1. ACL Injuries in Children Robert C. Dews MD

3. Incidence Increase in sports participation and level of competition among younger age groups (Title IX doubled the denominator) Increase in sports participation and level of competition among younger age groups (Title IX doubled the denominator) Societal and Parental Pressures Societal and Parental Pressures D1 Scholarships D1 Scholarships “Professional “ aspirations “Professional “ aspirations Improved examinations, Imaging and Diagnostic Methods:Increased Awareness and Index of Suspicion Improved examinations, Imaging and Diagnostic Methods:Increased Awareness and Index of Suspicion

4. Incidence 38 milion young athletes participate in organized sports in U.S 38 milion young athletes participate in organized sports in U.S 2 million high school athletes and 4 million athletes > age 14 treated yearly for sports related injuries 2 million high school athletes and 4 million athletes > age 14 treated yearly for sports related injuries Intrasubstance ACL tears in skeletally immature athlete once thought to be rare is now becoming common place Intrasubstance ACL tears in skeletally immature athlete once thought to be rare is now becoming common place

5. Gender Specific Differences Females 4-6X higher risk knee injury Females 4-6X higher risk knee injury Females 4-8X higher risk of ACL tear Females 4-8X higher risk of ACL tear Soccer and basketball Soccer and basketball

6. What contributes to ACL tear? Notch width index Notch width index Intercondylar notch type Intercondylar notch type Q angle Q angle Jumping mechanics Jumping mechanics Muscle strength Muscle strength Ligamentous laxity Ligamentous laxity Hormonal differences Hormonal differences

7. Clinical Presentation Valgus load (70% non contact) Valgus load (70% non contact) “Pop” “Pop” Hemarthrosis: Hemarthrosis: ACL tear (up to 65%) ACL tear (up to 65%) approx 6-12 hrs after injury approx 6-12 hrs after injury Patella dislocation/fracture Patella dislocation/fracture Physis fracture Physis fracture Meniscal tear Meniscal tear PCL tear PCL tear Capsular tear Capsular tear

8. Why is this different? 

9. Assessing Skeletal Maturity Chronologic age – rough estimate Chronologic age – rough estimate Physiologic age Physiologic age Tanner stages I /child <10: wide open plates Tanner stages I /child <10: wide open plates Tanner II,III/Pre-pubescent 10-13: open plates Tanner II,III/Pre-pubescent 10-13: open plates Tanner IV,V/Pubescent 13-16: narrowed plates Tanner IV,V/Pubescent 13-16: narrowed plates Skeletal Age Hand xray – Pyle Atlas

10. Assessing Skeletal Maturity Peak velocity Peak velocity Female – 11-13 (avg.11.5) Female – 11-13 (avg.11.5) Tanner III Precedes menarche by 1 year Males – 13-15 (avg 13.5) Tanner IV Precedes mature axillary hair Parental and Sibling heights Shoe Size stability

11. The Historical Dilemma Because the physes of prepubescent athletes are still open, nonsurgical treatment—braces and removal from athletic activities—is often recommended. Because the physes of prepubescent athletes are still open, nonsurgical treatment—braces and removal from athletic activities—is often recommended.

12. The Historical Dilemma Nonoperative treatment Delayed ACL reconstuction risks Ongoing instability Meniscal injury Cartilage injury Restricted activity until ??? Compliance Operative treatment Early Reconstructive Risks Growth disturbance Angular deformity Non-adult type reconstuction – less anatonic

13. Nonoperative Treatment Goal: Prevent Recurrent Injury: Preserve Meniscii and Articular Cartilage Goal: Prevent Recurrent Injury: Preserve Meniscii and Articular Cartilage “Temporizing measure” until pt can undergo “adult type” reconstruction “Temporizing measure” until pt can undergo “adult type” reconstruction Physical therapy Physical therapy Functional ACL brace Functional ACL brace Activity modification Activity modification

14. Skeletally Immature Operative Treatment Primary concern is growth disturbance Primary concern is growth disturbance Femoral tunnel Femoral tunnel Angular( valgus) deformity Angular( valgus) deformity Leg lengh discrepancy Leg lengh discrepancy Tibial tunnel Leg length discrepancy Recurvatum deformity Why?? Hardware across physis Bone plugs across physis Large tunnels

16. Re-injury Increased incidence ages 16-19 Increased incidence ages 16-19 4X higher rates in allograft in ages <25 compared to autograft 4X higher rates in allograft in ages <25 compared to autograft

17. Operative Techniques

18. Complete Transphyseal Femoral and Tibial Transphyseal tunnels Femoral and Tibial Transphyseal tunnels Soft tissue graft Soft tissue graft Central and more vertical Central and more vertical Paletta, AAOS ‘10

19. Physeal Sparing- “Over the Top” Reconstruction No bone tunnels No bone tunnels Distally based ST/G graft passed under the intermeniscal ligament and “over the top” of the femur Distally based ST/G graft passed under the intermeniscal ligament and “over the top” of the femur Groove in the anterior tibial epiphysis Groove in the anterior tibial epiphysis

20. Non-anatomic reconstruction – IT band

21. Physeal Sparing – All Epiphyseal Quad/HS graft Quad/HS graft Femoral/Tibial tunnels through epiphysis Femoral/Tibial tunnels through epiphysis Normal Lachman & Pivot Normal Lachman & Pivot KT1000 scroring improved and better IKDC objective scoring KT1000 scroring improved and better IKDC objective scoring Guzzanti, Stanitski AJSM 2003 Anderson JBJB Am 2005 Lawrence, Ganley CORR 2010

23. Prevention Jumping/landing mechanics Jumping/landing mechanics STOP Sports Injuries STOP Sports Injuries Cross training Cross training Bracing – not really Bracing – not really

24. Rehab Go slow, slow, slow Go slow, slow, slow Not as reliable pt population Not as reliable pt population Younger kids will surprise you Younger kids will surprise you Be careful with functional and isokinetic testing Be careful with functional and isokinetic testing

25. Summary “Save the Knee” - Bill McCluskey MD. UMC peds ortho “Save the Knee” - Bill McCluskey MD. UMC peds ortho “It’s really not fair to make young athletes wait for the surgery when we have the knowledge and the procedures to get them back in the game and protect them from sustaining meniscal and/or chondral damage.” “It’s really not fair to make young athletes wait for the surgery when we have the knowledge and the procedures to get them back in the game and protect them from sustaining meniscal and/or chondral damage.”