false
Catalog
IC 305-2022: Surgical Techniques for ACL Reconstru ...
Surgical Techniques for ACL Reconstruction in Pati ...
Surgical Techniques for ACL Reconstruction in Patients with Open Physes (3/8)
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Good morning, everybody. My name is Dan Green, and thanks for the invitation. It's a pleasure to be here talking about all epiphyseal ACL reconstruction, sort of disclosures. You know, how did we get started 10, 15 years ago? Basically in our institution there were still some senior surgeons doing over the top, over the top. We were also doing the modified McIntosh, and people were doing a very vertical transphysio approach to these young kids. And at the time, 10, 15 years ago, there wasn't a lot of data, clinical data, about the modified Mac. And we heard Dr. Anderson, the former president here of the AOSSM, talking about his approach and explored it further. So one of my pediatric colleagues, Eric Wall, was doing the technique in Cincinnati, Dr. Anderson, and then Dr. Liebowitz was very gracious with his time in the lab teaching Dr. Kordasko and I the all-inside ACL technique, and we basically adapted that approach to the all-epiphyseal. So there's no transphysio drilling. We did not use tunnels. We used sockets in the epiphysis, and that way there's no graft or graft fixation crossing the growth plate. And pretty much almost every case of all-epiphyseal pediatric ACL at our institution, Dr. Kordasko and I have done together. We tend to work well together in these cases. So again, this can be done with a hamstring or quad autograft approach. The graft itself is pretty short, so if you're using a hamstring, you can triple or quad it over. Generally, the graft site's pretty big, 9.5 to 11. Dr. Kordasko and I designed these pediatric epiphyseal guides that facilitate the socket formation. A couple articles describing one of our discopic techniques, one in JBJS. And as Jonathan said, we begin, every case gets a hand for bone age as well as a standing alignment x-ray. In this particular case, the kid had an asymmetric valgus on the ACL-deficient knee, so we added a plate. And you can see two years later on the far right that he had an epiphyseal ACL, and then after we took out his implant-mediated guide of growth, he no longer had structural valgus. If you're using a hamstring, be aware that if the hamstring attaches to the tibia, if you just pull on it to release it, you're going to get into the tibial tubercle, which is a growth plate, and you could definitely cause a deformity. So always cut the hamstring sharply off the tibia and don't pull it toward the tibial tubercle. We've transitioned to a quad tendon graft for all of our immature folks, unless we're using a McIntosh. And remember, because they're sockets, the graft can't be too long and it can't be too short. So we estimate about 20 millimeters in the femur, 20 to 25 in the joint, and around 15 in the proximal tibia, and we mark accordingly. Passport cannulas are essential for suture management and also allow the scope and the guides to go back and forth. This step-off cannula is really key when you're doing the retro-reaming. It stops the reamer from going through the cortex. It allows ease of suture passing. Dr. X has looked at the anatomic zone for doing a tunnel in the epiphysis in this really nice JBJS study from 2012. But remember, if you're doing a socket, you don't have to really follow this trajectory. You can angle your socket more anteriorly because you're not blowing through the cortex. It's very essential in the OR, when you're doing your femoral socket, you're going to be putting your guide in through the lateral portal. That's my big hand on a little knee because I want to know where the back of the condyle is. I don't want to be too posterior. So usually set the guide at about 90 degrees coming in through the anterior lateral portal. After I get guide wires in, I'll do a quick floral shot. And then if it looks good, I'll put in the retro-reamer. And this view here on the top, let's see. So here's the retro-reamer coming in the wall, the lateral wall. And one of the things that I learned is you really can't have, you can't hit the roof. The roof is, you know, because the grow plate's like a millimeter from the roof. So if you have a big, you're trying to put in a big graft and you're doing a 10.5 or 11, you'll often start infringing on the growth plate. So you have to be a little bit lowered away from the roof than you may want to be if you're using your adult approach and you definitely don't want to scrape the roof. On the tibia side, I like the, I think it's easy because you can actually feel the growth plate. You have your standard kind of anterior medial incision. You ride your finger up, you can feel the growth plate. It's a pretty sharp angle or shallow angle of 30 degrees. How can I feel the growth plate? The epiphysis is kind of convex and the metaphysis starts to become concave, so you can feel a little bump there. And then I'll just put the guide wire right superior to that. After I place the flip cutters or the retro reamers, I now do a 3D spin and it takes some time because I have had some growth disturbance when I was just using the mini C-arm. Here's an example of the 3D images we can get in the OR with the 3D C-arm. And you can see we're pretty, we're obviously flirting with the growth plate here. When I look at my post-op MRIs critically and I say, do I touch my growth plates with the femoral socket or the tibial sockets? When I was just using mini C-arm, I touched the growth plate 40% of the times on the femur and 60% of the time on the tibia. When I got the 3D C-arm out, it was 11% I touched the growth plate on the femur and 16% I touched the growth plate on the tibia. Here's the graft coveted, so the graft to be coveted in the medial portal. You can see the suspensory fixations already placed on the lateral cortex. Start shuttling the sutures, the buttons going in. One tip is when you're doing your, when you're dunking the graft in the tibia, these kids are pretty young and their epiphysis is very weak. If you really want to watch the sutures go into the tibial socket, you don't want to, or it'll be like a giggly saw, it'll kind of cut into the epiphysis. Here's the crab claw pushing the sutures away from the weak bone. And then we're basically just kind of doing your standard all inside technique after that. Here's a 10-year-old that we elected to do an all epiphyseal on. Here's the post-op x-ray. Here's post-op MRI. You can see we're coming right up to the growth plate on the femoral epiphysis. Here on the tibia side. What are the outcomes? When we looked at 300 patients, some had BTB, some had transficial hamstring, and compared them to the all epiphyseal hamstring, surprisingly, the all epiphyseal hamstring group had the lowest revision rate. It was a 6% in 40 died patients with over two-year follow-up and a good return to sport rate, compared to the older transficial hamstring, which had a terrible revision rate of 20%. And that led us to start using quad and LAT more frequently. Ted Ganley and the group at CHOP had the largest study in the literature, with 103 patients with a 20-month follow-up, average age 12. They had a revision rate of 10% and one concern of a growth disturbance. What are the pros? It's really, if you look inside the knee, it's very close to anatomic reconstruction. It can be used with a hamstring or quad. It has a low revision rate. And there's multiple centers of excellence. We tip our hat still to Dr. Anderson and the group at CHOP, Cincinnati's Children, San Diego, and Sheffield in the UK have all mastered this technique and report good results. The downside is it is technically demanding, both in terms of socket preparation, graft preparation, and even suture passing and management in the OR. There is certainly a risk of growth disturbance. We've seen that in some of our cases. And there's extra time for the 3D fluoro, which, as Jonathan pointed out, in my hands I can do a modified mac about at least an hour quicker. And so we're awaiting prospective studies that compare this with the other techniques. Here's one of my growth disturbances when I was using the mini C-arm. You can see a pretty significant disturbance in the distal femur that led to shortening and angulation and required a limb lengthening and osteotomy. So I'm a proud member of the Pluto study group that has 700 kids enrolled. So hopefully we'll have a little better data in the next few years to help guide us on which technique to pick. Thank you very much. I know it will be at the end of your guys' published studies. You guys do some Mechelia-type reconstructions. Where do you draw the line? Who gets the Mechelia? Who gets this? That's a great question. And I don't know the answer. You know, I really don't. Because basically it's... For me, I'm doing more Macintoshes than I used to do, partly because of the more acceptability of the LET, and it's quicker in the OR, and what else? And better clinical outcomes that we have now than when I embarked on olepipathy 10, 15 years ago. So when I started olepipathy, I would be doing a 9- or 10-year-old, because Dr. Anderson said that was fine. And I stick with it because it's anatomic, and it's got a low failure rate. But I don't know where that borderline is. So anybody that has kind of over four or five years of growth remaining, I'm definitely going to do a modified Mac. But still, my modified Mac indications are creeping up into the close to 13 age sometimes. I'm also curious. You guys train a lot of fellows and residents. Do you have a sense of what they end up doing when they go on to practice? That's kind of... You know, it's... I think they probably are scratching their heads kind of like we are here and why we're sharing ideas. You know, I think Peter Fabrikant, he did... My junior partner did a fellowship with Ted Ganley and learned olepipathy and did a fellowship with Min Poker, and she grew up in Boston. And I've never seen him doing olepipathy. I have a question for you. I've done a few cases with the on-site olepipathy, and it's not an easy surgery. What I found more difficult is avoid graft tunnel mismatch. So there is a huge difference between small patients and taller patients. And in a study that we recently published in arthroscopy, it can be up to one centimeter and a half in intra-articular length of the ACL. So you have any tips for length of the graft? Did you do any planning before? You know, I definitely think the size of the patient matters. So, you know, there's so many factors. Like I think when I started, I was trying to get the biggest graft I could and getting out there were a lot of 10.5, 11s. Now I'm kind of very happy with the 10, you know. And in terms of basically in practice on my table, if it's a big patient, anything less than 65, I'm not going to be... The graft will be at right tension. There won't be extra graft. I won't have a mismatch if it's under 65. In a smaller patient, it's like 60. I know it's not based on MRI, but that's kind of in practice what I'm shooting for. And the second question is sometimes in very small patients, this tibial tunnel is very, very horizontal and the aperture is quite oval and so it's... No, that's a great question. So what it like, you can imagine, is there enough space in the tibia? Yeah. And so I was worried about my biggest concern going into it. And I thought, well, what if I blew out the tibia a little bit, like had a trough instead of a socket in the epiphysis, then I know I could save that with the swivel lock or I could save that somehow. But I never had to do it. For me, once I felt the growth plate, did a 15 millimeter socket, that wasn't the problem in the OR, but I do... When I analyzed my post-op MRIs, I was touching the growth plate a lot. So it's true, there's not a lot of room there. Okay. Thank you. Hello. Stefan Zaffanini, if I may start. Oh, we have a traveling fellow. Yes. Thanks. Excellent talk. I work in Norway, and I followed 50 children for 10 years, and we used the transposal technique. And when we... The MRIs that we did after nine and a half years, the transposal technique, the graphs were so steep, and also the blue and sands line was really steep, and that button was way up at the top. And of course, it wasn't like this when we operated them. Did you know how the graphs sort of change as they grow using this technique? I mean, have you been able to have a look at them after quite a few years to see how the graph sort of matures and changes with the growth? You know, one of the... We've looked a couple of times. There's been critiques about the right angle, almost the 90 degree turn you have to make if you're in the notch in the epiphysis, and that must be a weak spot for the graft. And so we've looked for that, and the signal there looked good. Our all-epiphyseal signal looks better than the transphyseal signal. You could speculate that maybe it's not getting stretched or something, but we don't have enough data to make firm conclusions. But I do know all my Scandinavian friends and friends from New Zealand and Australia, they're not doing the modified MAC, they're not doing the all-epiphyseal, they're going transphyseal with smaller grafts and reporting no bad issues. So there's different ways to approach this young population. And these children, they were able to beat outcomes, but when you examine them, they're all quite loose. And it's no wonder. You can think when the graph is like... Oh yeah, I think that's... When that graph goes so vertical... And many of them have some pivoting picture. That's interesting. One of my partners in North Carolina presented a case, he did an all-epiphyseal ACL, and it ended up failing, and he showed his intraoperative pictures of his tunnel position, you know, in the notch at the original surgery, and then showed intraoperative pictures from the time of the revision, and it moved. He was right up against the back wall, he had a millimeter back wall, and then at the revision, you're like, why in the world would you put it there? It was like shallow in the anterior. And so even with an epiphyseal socket, because your femur, remember, is not just growing in length, it's growing in girth. And so you probably got growth through the perichondral ring, maybe he even simulated the perichondral ring in the back by getting so close, and so the relative distance to the back changes. So you're absolutely right. They can get sort of graft malposition simply by growing. Thank you. Can I ask you one more question? Sure. Do you use a tetrodesis or something? So we've had a few patients with what we felt were very high risk. We added a tetrodesis to our all-epiphyseals, and we're definitely adding it to most of our adolescent patients for transficials, lateral extraticular tenodesis. Do I agree? I haven't really teed to any transficial blood. Yeah. Thanks.
Video Summary
The speaker, Dr. Dan Green, discusses the technique of all-epiphyseal ACL reconstruction in pediatric patients. He explains that this approach was developed in response to the limitations of previous techniques like over-the-top and modified McIntosh. The all-epiphyseal technique involves using sockets in the epiphysis rather than tunnels, which avoids damaging the growth plate. Dr. Green discusses the surgical steps and considerations for this technique, including graft selection, socket preparation, and suture management. He also shares outcomes and findings from studies on all-epiphyseal ACL reconstruction, highlighting its low revision rate compared to other techniques. However, he acknowledges that this technique is technically demanding and carries a risk of growth disturbance. Dr. Green concludes by noting that more research is needed, and he mentions ongoing studies to further evaluate and compare different ACL reconstruction techniques in pediatric patients. Overall, the video provides a comprehensive overview of the all-epiphyseal ACL reconstruction technique and its implications.
Asset Caption
Daniel Green, MD
Keywords
all-epiphyseal ACL reconstruction
pediatric patients
sockets in the epiphysis
graft selection
suture management
×
Please select your language
1
English