1995
• Graft fixation across physisChudik Arthroscopy 2007
Vavken Arthroscopy 2011
Transphyseal ACL
• 26 pts (physis > 2 mm)
• 65% - meniscal tears
• F/U – 45 ± 18.3 months
• LL discrepancy ± 7 mm
• Angular ∆– 0.46°± 1.1°
• AP translation – 2.0 ± 1.0 mm
Cohen Arthroscopy 2009
ACL Outcome
(1997 – 2002)
Isolated ACL’s (14) � cons. rx.
Combined ACL’s (17) � surgical rx.
Tanner Slage I or II (median 11 y.o.)
F/U – 70 m, mean growth 20.3 cm
*** Surgical group did better!
* 58% cons. group � subsequent surgery
Streich KSSTA 2010
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Transphyseal ACL - Hamstrings
• 18 pts (mean age 14.2, 1(11), 1(12))
• F/U 24-87 months
• All stable, no ROM loss (>5°)
• No growth ∆‘s or angular deformities
• No re-ruptures – 3 contralateral
Redler Arthroscopy 2012
Pediatric ACL Biomechanics
• 6 cadaver knees (time 0) 0-90°
• AP, varus, I.R. @ 0-90°– ACL intact 2.8 ± 1.4 mm
– ACL def. 7.2 ± 2.7
– All epiphyseal 5.1 ± 2.3
– Trans tib (over) 4.8 ± 1.8
– ITB (Micheli) 1.7 ± 1.1
Kennedy AJSM 2011
ACL Meta-Analysis
• 55 studies (935 pts., median age 13)
• F/U – 40 months (median)
• LLD or deformity risk– 1.8% (95% C.I. 0 to 3.9%)
• Re-rupture – 3.8% (95% C.I. 2.6 –5.2%)
Frosch Arthroscopy 2010
ACL Tears in Skeletally Immature
• Systematic review – 47 studies
• Conservative rx.
Poor clinical outcomes
Secondary meniscal, chondral injury
• Surgical rx.
Weak evidence for growth ∆
Good stability and function
Vavken Arthroscopy 2011
ACL Systematic Review
Youngest patients (10-12 y.o.)
4 studies (Tanner I or II)
Significantly better results w/ surgery. No significant deformities.
Vavken Arthroscopy 2011
Recommendations
1. Teenagers with less than 6 months of growth remaining may be treated as adults if growth spurt has occurred.
2. Make every attempt to salvage the menisci.
Be Careful !
Examine Tibial Apophysis closely!
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Recommendations
Children, Adolescents, Teenagers
(unstable knees and/or physically active)
1. Pediatric Age ACL injuries should be reconstructed
2. Bracing, physical therapy, and activity modification alone is inadequate.
Rehabilitation
Wells J Pediatr Orthop 2009
• 55 patients—Avg age 15.9 yrs
• Time from surgery � 85% normal quad. Strength
– 5.42 ± 2.27 months
• Ability to return to sport after 6 months rehab.
– 50% of patients (strength)– vascularity and fiber
pattern
Kids - Sports
Unique dependent relationship
Separating Kids-Sports
Can Be Catastrophic
• Loss of identity
• Depression � drugs, alcohol
Thank You
Challenging Cases
• 13 yr. old football player
• 6 foot, 340 lbs
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9 year-old
Bilateral ACL Def
Children and Adolescents
If the growth plate is drilled, try to stay central. Start tunnel lower on tibia. Aim for posterior intra-articular placement.
(Andrews and Noyes, 1994)
Intra-articular – Trans-tibial Physis
• ITB graft
• 44 immature prepubescent patients
Results:
– 32 Normal exam
– 18 Nearly Normal
– 1 Abnormal
• Mean growth (height) – 21. 5 cm
Intra-Articular Extraphyseal
Kocher JBJS 2002
MichelliModification
6 Year Follow-up Technical Points
• only soft tissue should cross growth plate in bone tunnels.
• avoid excess tension (10 lbs)
• keep tunnels small (6-7mm)
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Summary
• ACL-R for children and adolescents for jumping, pivoting sports
• Repair essentially ALL menisci in kids
• Balance risks for return to sport!
Thank You
Nonoperative ACL Treatment OA
(Retrospective Cohort)
• 12-year follow-up of 84 female soccer players (82%)
• No difference between reconstructed and nonoperative group for symptoms or OA
Evidence Level II
Lohmander AJSM 2007
Nonoperative ACL Treatment OA
(Retrospective Cohort)
• 14-year follow-up of 205 male soccer players (94%)
• No difference between reconstructed and nonoperative group for symptoms or OA
• 41% of uninjured knees showed Rad OA Evidence Level II
Von Porat Ann Rheum Dis 2004
Nonoperative ACL Treatment OA
15-year follow-up
Rx Physical Therapy/Activity Modification
(Tegner decreased 7 to 4)
None of the knees with normal menisci developed Rad OA (p‹ 0.001)
44% (35/79) had meniscectomies
16% (13/79) → Rad OA, all had meniscectomies
Evidence Level II - Cohort
Neuman AJSM 2008
12-year followup in female Swedish soccer players. Reconstructive or Conservative Rx
82% - Rad OA
42% - Sx OA
8% - Rad OAuninjured knee
Post Injury Activity Level
Contact Sports
Lohmander AJSM 2004
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Soccer
• Injury reports
• 5-18yo
• 6 million athlete-years
• Knee: 30.8%
–ACL tears: 6.7%
Shea Sports Med 2003
Dilemma
Kids do worse than adults with conservative ACL injury treatment resulting in meniscal
tears and chondral injuries.
Graf Arthroscopy 1992
McCarroll AJSM 1988
Part of the Problem
Difficult to restrict physical activity in children, adolescents, and teenagers.
Rehabilitation
Age-specific components altering treatment course?
• Moksens Knee Surg Sports Traumatol Arthrosc2008
– Conservative—promising rehab. Results
• Roos Curr Opin Rheumatol 2005
– Significant risk for OA with injury
– Prognosis for children and
adolescents?
– Rehabilitation potential
Author Journal Year
MRI
96% Sensitivity (ACL)
59% (Meniscus)
91% (Specificity)
Samora JPO 2011
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Knee Function & OA After ACL-R
• Combined Injuries had more Rad OA than Isolated Injuries
80% vs. 62% (p=0.008)
(Contralateral, uninjured knee – 15% Rad OA)
• No significant difference in Sx OA46% vs. 32% (p=0.053)
Øiestad AJSM 2010
Lohmander AJSM 2007
(Clinical Review)
• 50% of ACL injuries with meniscectomies have Rad OA at 10-20 years (odds ratio 10)
• Worst outcome – obese women with ACL and lateral
meniscectomy
Transphyseal ACL
• 26 pts ( >2 mm femoral & tibial physis)
• Quad hamstring
• 3 re-ruptures
89% returned to same level
Cohen Arthroscopy 2009
Early
Surgery
Growth plate trauma
Limb length discrepancy
Angular deformity
Delayed Surgery
(or cons. Rx)
↑ Meniscal tears (loss)
↑ Chondral lesions
Balancing Risk
Early
Surgery
Delayed Surgery
(or cons. Rx)
Balancing Risk
Growth plate trauma
Limb length discrepancy
Angular deformity
↑ Meniscal tears (loss)
↑ Chondral lesions
Stoked the Controversy
• Theoretical computations based on assumption that a bony bar will form at physis.
• Assumes drill holes in the most peripheral locations in femur and tibia.
1. Trigonometric principals to determine shortening and angulation.
2. If physis drilled in boys <15.5 years old and girls < 13.4 year old,
Expect: 5°increased valgus
1 cm shortening
Wester J Ped Ortho 1994
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Multicenter ACL Study
• 68 pts. mean 12.5 y
• 4 surgical techniques (1984-2001)
• F/U – 32 months
• No angular deformity or LLD
• 6 recurrent instability
• Only 2 pts. Returned to same sports level
Gebhard KSSTA 2006
Growth Plate Disturbance After
Transphyseal ACL-R in Skeletally Immature Patients
• 43 pts, mean 14.8 years (12.4 – 16.5)
• F/U MR, mean 16m (6 – 36m)
• Bone tunnel / growth plate < 3% (femoral & tibial)
Yoon, Kocher, Micheli JPO 2011
Growth Plate Disturbance After
Transphyseal ACL-R in Skeletally Immature Patients
• 5 focal bone bridges (12%)– 4 tibial, 1 femoral
• 2 early physeal closures (tibia)
• No growth disturbances
Yoon, Kocher, Micheli JPO 2011