ACL in an 11YearOld Female Soccer Player All Epiphyseal, All Inside - PowerPoint PPT Presentation

ACL in an 11‐Year‐Old Female Soccer Player All Epiphyseal, All Inside Using Hamstring Christopher S. Ahmad, MD Professor Orthopedic Surgery Chief Sports Medicine Head Team Physician New York Yankees New York City Football Club

Disclosure 1. Basic Science Support a. Arthrex b. Smith-Nephew 2. Consultant a. Arthrex 3. Royalties a. Arthrex b. Lead Player Publishing 4. Board Member 1. Baseball Health Network 2. Sports Science Institute of America

Adolescent ACL Injury Intra-epiphyseal Technique

Technology - Adjusts to all tunnels Adjustable, Cortical - Better graft fill of sockets - Retensioning of the graft Button after fixation

Technology: GraftLink Can tension both ends of the graft

Technology: FlipCutter Retrodrill blind sockets

All‐Inside Anterior Cruciate Ligament Graft‐Link Technique: Second‐Generation, No Incision Anterior Cruciate Ligament Reconstruction James H. Lubowitz, MD, Christopher S. Ahmad, MD, and Kyle Anderson, MD Arthroscopy 2011

GraftLink Anatomic, All Epiphyseal ACL Recon

GraftLink • Anatomic, all epiphyseal drilling • Single hamstring harvest • Adjustable Cortical Fixation • Least invasive technique, femoral and tibial socket

GraftLink Graft Length 50 mm

Partial Transphyseal for Older Patients 1-3 yrs Growth Remaining

Does it work ?

All Epiphyseal using Hamstring Nawabi et al AJSM 2014 • 23 Patients (mean age 12.6 yo) • Mean follow up 18 months • KT1000, MRI, IKDC etc, Isokinetic Testing, Marx, Return to Play • Excellent scores • Avg Return to sport 1 year

Is it better ?

Growth plate disturbance after transphyseal reconstruction of the anterior cruciate ligament in skeletally immature adolescent patients: an MR imaging study. Yoo WJ, Kocher MS, Micheli LJ Journal of Pediatric Orthopedics 2011 CONCLUSIONS “MR imaging revealed that focal physeal disruption developed in 11.6% without a perceived clinical growth disturbance. May not be a benign procedure that can be applied safely to younger children with substantial growth remaining.”

Is it Safe ?

All‐Inside, Physeal‐Sparing Anterior Cruciate Ligament Reconstruction Does Not Significantly Compromise the Physis in Skeletally Immature Athletes A Postoperative Physeal Magnetic Resonance Imaging Analysis Nawabi et al, AJSM 2014 • 23 pts, ave age 12.6 years • 15 pts all-epiphyseal, 8 pts partial transphyseal No growth arrest or AVN on MRI • • No postop angular deformities or sig leg length discrepancies

Computer Navigation for Placement of an All-Epiphyseal Anterior Cruciate Ligament Tunnel Chan CM, Ahmad CS, Popkin CA No violation of femoral growth plate Presented AOA 2014

What should I do ?

21 Journal Pediatric Orthopedics 2017 Survey to 71 Pediatric Research in Sports Medicine (PRISM) study group

22 PRISM Survey What is your initial treatment recommendation for an 8-year old, athletic child with an acute, complete ACL tear? • 7% non operative • 53% ACLR iliotibial band (ITB) technique • 34% ACLR autograft hamstring and physealsparing or all-epiphyseal 2002 survey, 58% recommended nonoperative treatment

23 PRISM Survey Treatment with 2 years of growth remaining with an acute, complete ACL tear? • 0% would delay until skeletally mature • 31% ACLR physeal-sparing (ITB or all-epiphyseal) • 47% ACLR with physeal-respecting technique • 18% ACLR with adult-style technique and hamstring autograft

24 PRISM Survey Since 2002, have you seen growth disturbance as a result of an ACLR? • 29 cases In 2002 • 15 cases

25 PRISM Survey In your opinion, what was the cause of the growth distrubance? • 48% surgical error when drilling tunnels or another technical error

Pediatric Adolescent ACL Injuries Case • 11 yo boy • Soccer injury • Recurrent instability • Pre-adolescent • + Lachman • + Pivot • Tanner 2

Pediatric Adolescent ACL Injuries Case

Pediatric Adolescent ACL Injuries Case

Pediatric Adolescent ACL Injuries Case Tibial tunnel

Pediatric Adolescent ACL Injuries Case

Pediatric Adolescent ACL Injuries Case

Pediatric Adolescent ACL Injuries Case

All Epiphyseal using Hamstring Advantages • Does not cross either physis • Does not rely on interference fixation in softer epiphyseal bone • Anatomic restoration • Excellent results • Safe • Disadvantages • More technically demanding

Thank you