ACL Reconstruction in the Skeletally Immature: Do a Transphsyeal - PowerPoint PPT Presentation

ACL Reconstruction in the Skeletally Immature: Do a Transphsyeal Hamstring. It Will Be Fine. George A. Paletta, Jr., MD The Orthopedic Center of St. Louis Head Team Orthopedist, St. Louis Cardinals

Disclosure Arthrex – Consultant, Speakers Bureau

Fear of Deformity? • Physeal injury with premature closure • Leg length discrepancy • Angular deformity Where are the deformities?

“Reported” Complications • Kocher et al (JPO 2002) – Survey study, Herodicus members – Distal Femoral Valgus with Physeal Bar (8) • 3 screws, 3 bone plugs across physis • 1 - 12 mm tunnel, 1 over-the-top – Genu Valgum without Physeal Bar (2) • Lateral extra-articular tenodeses – Leg Length Discrepancy (2) • 2.5 cm short = patella bone block across physis • 3.0 cm overgrowth – Recurvatum with Apophyseal Bar (3) • Hardware across tibial tubercle apophysis

Bad Study! Bad Data! • Survey Study! • NO Denominator • Technical Errors – Guidebook for creating deformity • Stop citing this study!!

Basic Science Studies SUPPORT conclusion that complete transphyseal reconstruction using soft tissue graft is likely SAFE! • Stadelmaier et al • Guzzanti et al – AJSM 1995 – Rabbit Model – Canine Model – Risk of Growth Arrest – fascia lata graft vs empty • related to drill hole size – Non-grafted animals – Tibial side • 100% bone bridges • 12% frontal plane – Grafted animals • 4% cross-section • 0% bone bridges – Femoral Side • no limb length diff. • 11% frontal plane • 3% cross-section

Transphyseal Tibial Tunnel/Soft Tissue Graft • Central placement • Anatomic position • Small % physeal area • Low risk for physeal bar

The Relationship of the Femoral Attachment of the ACL to the Distal Femoral Physeal Plate in the Skeletally Immature Knee: An Anatomical Study Behr, CT, Paletta, GA, Jr., and Potter, HG. (AJSM 2002) 5 F e 4 t 6 10 5 a 3 (mm) l From 2 physis 1 0 2.5 mm Distance remains constant (2.5 mm) throughout skeletal growth! Over-the-Top @ PHYSIS!

Femoral Tunnel Alternatives • Over-the-Top – Avoids drilling through physis – Non-anatomic placement • Transverse Tunnel (Anderson) – Distal to physis – Potential for “longer” physeal injury • Transphyseal

Transphyseal Reconstruction: Reported Results • Lipscomb and Anderson (JBJS 68-A, 1986) • Fowler (AOSSM, 1994) • Parker et al (AJSM, 1994) • Andrews et al (AJSM, 1994) • McCarroll et al (AJSM, 1988, 1994)

Shortcomings of Prior Studies • Study Design Faults – Retrospective series with small numbers • Lack of Specificity of Diagnosis – ? Concomitant pathology • Lack of Skeletal Maturity Documentation – skeletal vs. chronologic ag • Lack of Physiologic Maturity Documentation – Tanner staging, menarchal status

Transphyseal ACL Reconstruction in Skeletally Immature Prepubescent Adolescents Kocher et al, JBJS 89, 2007 • 59 patients Tanner stage III, ave age 14.7 yrs • Quad hamstring transphyseal reconstruction • Follow-up = 3.6 yrs (2-10) • Lysholm = 91.2 +/- 10.7 • IKDC Score = 89.5 +/- 10.2 • Lachman normal/near normal 59/59 • Pivot normal/near normal 59/59 • NO LLD or angular deformities

Transphyseal ACL Reconstruction in the Skeletally Immature Follow-up to a Minimum of 16 Years of Age Kumar, S et al. JBJS , 2013 Jan 02; 95-A (1) • 32 pts – 28 = Tanner 1 or 2, 4 = Tanner 3 • Mean age = 11.25 yrs • Mean F/up = 72.3 months • Mean Lysholm = 95.86, Mean Tegner = 7.66 • 0/32 with LLD • 1/32 – “mild valgus deformity with no functional disturbance”

Transphyseal ACL Reconstruction in Patients With Open Physes 10-Year Follow-up Study Calvo, R et al, AJSM February 2015 vol. 43-2, 289-294 • 27 skeletally immature patients. A • Average age = 13 yrs (12-16 years) • Average f/up = 10.6 years (10-13 years) • Mean IKDC = 94 Mean Lysholm = 92 • No leg length discrepancy • No axis malalignment

ACL Reconstruction in the Skeletally Immature Paletta et al • 96 patients, Tanner stage I,II,III or pre-menarchal F • Average age 11.5 yrs (7-13) • Quad hamstring transphyseal reconstruction • 70/96 Follow-up: UNTIL SKELETAL MATURITY • Lysholm = 93.6 +/- 6.2 • IKDC – normal, nearly normal 67/70 • Mean KT-1000 = 1.3 mm, 2/70 (4%) > 3mm • 0/70 with LLD • 1/74 (1.35%) with measurable angular deformity – 6o decrease in posterior tibial slope

My Technique - Pearls • Autograft Quadruple Hamstring • Steep Tibial Tunnel = Guide angle at 60 o • High Torque, Low Speed Reamer – Minimize heat generation, drill ONCE • Tight Tunnel Fit - 0.5 mm reamers • Fixation – Suspensory Femoral Fixation above physis – Tibial Fixation Below Physis – Screw & Post • Intra-op Fluoroscopy

Summary • Transphyseal Reconstruction is SAFE and EFFECTIVE • Soft tissue graft • Fixation proximal/distal to physes • LOW risk of physeal injury • LLD or angular deformity rare JUST DO IT!

Thank You