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

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

Jan 17, 2023 358 likes •713 views

ACL in an 11YearOld 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

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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

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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

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Adolescent ACL Injury

Intra-epiphyseal Technique

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Technology

Adjustable, Cortical Button

  • Adjusts to all tunnels
  • Better graft fill of sockets
  • Retensioning of the graft

after fixation

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Technology: GraftLink

Can tension both ends of the graft

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Technology: FlipCutter Retrodrill blind sockets

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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

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GraftLink

Anatomic, All Epiphyseal ACL Recon

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GraftLink

  • Anatomic, all epiphyseal

drilling

  • Single hamstring

harvest

  • Adjustable Cortical

Fixation

  • Least invasive

technique, femoral and tibial socket

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GraftLink

Graft Length 50 mm

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Partial Transphyseal for Older Patients 1-3 yrs Growth Remaining

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Does it work ?

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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
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Is it better ?

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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.”

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Is it Safe ?

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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

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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

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What should I do ?

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

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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

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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

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PRISM Survey

Since 2002, have you seen growth disturbance as a result of an ACLR?

  • 29 cases

In 2002

  • 15 cases

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PRISM Survey In your opinion, what was the cause of the growth distrubance?

  • 48% surgical error when drilling tunnels or

another technical error

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Pediatric Adolescent ACL Injuries

Case

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

Case

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Pediatric Adolescent ACL Injuries

Case

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Pediatric Adolescent ACL Injuries

Case

Tibial tunnel

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Pediatric Adolescent ACL Injuries

Case

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Pediatric Adolescent ACL Injuries

Case

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Pediatric Adolescent ACL Injuries

Case

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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
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Thank you