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?