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!

• Guzzanti et al

– Rabbit Model – Risk of Growth Arrest

• related to drill hole size

– Tibial side

• 12% frontal plane
• 4% cross-section

– Femoral Side

• 11% frontal plane
• 3% cross-section
• Stadelmaier et al

– AJSM 1995 – Canine Model – fascia lata graft vs empty – Non-grafted animals

• 100% bone bridges

– Grafted animals

• 0% bone bridges
• no limb length diff.

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)

1 2 3 4 5

Distance remains constant (2.5 mm) throughout skeletal growth! Over-the-Top @ PHYSIS!

(mm) From physis

F e t a l 5 6 10 2.5 mm

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 60o
• 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