ACL Injuries In the Skeletally Immature

ACL Injuries In the ACL Injuries In the Skeletally ImmatureSkeletally Immature

Jason W. Folk, MDJason W. Folk, MDSteadman Hawkins Clinic of the Steadman Hawkins Clinic of the

CarolinasCarolinasFebruary 2012February 2012

Consultant Smith & Nephew Consultant Smith & Nephew EndoscopyEndoscopy

DisclosuresDisclosures

ObjectivesObjectives Describe the epidemiology, Describe the epidemiology,

pathophysiology, and treatment pathophysiology, and treatment principles of ACL injuries in skeletally principles of ACL injuries in skeletally immature patientsimmature patients

ACL Injuries: ACL Injuries: IntroductionIntroduction

Epidemiology: Epidemiology: – Intrasubstance tears once Intrasubstance tears once

considered rare in considered rare in pediatric populationpediatric population

– Tibial eminence fx Tibial eminence fx considered pediatric ACL considered pediatric ACL equivalentequivalent Typically under 12yoTypically under 12yo

– Increasing numbers over Increasing numbers over past decadepast decade

– Increased attentionIncreased attention

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Reasons for increased Reasons for increased incidence:incidence:– Increased participation in Increased participation in

sportssports– Higher competitive levels Higher competitive levels

early onearly on– Increased awareness of Increased awareness of

injuryinjury– Decreased conditioningDecreased conditioning


ACL Injuries in Soccer Players 5-18 ACL Injuries in Soccer Players 5-18 (Shea, et al. JPO 2004.)(Shea, et al. JPO 2004.)– Based on insurance data from 6 million Based on insurance data from 6 million

player-yearsplayer-years– 6.7% of total injury claims6.7% of total injury claims– 30.8% of all knee injury claims30.8% of all knee injury claims

True incidence unknownTrue incidence unknown


Differences in pediatric populationDifferences in pediatric population– Often lack fully developed complex Often lack fully developed complex

motor skillsmotor skills– May have temporary decline in motor May have temporary decline in motor

and balance during pubertyand balance during puberty– Open physesOpen physes– Higher strength of ligaments vs. bone-Higher strength of ligaments vs. bone-

ligament interfaceligament interface

ACL Injuries:ACL Injuries:DiagnosisDiagnosis

History: History: – Patient describes a Patient describes a

characteristic “Pop”characteristic “Pop”– Effusion forms quickly Effusion forms quickly

after injuryafter injury 47% of patient’s aged 7-47% of patient’s aged 7-

12 with traumatic effusion 12 with traumatic effusion had ACL disruptionhad ACL disruption

65% in 13-18 year old 65% in 13-18 year old group. (Stanitski et al. group. (Stanitski et al. 1993)1993)

Approximately 60% partial Approximately 60% partial tearstears

ACL Injuries: ACL Injuries: DiagnosisDiagnosis

Physical ExamPhysical Exam– Often more difficult in kids than adultsOften more difficult in kids than adults

Acute painAcute pain Frightened Frightened Unable to relaxUnable to relax

– Examine uninjured leg for baseline Examine uninjured leg for baseline laxity or congenital absence of ACLlaxity or congenital absence of ACL

ACL Injuries: ACL Injuries: ImagingImaging

Plain Radiographs (4 views)Plain Radiographs (4 views)– For anyone suspected of For anyone suspected of

having an ACL injuryhaving an ACL injury Bony avulsionsBony avulsions Osteochondral fracturesOsteochondral fractures Physeal fracturesPhyseal fractures Patellar dislocation/subluxationPatellar dislocation/subluxation Degree of physeal closureDegree of physeal closure

– CT scan also used for CT scan also used for evaluation of physeal closure. evaluation of physeal closure.

Tibial Eminence FractureTibial Eminence Fracture In skeletally immature, In skeletally immature,

chondroepiphysis is chondroepiphysis is weaker than the weaker than the ligament.ligament.

Mechanism of injury Mechanism of injury typically hyperflexiontypically hyperflexion

Most commonly 8-Most commonly 8-12yo12yo

Present w/ pain and Present w/ pain and limited ROMlimited ROM

Dx on x-ray and CTDx on x-ray and CT

Tibial Eminence FractureTibial Eminence Fracture Type I: LLC x 3-6 weeks in 20degrees Type I: LLC x 3-6 weeks in 20degrees

flexionflexion Type II/III: Attempted closed reduction, Type II/III: Attempted closed reduction,

++aspiration of hemarthrosis (may help aspiration of hemarthrosis (may help reduction), LLC in extension x 4-6 reduction), LLC in extension x 4-6 weeksweeks

Irreducible Type II/III or IV: arthrocopic Irreducible Type II/III or IV: arthrocopic vs open ORIF with suture, retrograde vs open ORIF with suture, retrograde wire, or screw fixationwire, or screw fixation

Some argue all Types II-IV should be Some argue all Types II-IV should be fixed anatomically with countersinking fixed anatomically with countersinking of fragment because of residual laxityof fragment because of residual laxity

Results of fixation usually excellentResults of fixation usually excellent

ACL Injuries: ACL Injuries: ImagingImaging

MRIMRI– Should not be used as Should not be used as

replacement for physical exam replacement for physical exam and routine radiographsand routine radiographs

– Look for ACL tear, meniscal Look for ACL tear, meniscal injury, chondral injuryinjury, chondral injury

– IndicationsIndications Failing to improve ROM Failing to improve ROM Persistent effusionPersistent effusion Physical exam difficult to interpret. Physical exam difficult to interpret. Help define anatomy of physisHelp define anatomy of physis

ACL Injuries: ACL Injuries: EtiologyEtiology

Can occur with fracturesCan occur with fractures– Distal femoral physeal Distal femoral physeal

fractures (25-45%)fractures (25-45%)– Salter-Harris III fxs at Salter-Harris III fxs at

increased risk because increased risk because frequently exits intra-frequently exits intra-articularly at notcharticularly at notch

– Proximal tibial physeal Proximal tibial physeal fracturesfractures

The PhysisThe Physis Concern about Concern about

iatrogenic injury to iatrogenic injury to physis is what physis is what drives the debate drives the debate about treatment about treatment strategiesstrategies

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The PhysisThe Physis Distal femoral and Distal femoral and

prox tibial physisprox tibial physis– Contribute more to Contribute more to

limb length than hip limb length than hip and ankleand ankle

– DF 1.2 cm/yrDF 1.2 cm/yr– PT 0.9 cm/yrPT 0.9 cm/yr– Overall 65% of length Overall 65% of length

contributed to kneecontributed to knee– Closure typically Closure typically

occursoccurs M=16M=16 F=14F=14 1616

Anatomy of PhysisAnatomy of Physis MRI closure of PhysisMRI closure of Physis

– 0% at 11 years0% at 11 years– 5% at 12 years5% at 12 years– 34% at 13 years34% at 13 years– 53% at 14 years53% at 14 years– 94% at 15 years94% at 15 years– 100% at 16 years100% at 16 years

Central tibial physis closes prior to Central tibial physis closes prior to peripheral physisperipheral physis– ?More central tunnel?More central tunnel– ?Smaller tunnel?Smaller tunnel

Sasaki et al., J Knee Surg 2002Sasaki et al., J Knee Surg 2002

ACL Injuries:ACL Injuries:TreatmentTreatment

Concern for possible growth abnormality Concern for possible growth abnormality fuels debate on treatmentfuels debate on treatment– Non-operativeNon-operative– OperativeOperative

Direct RepairDirect Repair Extra-articular Extra-articular Intra-articularIntra-articular Intra/Extra articular reconstructionsIntra/Extra articular reconstructions

– Physeal sparingPhyseal sparing– Partial Transphyseal Partial Transphyseal – Complete transphysealComplete transphyseal– Trans epiphysealTrans epiphyseal

ACL InjuriesACL InjuriesNonoperative ManagementNonoperative Management

Avoids risk of physeal Avoids risk of physeal damagedamage

Sometimes used as a Sometimes used as a temporizing measure temporizing measure until skeletal maturityuntil skeletal maturity

Very difficult to Very difficult to reasonably limit young reasonably limit young patient’s activitiespatient’s activities

ACL Injuries:ACL Injuries:Nonoperative managementNonoperative management

So what if we don’t So what if we don’t treat these injuries?treat these injuries?– Angel et al. Arthroscopy Angel et al. Arthroscopy

1989 1989 27 children with 27 children with

arthroscopically arthroscopically documented ACL tearsdocumented ACL tears

22 patients at 51mo f/u22 patients at 51mo f/u None able to return to None able to return to

sports at preinjury levelsports at preinjury level

Non-op ACL Open PhysisNon-op ACL Open Physis

40 pts under 14 y/o open physis40 pts under 14 y/o open physis

16 conservative16 conservative– 6 scope for meniscal tears6 scope for meniscal tears– Only 7 return to sportsOnly 7 return to sports

All recur giving way, swelling, painAll recur giving way, swelling, pain

McCarroll et al., AJSM 1988McCarroll et al., AJSM 1988


18 pts ACL injury open physis18 pts ACL injury open physis Only one returned to Only one returned to

preinjury level of sportspreinjury level of sports Initial scope 13 meniscal Initial scope 13 meniscal

tearstears Later secondary meniscal Later secondary meniscal

tears in 9tears in 9 Degen changes 11 of 18 pts Degen changes 11 of 18 pts

by Xrayby Xray

Mizuta et al., JBJS Br 1995Mizuta et al., JBJS Br 1995


60 children with ACL tear60 children with ACL tear 23 nonop23 nonop

• Nat Hx continued instability, further Nat Hx continued instability, further meniscal and chondral damagemeniscal and chondral damage

• 25 % secondary meniscal tears25 % secondary meniscal tears• Few able to participate in sportFew able to participate in sportss

Aichroth et al., JBJS BR, 2002Aichroth et al., JBJS BR, 2002

Non-op ACL Open PhysisNon-op ACL Open Physis ? Effect of delay in ? Effect of delay in

treatmenttreatment 39 pt < 14 y/o39 pt < 14 y/o Sig increase in MMT Sig increase in MMT

with delay in treatment with delay in treatment > 6 weeks> 6 weeks• 36% chronic vs 11% in 36% chronic vs 11% in

acute Rxacute Rx No diff in rate of LMTNo diff in rate of LMT

Millett et al., Arthroscopy 2002Millett et al., Arthroscopy 2002

ACL InjuriesACL InjuriesNonoperative ManagementNonoperative Management

Graf et al: Graf et al: – 12 skeletally immature patients with ACL tears12 skeletally immature patients with ACL tears– 8 patients underwent non-op and no restriction 8 patients underwent non-op and no restriction

management. management. 7 of the 8 had new meniscal tear at follow up7 of the 8 had new meniscal tear at follow up

ACL Injury:ACL Injury:Long Term ResultsLong Term Results

Kannus et al. JBJS-B. 1988Kannus et al. JBJS-B. 1988• 8 year F/U – 4/7 Pediatric Patients that had 8 year F/U – 4/7 Pediatric Patients that had

Untreated ACL Tears showed Advancing Untreated ACL Tears showed Advancing OA radiographicallyOA radiographically

Nonoperative Rx in ChildrenNonoperative Rx in Children

Non-op treatment Non-op treatment has not resulted has not resulted in good outcomesin good outcomes

ACL Injuries:ACL Injuries:Physeal ConcernsPhyseal Concerns

Fear disruption of open Fear disruption of open physesphyses

Risk of epiphysiodesis, LLD, Risk of epiphysiodesis, LLD, angular deformityangular deformity

Caused by crossing physis Caused by crossing physis with bone plug and/or with bone plug and/or fixation devicesfixation devices

ACL Injuries:ACL Injuries:Physeal ConcernsPhyseal Concerns

History History – Campbell et al. (1959)Campbell et al. (1959)

Large holes drilled through the physis have maximal Large holes drilled through the physis have maximal retardation of growth plateretardation of growth plate

Insertion of cortical bone across physis causes arrestInsertion of cortical bone across physis causes arrest– Makel et al (1988)Makel et al (1988)

Destruction of >7% of physis causes growth arrestDestruction of >7% of physis causes growth arrest Destruction of 3% or less…no arrestDestruction of 3% or less…no arrest

– Stadelmeir et al (1995)Stadelmeir et al (1995) Soft tissue graft placed in drill hole did not cause Soft tissue graft placed in drill hole did not cause

physeal bar. physeal bar.

Factors Influencing Physeal ArrestFactors Influencing Physeal Arrest

Diameter of drill holeDiameter of drill hole Soft tissue graft within tunnelSoft tissue graft within tunnel Tension of graft across physisTension of graft across physis Tunnel location? (Central and vertical)Tunnel location? (Central and vertical)

ACL Injuries: ACL Injuries: Operative ManagmentOperative Managment

Direct Repair:Direct Repair:– A historic treatment modalityA historic treatment modality– Inflammatory changes and Inflammatory changes and

degeneration begins within 48 hours degeneration begins within 48 hours after injuryafter injury

– Metalloproteases and cytokine Metalloproteases and cytokine inflammatory factors affect healing inflammatory factors affect healing potential of direct repair potential of direct repair

– Poor resultsPoor results Delee and Curtis, CORR 1983Delee and Curtis, CORR 1983 Engebretsen, et al. Acta Orthop Scand 1988Engebretsen, et al. Acta Orthop Scand 1988

ACL Injuries:ACL Injuries:Operative ManagementOperative Management

Extra-Articular repairExtra-Articular repair– Temporizing methodTemporizing method– Non-anatomic reconstructionNon-anatomic reconstruction– Poor resultsPoor results

Dahlstedt , et al. Acta Orthop Scand Dahlstedt , et al. Acta Orthop Scand 19881988

McCarroll et al. AJSM 1998McCarroll et al. AJSM 1998 Graf, et al. Arthrsocopy 1992Graf, et al. Arthrsocopy 1992

ACL Injuries: ACL Injuries: Assessment of maturityAssessment of maturity

Tanner et al. : Tanner et al. : – Adolescent growth spurt begins Adolescent growth spurt begins

at 12.5 years in boys and 10.5 at 12.5 years in boys and 10.5 years in girls. years in girls.

– Peak Growth velocity 1 year Peak Growth velocity 1 year laterlater

Menarche is good indication of Menarche is good indication of maturity in girlsmaturity in girls– In athletic girls, menarche may In athletic girls, menarche may

be delayed. be delayed. Axillary and pubic hair appear in Axillary and pubic hair appear in

boys after growth spurtboys after growth spurt Bone age: Most accurate method Bone age: Most accurate method

to determine skeletal maturity to determine skeletal maturity

General GuidelinesGeneral Guidelines Think about physis if:Think about physis if:

– MaleMale Tanner stage 1 or 2Tanner stage 1 or 2 Not shavingNot shaving Not reached growth spurtNot reached growth spurt 14 y/o or less14 y/o or less

– FemaleFemale PremenarchalPremenarchal Tanner stage 1 or 2Tanner stage 1 or 2 Not reached growth spurtNot reached growth spurt 12 y/o or less12 y/o or less

ACL Reconstruction ACL Reconstruction TechniquesTechniques

ACL Injury:ACL Injury:Physeal Sparing Physeal Sparing ReconstructionReconstruction

Intra-articular, non-anatomic, extra-physealIntra-articular, non-anatomic, extra-physeal

Stanitski. JAAOS 1985

ACL Injury:ACL Injury:Kocher TechniqueKocher Technique

Physeal-Sparring Combined Intra- and Extra-articular Reconstruction

ACL Injury:ACL Injury:Partial TransphysealPartial Transphyseal

Hybrid of physeal Hybrid of physeal sparing and adult-sparing and adult-type reconstructiontype reconstruction

Femoral physis left Femoral physis left intactintact

Graft: Hamstring or Graft: Hamstring or patellapatella– Passed through 6-Passed through 6-

8mm tunnel8mm tunnel <5% physeal X-<5% physeal X-

sectional areasectional area– Fixed in over the top Fixed in over the top

positionposition

ACL Injury:ACL Injury:TransepiphysealTransepiphyseal

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ACL Injury:ACL Injury:TransphysealTransphyseal

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ACL Injuries In the Skeletally Immature