Pediatric ACL A New Technique Koco Eaton M

Pediatric ACL: A New Technique Koco Eaton, M. D.

Injuries in Younger Patients n Why are kids tearing their ACLs at such a young age? n Increasing number of children playing organized sports at a younger age n Correlates with the increasing number of ACL injuries

Treatment Options n Conservative treatment: n Bracing n Physical therapy to strengthen the quadriceps and hamstrings n Counseling n Activity modification

Treatment Options n Conservative treatment: n Various authors have reported poor outcomes with non-operative treatment n Bracing may not prevent instability n Further episodes of instability will most likely result in new meniscus tears and early arthritis

Treatment Options n Primary repair: n May be attempted if ligament is avulsed from femoral or tibial insertions – may heal to provide temporary stability n Repair of midsubstance tears has resulted in persistent instability and decreased activity level

Treatment Options n Extraarticular tenodesis: n May provide anterior tibial stability and eliminate the pivot shift n Not an anatomic reconstruction n Overloaded lateral joint compartment may undergo premature degenerative changes

Treatment Options n Intra-articular reconstruction: n Should be avoided in young patients with open growth plates n Involves drilling through growth plates, which may cause physeal injury and growth arrest

The Million $$$ Question: n What is the best option for a patient with a torn ACL and open growth plates? n. ACL Repair with Semitendinosus Augmentation

The New Technique Semitendinosus is detached proximally, remains intact at the insertion n Passed under the intermeniscal ligament, running alongside the remaining stump of the ACL n Passed over the top of the femur n Held in place with screw and ligament washer proximal to physis n

The New Technique Clinical Orthopaedics, George A. Paletta, and Carl L. Stanitski; Ch. 63, p. 779

The New Technique n Three #1 PDS sutures are passed through the remaining stump of the ACL

The New Technique n ACL stump is freed up from adhesions to PCL, to increase excursion

The New Technique n Gaffe is introduced into the lateral portal, passed intra-articularly to locate the over-the-top position n Skin incision made over the gaffe n IT band is split

The New Technique n Double-looped passing suture is placed through the gaffe and brought out through the medial portal

The New Technique n Sutures from the ACL are then brought out through a cannula placed in the medial portal n ACL sutures are then passed through the double-looped passing suture to the over-the-top position

The New Technique n Incision is made over the hamstrings, semitendinosus is harvested

The New Technique n 2 -0 Ticron is placed through the detached proximal end of the semitendinosus n A 60° suture passer containing the Tycron is placed through the incision and under the intermeniscal ligament into the knee joint

The New Technique

The New Technique n The harvested semitendinosus is then pulled through the knee joint, also to the over-the-top position alongside the remaining stump of the ACL

The New Technique n The graft and sutures are tied down over a 6. 5 mm screw and spiked ligament washer

The New Technique n Graft in full extension:

After Surgery n Typically 3 -5 days on crutches n Physical therapy is initiated as soon as possible after surgery n Most patients report less pain after ACL repair with semitendinosus augmentation than with traditional intra-articular ACL reconstruction

Results n Since 1993, 13 patients have undergone this procedure n No growth arrest or angular deformity is present post-operatively n 100% of patients have returned to pre-injury activities

X-rays n Pre-op n Post-op

Graft at Later Arthroscopy n Initial surgery n 1 year later

Case Study n 12 -year old female gymnast falls off balance beam, tears her ACL n Growth plates wide open on x-ray n Undergoes successful ACL repair with semitendinosus augmentation

Case Study n Same female, now age 14, tears her ACL in opposite knee running bases n Growth plates are now closed n Undergoes traditional ACL reconstruction with bone-tendon-bone autograft

Comparative X-rays n 12 years old n 14 years old

Case Study n Comparing knees, patient reports: n Easier recovery and quicker return to activity with repair n Equal strength bilaterally n Full range of motion bilaterally n Equal stability bilaterally

Summary n ACL repair with semitendinosus augmentation is a safe and effective procedure in patients with a torn ACL and open growth plates n QUESTIONS?