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ACL Rupture in the

Skeletally Immature Athlete – the End of

the Career?

Edward M. Wojtys, M.D.

University of Michigan

Conflicts of InterestNone

DisclosuresNIH/NIAMS—R01 AR054821

Coulter Foundation Grant

KIA Research—Consultant

Center for Organogenesis

NFL—Injury and Safety Panel

Sports Health—Editor

Age Distribution

Scandanavianregistry:

•Median age ~25

•Range= 5-70 years

Danish registry

Adolescent females

Lind Acta Orthop 2009

Granan Acta Orthop 2009

• 46,472 adolescents, 14-18yo

• 9 year period

• 60.9 per 100,000 person years

• Hazard ratio—Organized sports >4x/wk

•Males� 4.0

•Females� 8.5

Incidence Rates

Parkkari Br J Sports Med 2008

Inconclusive Results

• Systematic review: 615 articles — 7 compared

• Question unanswered!

•Future?

•Follow similar cohorts over time

Mohtadi Clin J Sport Med 2006

Øiestad AJSM 2009

Systematic Review

7 prospective, 24 retrospective studies

Evidence Level II - Cohort

3069 ACL patients

10 year follow-up with X-rays

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Øiestad AJSM 2009

• Isolated ACL Injury – 0-13% OA(3 prospective studies)

• ACL & Meniscal Injury – 21-100% OA

Best rated studies show lowest rate of OA

Coleman Methodology – Mean 52(90)

Evidence Level II - Cohort

Primary Risk Factors

• Meniscal Injury with ACL

• High level sports with cutting, pivoting and twisting

Øiestad AJSM 2009

Knee Function & OA After ACL-R

• 181 pts. (82% follow-up) at 10-15 years

• No significant knee function difference between Isolated and Combined Injuries

Evidence Level II - Cohort

Øiestad AJSM 2010

Knee Function & OA After ACL-R

• 106 (221) pts – 127 partial Meniscectomies

• 8 Meniscal repairs

• Mean time from injury to ACL-R,

28 months (0-278)

Øiestad AJSM 2010

ACL with meniscectomy OA

Prospective cohort - 10.4 years follow-up

63/103 pts (61%)

Evidence Level II

Wu AJSM 2002

Meniscal Status and ACL-R

• 92% pts with “Intact” menisci had normal X-rays

(22 repairs, 21 stable tears, 38 normal)

• Any meniscal resection led to more complaints, limitations, lower IKDC and Lysholm

• All 9 complete meniscectomies → OA

Evidence Level II - ProspectiveCohort

Wu AJSM 2002

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Predictive Factors for OA after ACL

Rupture

• 56 patients follow-up – 6 years(Consecutive series of PT & STG grafts)

• No Meniscal Repairs

Evidence Level I - Cohort

Keays AJSM 2010

Predictive Factors for OA after

ACL Rupture

Evidence Level I - Cohort

Discriminant Analysis(Tibiofemoral OA)

Meniscectomy .72

Weak Quadriceps .39

Chondral Damage .41

Pat. Tendon Graft .37

Low Q/H ratio .06

Keays AJSM 2010

Meniscus Repair with ACL-R

Sample size still too small to provide a detailed analysis of meniscal injuries...”

Evidence Level II - Cohort

448 pts

24 Medial repairs

12 Lateral repairs

“

Spindler AJSM 2011

Meniscal Pathology w/ACL

Tears in Patients w/Open Growth Plates

80 Males (ave. 14.3)

44 Females (ave. 14.1)

Samora JPO 2011

Meniscus Tears

(Within 3 Months of Injury)

• 51 Lateral

• 17 Medial

• 19 Medial and lateral

69.3% Meniscal tears

? Repair ?

Samora JPO 2011

Successful athletic career

Good functional, lifelong outcome

1. Early ACL-R

2. Menscus repair

ACL Injury

Preserving menisci

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ACL Injury in Children

Henry KSSTA 2009

56

Children’s hosp.29 (early surgery)

Mean 13.5 m

Adult hosp.27 (delayed surgery)

Mean 30 m

Med. mensical tears(3) 16%

Med. mensical tears(11) 41%

69 pts ≤ 14 y.o.

40 pts (< 12 weeks) � 7% irreparable menisci

Lawrence AJSM 2011

ACL InjuryCons. Rx. or Delayed Surgery (>12 weeks)

Delay ACL Treatment?

29 pts (> 12 weeks)

1. Delay Increases risk of medial meniscal tear 4 fold.

2. severity of med men tears

(24% irreparable)

3. lateral chondral injuries

Lawrence AJSM 2011

Early

Surgery

Growth plate trauma

Limb length discrepancy

Angular deformity

? Unnecessary

Delayed Surgery

(or cons. Rx)

↑ Meniscal tears (loss)

↑ Chondral lesions

? OA

Balancing Risk

1. Central growth plate injury from tunnels.

2. Peripheral growth plate injury from periosteal elevation.

3. Pressure generation across growth plate from tight graft fixation.

ACL Reconstruction Pitfalls

(21) 8 week old rabbits 1. Femoral tunnel -- 11% frontal plane, 3% cross-

sectional area -- no growth or angular deformities

2. Tibial tunnel – 12%

frontal plane, 4% cross-

sectional area

2 valgus tibias ,

1 shortened tibia

Stoked the Controversy

Guzzanti JBJS-B 1994

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Stoked the Controversy

(12) immature dogs

4 mm tunnels

fascia lata grafts

Tensioned at 80N (fascia lata

ACL graft)

Significant femoral valgus and tibial varus

developed in all limbs.

Edwards JBJS 2001

Stoked the Controversy

(44) 5 week old rabbits

Distal Femoral physis

1. 2 mm drill hole (3% cross-sectional area)

No problems

2. 3.5 mm drill hole (7% cross-sectional area)

permanent growth disturbance and limb shortening

Makela JBJS-B 1988

Calmed the Controversy

(8) immature dogs

5/32 transphyseal tibial and femoral tunnels

(4) dogs – fascia lata grafts

(4) dogs – no graft

NO tension on graft

Bony bridges formed in non-grafted

tunnels only.

Stadelmaier AJSM 1995

Physeal Injury

• Tunnel diameter / physeal CSAGuzzanti AJSM 2003

• Excessive graft tensioningEdwards JBJS 2001

• Incomplete tunnel fillStadelmaier AJSM 1995

• Graft fixation across physisChudik Arthroscopy 2007

Vavken Arthroscopy 2011

Transphyseal ACL

• 26 pts (physis > 2 mm)

• 65% - meniscal tears

• F/U – 45 ± 18.3 months

• LL discrepancy ± 7 mm

• Angular ∆– 0.46°± 1.1°

• AP translation – 2.0 ± 1.0 mm

Cohen Arthroscopy 2009

ACL Outcome

(1997 – 2002)

Isolated ACL’s (14) � cons. rx.

Combined ACL’s (17) � surgical rx.

Tanner Slage I or II (median 11 y.o.)

F/U – 70 m, mean growth 20.3 cm

*** Surgical group did better!

* 58% cons. group � subsequent surgery

Streich KSSTA 2010

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Transphyseal ACL - Hamstrings

• 18 pts (mean age 14.2, 1(11), 1(12))

• F/U 24-87 months

• All stable, no ROM loss (>5°)

• No growth ∆‘s or angular deformities

• No re-ruptures – 3 contralateral

Redler Arthroscopy 2012

Pediatric ACL Biomechanics

• 6 cadaver knees (time 0) 0-90°

• AP, varus, I.R. @ 0-90°– ACL intact 2.8 ± 1.4 mm

– ACL def. 7.2 ± 2.7

– All epiphyseal 5.1 ± 2.3

– Trans tib (over) 4.8 ± 1.8

– ITB (Micheli) 1.7 ± 1.1

Kennedy AJSM 2011

ACL Meta-Analysis

• 55 studies (935 pts., median age 13)

• F/U – 40 months (median)

• LLD or deformity risk– 1.8% (95% C.I. 0 to 3.9%)

• Re-rupture – 3.8% (95% C.I. 2.6 –5.2%)

Frosch Arthroscopy 2010

ACL Tears in Skeletally Immature

• Systematic review – 47 studies

• Conservative rx.

Poor clinical outcomes

Secondary meniscal, chondral injury

• Surgical rx.

Weak evidence for growth ∆

Good stability and function

Vavken Arthroscopy 2011

ACL Systematic Review

Youngest patients (10-12 y.o.)

4 studies (Tanner I or II)

Significantly better results w/ surgery. No significant deformities.

Vavken Arthroscopy 2011

Recommendations

1. Teenagers with less than 6 months of growth remaining may be treated as adults if growth spurt has occurred.

2. Make every attempt to salvage the menisci.

Be Careful !

Examine Tibial Apophysis closely!

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Recommendations

Children, Adolescents, Teenagers

(unstable knees and/or physically active)

1. Pediatric Age ACL injuries should be reconstructed

2. Bracing, physical therapy, and activity modification alone is inadequate.

Rehabilitation

Wells J Pediatr Orthop 2009

• 55 patients—Avg age 15.9 yrs

• Time from surgery � 85% normal quad. Strength

– 5.42 ± 2.27 months

• Ability to return to sport after 6 months rehab.

– 50% of patients (strength)– vascularity and fiber

pattern

Kids - Sports

Unique dependent relationship

Separating Kids-Sports

Can Be Catastrophic

• Loss of identity

• Depression � drugs, alcohol

Thank You

Challenging Cases

• 13 yr. old football player

• 6 foot, 340 lbs

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9 year-old

Bilateral ACL Def

Children and Adolescents

If the growth plate is drilled, try to stay central. Start tunnel lower on tibia. Aim for posterior intra-articular placement.

(Andrews and Noyes, 1994)

Intra-articular – Trans-tibial Physis

• ITB graft

• 44 immature prepubescent patients

Results:

– 32 Normal exam

– 18 Nearly Normal

– 1 Abnormal

• Mean growth (height) – 21. 5 cm

Intra-Articular Extraphyseal

Kocher JBJS 2002

MichelliModification

6 Year Follow-up Technical Points

• only soft tissue should cross growth plate in bone tunnels.

• avoid excess tension (10 lbs)

• keep tunnels small (6-7mm)

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Summary

• ACL-R for children and adolescents for jumping, pivoting sports

• Repair essentially ALL menisci in kids

• Balance risks for return to sport!

Thank You

Nonoperative ACL Treatment OA

(Retrospective Cohort)

• 12-year follow-up of 84 female soccer players (82%)

• No difference between reconstructed and nonoperative group for symptoms or OA

Evidence Level II

Lohmander AJSM 2007

Nonoperative ACL Treatment OA

(Retrospective Cohort)

• 14-year follow-up of 205 male soccer players (94%)

• No difference between reconstructed and nonoperative group for symptoms or OA

• 41% of uninjured knees showed Rad OA Evidence Level II

Von Porat Ann Rheum Dis 2004

Nonoperative ACL Treatment OA

15-year follow-up

Rx Physical Therapy/Activity Modification

(Tegner decreased 7 to 4)

None of the knees with normal menisci developed Rad OA (p‹ 0.001)

44% (35/79) had meniscectomies

16% (13/79) → Rad OA, all had meniscectomies

Evidence Level II - Cohort

Neuman AJSM 2008

12-year followup in female Swedish soccer players. Reconstructive or Conservative Rx

82% - Rad OA

42% - Sx OA

8% - Rad OAuninjured knee

Post Injury Activity Level

Contact Sports

Lohmander AJSM 2004

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Soccer

• Injury reports

• 5-18yo

• 6 million athlete-years

• Knee: 30.8%

–ACL tears: 6.7%

Shea Sports Med 2003

Dilemma

Kids do worse than adults with conservative ACL injury treatment resulting in meniscal

tears and chondral injuries.

Graf Arthroscopy 1992

McCarroll AJSM 1988

Part of the Problem

Difficult to restrict physical activity in children, adolescents, and teenagers.

Rehabilitation

Age-specific components altering treatment course?

• Moksens Knee Surg Sports Traumatol Arthrosc2008

– Conservative—promising rehab. Results

• Roos Curr Opin Rheumatol 2005

– Significant risk for OA with injury

– Prognosis for children and

adolescents?

– Rehabilitation potential

Author Journal Year

MRI

96% Sensitivity (ACL)

59% (Meniscus)

91% (Specificity)

Samora JPO 2011

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Knee Function & OA After ACL-R

• Combined Injuries had more Rad OA than Isolated Injuries

80% vs. 62% (p=0.008)

(Contralateral, uninjured knee – 15% Rad OA)

• No significant difference in Sx OA46% vs. 32% (p=0.053)

Øiestad AJSM 2010

Lohmander AJSM 2007

(Clinical Review)

• 50% of ACL injuries with meniscectomies have Rad OA at 10-20 years (odds ratio 10)

• Worst outcome – obese women with ACL and lateral

meniscectomy

Transphyseal ACL

• 26 pts ( >2 mm femoral & tibial physis)

• Quad hamstring

• 3 re-ruptures

89% returned to same level

Cohen Arthroscopy 2009

Early

Surgery

Growth plate trauma

Limb length discrepancy

Angular deformity

Delayed Surgery

(or cons. Rx)

↑ Meniscal tears (loss)

↑ Chondral lesions

Balancing Risk

Early

Surgery

Delayed Surgery

(or cons. Rx)

Balancing Risk

Growth plate trauma

Limb length discrepancy

Angular deformity

↑ Meniscal tears (loss)

↑ Chondral lesions

Stoked the Controversy

• Theoretical computations based on assumption that a bony bar will form at physis.

• Assumes drill holes in the most peripheral locations in femur and tibia.

1. Trigonometric principals to determine shortening and angulation.

2. If physis drilled in boys <15.5 years old and girls < 13.4 year old,

Expect: 5°increased valgus

1 cm shortening

Wester J Ped Ortho 1994

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Multicenter ACL Study

• 68 pts. mean 12.5 y

• 4 surgical techniques (1984-2001)

• F/U – 32 months

• No angular deformity or LLD

• 6 recurrent instability

• Only 2 pts. Returned to same sports level

Gebhard KSSTA 2006

Growth Plate Disturbance After

Transphyseal ACL-R in Skeletally Immature Patients

• 43 pts, mean 14.8 years (12.4 – 16.5)

• F/U MR, mean 16m (6 – 36m)

• Bone tunnel / growth plate < 3% (femoral & tibial)

Yoon, Kocher, Micheli JPO 2011

Growth Plate Disturbance After

Transphyseal ACL-R in Skeletally Immature Patients

• 5 focal bone bridges (12%)– 4 tibial, 1 femoral

• 2 early physeal closures (tibia)

• No growth disturbances

Yoon, Kocher, Micheli JPO 2011