false
Catalog
IC 105-2023: Surgical Techniques for ACL Reconstru ...
IC 105 - Surgical Techniques for ACL Reconstructio ...
IC 105 - Surgical Techniques for ACL Reconstruction in Patients with Open Physes (2/6)
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
It's a pleasure to be here with this esteemed group of thought leaders, international. I'm going to give a little talk here about all epiphyseal reconstructions and I just need to advance the slide. Is it with the mouse? There we go. So those are my disclosures which are available on the Academy website. So I'll talk a little bit about the natural history of ACL injuries in young patients. We'll talk about injury rates and operations available, techniques and outcomes and the rationale for the all epiphyseal as well as some experience regarding the young population under the age of 20. And then the evolution rather of graft choices and extra articular tenodesis, et cetera. So natural history, this is a paper that was published by some of my colleagues in New York, Dan Green and Bob Marks. They basically mined the New York State database and as you can see here, over two decades there was a threefold increase in injury rates among young adolescents and pediatric groups and that led to images like the one on your right in my office where we have two athletes with ACL tears, one who's in the NFL and the other who's a fifth grader. So this has been concerning to all of us and it clearly wasn't the case say 20 or 25 years ago. This is from the Pluto Study Group. It's a systematic review and meta-analysis of early operative versus delayed operative versus non-operative published a couple of years ago, nearly 1,200 patients and clearly a delay of surgery even beyond just 12 weeks from injury leads to increasing risks of irreparable tears and non-operative management is even worse with high rates of residual instability and increased risk of tears, et cetera. So clearly non-operative and delayed ACL treatment even out to 12 weeks yields poor outcomes in this population. So if surgery is the conservative approach, really where do we start? And so we published this guideline 10 years ago. It begins with the determination of skeletal age. We happen to use the HSS shorthand bone age measurement scale which is an easy technique. You can also use the Gorilla Compile Atlas and basically once you've established skeletal age then you can look at your menu of operations including the modified McIntosh as popularized by Lyle McHaley, the all epiphyseal, the partial transphysial or hybrid approach and then the complete transphysial approach. I won't touch specifically on repair or bear. We just heard a little bit from Davida. And it's certainly got some potential. Unfortunately the outcomes thus far in this high-risk population have not been optimal but it'll be interesting to see how things play out over time. When we have extra articular augmentations, when to use them, et cetera. This paper really was prompted by my colleague Dan Green who's a pediatric sports medicine specialist and he approached me about 15 years ago and said I know you're doing these all inside reconstructions and I was using at the time Jim Lubowitz's technique. And he thought how could we marry that technique with the late Alan Anderson's landmark paper on transepiphyseal reconstructions using tunnels with an outside-in technique. So we thought about this for a while and then we developed this approach which was an all inside approach using sockets not tunnels with retro cutters. We were using a hamstring graft at the time which we linked with adjustable loop buttons. These were shorter and larger diameter grafts so they were stiffer. And we developed pediatric specific guides particularly for this population because of the angles that were necessary and the adult guides weren't as effective. So we started in the biomechanics lab actually and this is Maura McCarthy who was a resident at the time. She's now a colleague. She's at HSS. And we took our concept to the biomechanics lab, compared the all epiphyseal to the over the top and the complete transphyseal and we found improved kinematics and contact stresses of the ACL deficient knee. We felt that this was an effective technique. Dan Nawabi who was a fellow at the time and again a colleague now at HSS spoke with Hollis Potter who's our MSK radiologist and came up with a physeal map, looked at our first 25 patients with all epiphyseals and partial transphyseals and then evaluated them at one year and it appeared that we had no growth disturbances and we felt that this was a safe technique. Of course, there's nothing like follow-up and so we found that we did have some growth disturbances over the subsequent eight years and we decided that we wanted to mitigate against this potential and we compared then 2D and 3D imaging and we found that there was improved epiphyseal socket placement with intraoperative 3D. It's a little bit more time consuming but we feel that it's a better approach and as you can see, the percentage of sockets that touch the distal femoral physis was diminished dramatically. Now simply touching the physis of course doesn't lead to a growth disturbance but if you can avoid touching the physis, you certainly have benefited the athlete. And these are just some images showing how this is performed intraoperatively and you can really get a good flavor before you ream the socket. You can place your guide pin and determine where you are relative to the physis and it's really the distal femoral physis that we are most concerned about although you can obviously develop recurvotum with a proximal tibial compromise. What about outcomes? Well, this paper from CHOP with Ted Ganley and colleagues reviewed 103 skeletally mature patients. They were performing an all-epiphyseal reconstruction, followed them for 21 months. Mean age was 12.1 and the complication rate was 16.5 percent. They had 11 percent essentially re-rupture rate and then the other complications that you can see there. So this is something that we are aware of, we're concerned about, and we continue to improve the outcomes based upon some of the changes I've mentioned. This was our first paper. It was a small prospective study of 23 skeletally immature patients. They all had all-epiphyseal reconstructions with hamstring autographs and we followed them with a quality of movement assessment until they returned to sport. Mean age was 12.5. Middle school athletes predominantly in the United States which are 6th and 7th graders. Mean follow-up, 32 months. You can see the outcome scores were respectable. Mean KT was respectable. We had no significant growth disturbances but we did find leg length discrepancies of more than 5 millimeters in 6 of the athletes and 2 athletes actually had overgrowth up to beyond 15 millimeters, none more than 2 centimeters. And this is not dissimilar from other pediatric injuries whether it be fractures or infections. We know that there's the potential for overgrowth so we should be aware of that and we should probably measure it preoperatively so that we're clear on what actually was the result of the surgery or the injury. Our second surgery rates were respectable. We had one revision for 4.3% rate and one failed meniscus repair with an intact graft again with 4.3% rate. And the mean return to sport which is important to recognize in this population, excuse me, was over a year. So our experience with athletes under the age of 20, this is a study we put together. It was a prospective study, 324 athletes under the age of 20 and they were my patients and Dan's patients and in the pediatric group we worked together. You can see there were three groups. Group 1 was an all epiphyseal group, 49 patients. The school grade was 6th and they had a revision rate of 6% and decent return to sport rates. Group 3 was a skeletally mature group of 209 athletes with bone tendon bone autografts. Again, a very nice respectable 6% failure rate with decent outcomes with respect to return to sport. This group was the problem group, 66 patients with mostly complete transphysials, a couple partial transphysials and you can see the failure rate was unacceptable, 20% and for males it was 25% and we found that this was a problem and as a result of this study we made two changes. We transitioned to quadriceps grafts, all soft tissue quadriceps grafts from hamstring grafts. We added an LAT and a subgroup within the cohort based upon several factors and I guess the question for all athletes, not just pediatric athletes is when do we add an LAT or an ALL and also how does the quad compare in the adult population to the BTB which is really the subject of a study which is a multi-center international stability 2 study which is currently ongoing. This was our technique which we described. This is an all soft tissue quad autograft. This is a short video. We prefer using a longitudinal open approach. It's a 5 centimeter incision and we release it from the superior pole of the patella, measure it. It's usually in the range for the AE group, it's in the range of 55 to 60 millimeters long. For the adult it's more like 65 to 70 and it's worked well in our hands. We compared MRI signal intensity ratios of the quad tendon and the hamstring tendon at one year following ACL reconstruction and we found that the, for those who are unfamiliar with SIR, lower SIR suggests increased tensile strength, load to failure and vascularity and the quad tendon had significantly lower signal intensity ratios at 12 months compared to the hamstring with greater graft remodeling and maturity. This is a brief summary of the potential benefits of the quad autograft in this population. So as we know, the options for a hamstring graft, if it's insufficient or not optimal, we can perform a contralateral harvest but we do know that this cohort has a high level, a high incidence of bilateral injuries so that's a concern. We know that augmenting insufficient hamstrings with allograft has mixed reviews in the literature. There are multiple papers suggesting poorer outcomes with this approach and others that suggest that there's no difference. We know we can get a more consistent size with a quad and we know that we have higher failure rates with a hamstring in this young population. We also know that hamstring quadriceps ratios are a concern with hamstrings particularly in females and that there can be persistent hamstring weakness in association with knee kinematic abnormalities as a concern. So in summary, I think surgery is a conservative treatment for the young athlete with an ACL. We should determine skeletal age either using the Groylek and Pyle Atlas or a validated HSS shorthand bone age measurement guide. We should select the appropriate surgical technique from the menu of options predicated upon by skeletal age. We should assess for non-modifiable risk factors prior to surgical treatment. And we should avoid hamstring autografts in this cohort of athletes. We should proceed with a quality of movement assessment prior to return to sport to address modifiable risk factors. Thank you for your attention. »» Thank you.
Video Summary
The video transcript discusses the topic of ACL injuries in young patients and the surgical options available for reconstruction. The speaker presents information on the increasing rates of ACL injuries among young adolescents, the risks associated with delayed surgery or non-operative management, and the different surgical techniques available. They focus on the all epiphyseal approach, which uses sockets instead of tunnels, and share their experience with this technique, including the use of pediatric-specific guides and the importance of avoiding contact with the distal femoral physis to prevent growth disturbances. The speaker also discusses outcomes and complications associated with the all epiphyseal reconstruction and emphasizes the need for assessing skeletal age, selecting appropriate surgical techniques, and conducting quality of movement assessments before returning young athletes to sport. No credits were mentioned in the transcript.
Asset Caption
Frank Cordasco, MD, MS
Keywords
ACL injuries
surgical options
all epiphyseal approach
pediatric-specific guides
growth disturbances
×
Please select your language
1
English