1

Prof. Romain Seil, MD, PhD

Centre Hospitalierde Luxembourg

OrthopaedicSurgery

Sports Medicine Research Laboratory

Centre de RecherchePublic – Santé,

Luxembourg

ACL reconstruction in the Skeletally Immature Patient

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Types of pediatric ACL lesions

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0 8 14

Bonyavulsions

years

Midsubstancetears

Cartilaginousavulsions

Chotel, KSSTA 2013

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In-house ACL registry: 2011-2012

0

5

10

15

20

25

30

11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 +56

Po

urc

en

tag

e(%

)

Women

Men

: 32%

: 68%

Frobell RB, Scand J Med Sci Sports 2007Granan LP, Am J Sports Med 2009Renstrom P, Br J Sports Med 2012

� 30% reruptures

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4-5%

Few precise epidemiological data

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Presence of

growth platesLanding

in

valgus

High

physiologic

laxity

Changing

osteoligamentous

stiffness

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TREATMENT UNSTABLE

KNEES (%)

nonoperative 91

sutures 73

Extraarticularreconstructions

64

Intraarticularreconstructions

14

17 studies

(1983– 1999), 458 knees

Seil R, 2000

2000

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Surgical treatment

1. Evaluate remaining growth

2. Know specific anatomy

3. Fill the tunnels with soft tissues

4. Small tunnels (< 9mm)

5. Perpendicular to physis

6. Graft tension not too high

7. No physeal-crossing fixation

Seil R, 2010

Surgical rules

well established !

2013

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Landing in Valgus

High physiologiclaxity

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good stability control despite

unfavourable biomechanical

conditions

Growth and maturation of knee joint

Many physiologic and pathologic issues

poorly understood in this young population.

Children before puberty:

2

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Boys

Girls

Gro

wth

sp

eed

1

2

3

4

5

6

Knee laxity

(mm

)

0

20

40

60

80

100

120

140

9 10 11 12 13 14 15 16 17 18 19 20 21

Nu

mb

er

of

surg

eries /

yea

r

Age (years)

Baxter MP, 1998

Gicquel P, 2007

Swedish ACL registry 2010

Growth speed

lower extremity

Knee laxity

(mm)

No. of surgeries

per year

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Growth and maturation of knee joint

End of growth period:

Knees stiffen,

injuries increase

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Knee function & laxity in children

Current understanding of knee maturation at end of growth period is poor.

Baxter MP, 1998

Hinton RY, 2008

Changes of physiological laxity and their influence on active knee stabilization need further analysis

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Treatment

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Low treatment evidence

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Treatment algorithm

Isolated ACL tear:

NO early reconstruction !

• Explanations +++• Rehabilitation for 3-6 mo.• Limitation of physical activity• Close FU• (Brace)

Indication for surgery:

1. If primary meniscal tear2. @ skeletal maturity3. If secondary meniscus tear4. If functional instability5. High sports demand (?)

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No international consensus, expert-opinion level discussions

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Treatment

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MFC

Surgery Nonoperative

Growth changes Meniscal tears

Signs of OA

Therapeutic dilemma

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Nonoperative treatment debate

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• children < 12 years, no surgery

• 65% returned to pre-injury level of sport

Streich NA, KSSTA 2010

• Tanner I or II (median 11 years)

• 42 % of conservatively treated children

did not need surgery over a 5-years period

• 58 % developed instability and received

an ACL-reconstruction

Moksnes H, KSSTA 2008

• children < 14 years, surgery

• more medial meniscus & cartilage lesions

if surgery > 3 months after injury

Henry J, KSSTA 2009

• higher MMT rate in late surgery group

Lawrence J, AJSM 2011

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Nonoperative treatment debate

Patients’ & families’ adherence to:

• Less active lifestyle

• Damocles sword of later surgery and

subsequent meniscus tear / cartilage

lesions

• Level II sports

• Brace

Functional tests

Reliability ?Sensibility ?

Limited option for some patients & their family

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Preoperative planning

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• Remaining knee growth

• Leg length

• Alignment

• Skeletal age

• Tanner staging non reliable

Slough JM MedSciSportsExerc 2013

Greulich & Pyle Atlas

Anderson M, JBJS 1963

No international consensus

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3 physiological stages

Growth and maturation of knee joint

Pre

pubert

y

Pubert

y

Adult

Skeletal age

Growthspeed Girls 11 y.

Boys 13 y.Girls 13 y.

Boys 15 y.

Girls 14 y.

Boys 16 y.

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Gicquel P, 2007

Preoperative evaluation: growth assessment

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• ♂ ACL tear @ 12

• Chronological age: 14,9 y.

5 cm 1 cm 0 cm

• Skeletal age: 12,9 y.

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Preoperative planning

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Growth and maturation of knee joint

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From: Yoo WJ, J Ped Orthop 2011

Focal bone bridge formation

without growth disturbance

in 11 % of adolescent patients

Adequate timing for surgery debatable

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Pre

pubert

y

Pubert

y

Adult

Skeletal age

Growthspeed

Girls 11 y.

Boys 13 y.Girls 13 y.

Boys 15 y.

Girls 14 y.

Boys 16 y.

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Gicquel P, 2007

Preoperative evaluation: growth assessment

Malalignment:Higher risk,

little deformity

Malalignment:Lower risk;

large deformity

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Surgical techniques

Transphyseal Extraphyseal Epiphyseal

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Physeal sparing

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HJ *1994 OP 2005

• Transphyseal 4-fold-Semi-

tendinosus/Gracilis graft

• 6-8 mm

• distal fixation

• no transphyseal hardware or bone block

• anatomic technique ?

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Surgical technique

Large variety of surgical techniques, ongoing debate

Fate of graft ? Bollen S, JBJS-B 2008

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Tibial tuberosity apophysis

Anatomy

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central

Tibial drill injury

♂ 10 y

+ 1 cm

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Stadelmaier D, 1995

Bone bridge formation

Can be prevented with soft tissue filling

Principles of physeal injuries

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Johnson JT, 1960; Nordentoft EL, 1969;

Janarv PM, 1998

Drill injury

< 7-9 % of surface

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posterolateral

Femoral drill injury

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♂ 11 y

♂ 11 y

5

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Ford & Key, JBJS-A, 1956

Peripheral damage

Axial deviation

Principles of physeal injuries

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3-4% of surface

Seil R, 2008

Masson-Goldner, 25 x

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Isolated ACL replacement:

- 6 weeks brace

- FWB

- Free ROM

Meniscal repair:

- 6 weeks brace

- 6 w. 0-0-90°

- 6 w. FWB in extension

- Return to sports 9-12 months

Rehabilitation

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Need for precise rehabilitation programmesMoksnes H, JBJS-A 2012

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Chotel F, KSSTA 2010

• Rare in experienced hands (< 50 cases)

• Most related to surgical technique

• If they occur:

continue until end of growth

Complications

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Growth arrest

3 types of growth changes

Chotel F, KSSTA 2010

Arrest Boost deCeleration

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4 types of gross complications

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Arrest distal lateralfemur physis: valgus knee

Arrest tibial tuberosity: recurvatum

Arrest medialProximal tibial

physis: Varus knee

NO transphysealhardware placement

Complications probably underreported

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Bonnard C, Chotel F, RCO 2007

Results

• IKDC A&B: 84 %

• Retears: 5 %

• Return to sports: 91 %

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Caution is necessary when interpreting study resultsMoksnes H, JBJS-A 2012

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♂ ACL-replacement @ 11 y.; Control @ 16 (+ 20 cm)Lachman -; pivot shift –No recurvatum

GOOD RESULT

Laxity profile at maturity

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Results less predictable than in adults

♂ ACL-replacement @ 13 y.; Control @ 17Lachman +; pivot shift ++Recurvatum ++

BAD RESULT

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Distribution of laxity in IR at 5 Nm in healthy legs

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°

Mouton C, Theisen D, Seil R, ISAKOS 2013

Individual laxity profile at maturity unforeseeable

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Summary

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Topic Problem Need for further

investigation

Epidemiology No register Yes

Growth / maturation / evolution of laxity

Little investigations Yes

Prevention No studies for children Yes

Injury risk factors Yes

Treatment indications / algorithms

No consensus Yes

Surgical techniques / (No)

Surgical risk factors Types of complicationsReported complications

(No)Yes

Outcome Graft evolutionKnee functionReoperationsReturn to sportsLong term outcome

YesYesYesYesYes

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16th ESSKA CongressMay 14-17, 2014

AMSTERDAM / THE NETHERLANDS

CONGRESS PRESIDENTC. Niek van Dijk

ESSKA PRESIDENTJoão Espregueira-Mendes

SCIENTIFIC CHAIRMENStefano Zaffagnini

Roland BeckerGino Kerkhoffs

ORGANISEResska@intercongress.de

www.esska-congress.org

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Pediatric ACL Monitoring Initiative (PAMI)

Håvard MoksnesLars Engebretsen

Romain Seil

• Online survey on the current treatment of pediatric ACL injuries

• Planned submitted to ESSKA members and affiliates

• Potentially 2500 recipients

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Example survey

7

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Objectives

To establish knowledge on

� The magnitude of pediatric ACL injuries

� Current trends in treatment algorithms

� Preferred surgical techniques

� Rehabilitation protocols

� Success criteria

Clinical, functional and radiological data to share knowledge and to improve:

� the understanding of the injury’s occurrence

� the current treatment approaches

� the understanding of the long term effects

� the knowledge on the specific anatomy and the biomechanics subsequent to ACL injury

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Quadriceps tendon

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Graft selection

Hamstrings Patellar tendonwithout bone blocks

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Transtibial Anteromedial

9 mm tunnel : 70 mm2 245 mm2

7 mm tunnel : 42 mm2 148 mm2

Femoral drill injury

x 3,5 =x 3,5 =

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Surgical technique

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Acute setting: clinical examination

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Pivot-shift test:Hefti F, Muller W 1993

Frequently pathologicin healthy children

Lachman test:

High physiologic laxity in children !

Baxter MP, J Ped Orthop, 1998

Haemarthrosis:

• 1/3 ligamentous tears (♂>♀)

• 1/3 patella dislocations (♀>♂)

• 1/3 meniscal tears

Luhmann SJ, 2003

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Kocher MS, 2001

sensitivity specificity

< 12 y.: 62 % 90 %

12-16 y.: 78 % 96 %

BEWARE false positive (up to 25 % !)

♂, 9 y.

Lee K, 1999

Acute setting: MRI

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