Presented by Frank A. Cordasco, MD, MS, The Sports Medicine and Shoulder Service, Hospital for Special Surgery

1. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. {Frank A. Cordasco, MD, MS} {HSS} Disclosure: I {DO NOT} have a financial relationship with any commercial interest related to the content of this lecture.

2. ACLReconstruction in the Adolescent Athlete Frank A. Cordasco, MD, MS The Sports Medicine and Shoulder Service Hospital for Special Surgery New York, NY

3. ACL Tears - Epidemiology 1/2452 skier visits Johnson ‘91 College football 42:1000 players/yr = 16% risk in 4 year career Hewson ‘86 100,000-250,000 ACL injuries/yr Zarins ‘88, www.cdc.gov Annual cost >$2 billion www.cdc.gov Skeletally Immature?: Incidence is Rising, Kocher ‘05 AOSSM – STOP Program

4. Increasing Incidence of ACL Injury Increase in Sports Participation and Level of Competition among younger age groups (Title IX doubled denominator) Societal and Parental Pressures D1 Scholarships College “Hook” “Professional” Aspirations Improved Examination, Imaging and Diagnostic Methods: Increased Awareness and Index of Suspicion

5. Public Health Costs Average Cost surgical treatment rehabilitation per Athlete = $30,000 Loss of season Academic performance Scholarship funding Mental health

6. Gender Specific Differences Females 4-6 X higher risk knee injury Females 2-8 X higher risk of ACL tear

7. Female ACL Injury Rate NCAA Soccer: 2.4 X higher Basketball: 4-5 X higher Volleyball: 4 X higher US Naval midshipmen: ~4X higher

8. Female Intrinsic Factors: Anatomic Wider Pelvis Greater Hip Varus Femoral Anteversion Knee Valgus Increased Q-Angle Foot Pronation Smaller Notch Increased general laxity

9. Female Intrinsic Factors: Hormonal Estrogen receptors ACL fibroblasts Liu ’96 Elevated estradiol: decreased fibroblast proliferation and collagen synthesis Liu ’97 ACL tears > ovulatory phase Wojtys ’98 Pregnancy: Elevated Estrogen & Relaxin No Consensus – more study required

10. Female Extrinsic Factors: Biomechanical Cutting/landing: more erect hip/trunk Cutting/landing: less knee flexion “Quadriceps dominant” (males fire their hamstrings 3 X the level of females when landing from a jump & cutting) Muscle fatigue ~ dynamic stability

11. ACL Anatomy Intraarticular and extrasynovial Ave length 31 mm Lg collagen bundles Type I collagen, small % Type II Mechanoreceptors

12. ACL Anatomy Anteromedial: taut in flexion Posterolateral: taut in extension Different portions in tension or relaxed at various angles

13. ACL Anatomy NWI: notch width/condyle width NWI < 0.2 60 X higher risk of noncontact tear and bilateral tear

14. ACL Anatomy Majority: disrupt femoral origin or intrasubstance Tibial eminence fx in children Bony avulsion rare in adults

15. Clinical History Low velocity Deceleration Non-contact Mechanism Valgus/ER Hyperextension Snap or “pop” Giving way

16. Clinical Presentation Hemarthrosis ACL tear (10-65%) Patellar Dislocation Fracture, Physis Meniscal tear PCL tear Capsular tear Stanitski et al, J Ped Ortho ‘93 Matelic et al, AJSM ‘95 Kocher et al AJSM ‘01

18. Posterolateral (translational contusion)

19. Joint line (meniscus, chondral)

22. Skeletal Growth Peak velocity girls at age 11.5, boys at age 13.5 Determination of skeletal maturity Tanner scale Bone age (left hand PA view) “Simple approach”: pubescent vs prepubescent Average growth (Dorias, 2003) Girls (11-15 years) Distal femur 9.8 cm Proximal tibia 5.9 cm Boys (11-17 years) Distal femur 18.5 cm Proximal tibia 9.7 cm

24. Onset of menarche/axillary hair: preceded by growth phase of peak height velocity (M-13.5/F-11.5)

26. Assessing Skeletal Maturity Chronologic age Physiologic age Tanner I/Child < 10: wide open plates Tanner II,III/Pre-pubescent 10-13: open plates Tanner IV,V/Pubescent 13-16: narrowed plates Skeletal age Bone age (left hand PA view or MRI w Physeal windows)

27. Assessing Skeletal Maturity Peak velocity Females Age 11-13 (avg. 11.5) Tanner III Precedes menarche by 1 year Males Age 13-15 (avg. 13.5) Tanner IV Precedes mature axillary hair Parental & Sibling heights Shoe size stability

28. The Dilemma Historically Operative Treatment Nonoperative Treatment Early Reconstruction Risks: Growth disturbance Angular deformity Non-Adult Type Reconstruction: Less “Anatomic” Possible Revision in Future, “Bridge to Adult Type Reconstruction” Delayed Reconstruction Risks: Ongoing instability Meniscus injury Cartilage injury Restricted Activity until Skeletal Maturity: Compliance

29. Associated Pathology (ACL+) Multiple ligaments Repairable meniscus Osteochondral lesions

30. Nonoperative Treatment Goal: Prevent Recurrent Injury: Preserve Meniscii and Articular Cartilage “Temporizing Measure” until patient can undergo an “adult type” transphyseal reconstruction Physical therapy Three Phase Program (Stanitski) Functional ACL brace Activity modification

31. Phase I 7-10 days PWB, brace Active flexion, Passive extension Patient education re consequences of high risk activities

32. Phase II 6 weeks Restore FROM Normalize muscle balance: quad/hamstring ratio Crutches discontinued

33. Phase III Functional Bracing Return to low or moderate demand activities when Isokinetc testing reveals strength equal to opposite side at functional speeds (>260 degrees/sec)

34. Activity Level Level I (low risk) Cycling Swimming Weight Training Stairclimbing

35. Activity Level Level II (med risk) Skiing-intermediate Tennis

36. Activity Level Level III (high risk) Skiing-expert Basketball Football Soccer Lacrosse Volleyball

37. Outcomes of Nonoperative Treatment

38. ACL Deficiency: Natural HistoryNon-operative treatment Instability 72% Pain 48.5% Swelling 34.7% ACL reconstruction – late 56.9% Xray OA 21-85% Marzo & Warren ’91

39. Nonoperative Treatment Outcomes Moksnes et al. KSSTA 2008 20 patients < age 12, 21 knees Avg age 10 at time of injury Evaluated 2 years after injury Classified as copers if: resumed pre-injury level, performed >90% on all hop tests 65% had resumed preinjury activity, 50% classified as copers 9.5% with secondary meniscus injury

40. Nonoperative Treatment Outcomes Woods GW, O’Connor DP AJSM 2004 13 adolescents delayed reconstructions until physeal bridging Avg 70 weeks to reconstruction Compared to 116 skeletally mature adolescents who underwent ACL reconstruction Strict activity restriction from all cutting/jumping activities Brace wear at all times No difference in rates of: Meniscal injury Articular cartilage injury Additional surgery

41. Nonoperative Treatment Outcomes

42. Skeletally ImmatureNon-operative treatment Trends parallel Adult Natural History: Increased risk for further Instability Episodes, Meniscus and Chondral Injuries Nonoperative Treatment Requires Strict Activity Limitations Easy to Control Organized Sports Difficult to Control Free Play

43. Skeletally ImmatureOperative treatment

44. Skeletally ImmatureOperative treatment Primary concern is growth disturbance Femoral tunnel Angular (Valgus) deformity Leg length discrepancy Tibial Tunnel Leg length discrepancy Recurvatum deformity

45. Skeletally ImmatureOperative treatment Kocher MS et al JPO 2002 Herodicus and ACL Study Group Survey 15 cases of growth disturbance 8 femoral valgus deformity with lateral distal femoral Physis arrest 3 tibial recurvatum 2 LLD 2 genu valgum without arrest Observed potential factors: Hardware across Physis Bone plugs across Physis Large tunnels Hardware across Tibial Tubercle Apophysis

46. Transphyseal Surgical Principles from Animal Studies Tunnels filled with soft tissue grafts may not result in transphyseal bone bridges (Stadelmaier et al. 1995, Seil et al. 2008) Grafts placed under tension may cause physeal injury/growth arrest without a bar (Edwards et al. 2001) The cross-sectional area of the drill hole should be minimized in transphyseal approaches Safe zone 3-7% (Guzzanti et al 1994, Janarv et al 1998) Limitation: In animal models remaining growth duration quite brief compared to adolescent boys

47. Reconstruction Techniques Extraarticular Approaches Intraarticular Approaches Graft Options

48. Extraarticular Approaches McIntosh Technique Iliotibial Band Tenodesis Largely historic techniques Stretch out over time, poor rotational control

49. Intraarticular Approaches Goal: Provide Stability, Avoid Physeal Injury and Prevent Meniscus/Cartilage Injury Physeal-Sparing Techniques Partial Intra-articular/Extra-articular: Modified McIntosh (Kocher) All-Epiphyseal: More Anatomic (Guzzanti/Stanitski, Anderson, Ganley) Partial Transphyseal Techniques (Transtibial, Over-the-Top Femur) Complete Transphyseal Techniques (Paletta)

50. Graft Options Hamstring Autograft in most cases BTB Autograft reserved for Adult-Type Reconstructions in Older Adolescents with closing physes Allografts: High Failure Rates in the Adolescent population (Moon Consortium ‘10)

51. Physeal-Sparing: “Over-the-Top” on Tibia and Femur No Bone Tunnels Distally based ST/ G Over-the-Top on the Femur Under meniscal coronary ligament (Brief, Arthroscopy, 1991) Groove anterior tibial epiphysis (Parker et al, AJSM 1994)

52. Physeal-Sparing: Modified McIntosh Kocher, Micheli JBJS Am 2005 ITB harvested proximally  over the top position  under meniscal coronary ligament 44 patients, Tanner I/II 2 revisions at 5, 8 years 98% normal/near normal Lachman 100% normal/near normal Pivot Mean IKDC 96.7, mean Lysholm 95.7 No growth disturbances ? Over-Constrained

53. Physeal-Sparing: All-Epiphyseal Guzzanti, Stanitski AJSM 2003 8 patients, Tanner I Age 11.5 Bone age 10.9 ST/GR graft, left attached to tibia Transphyseal tibial tunnel, looped around staple in shallow groove at femoral origin No LLD or angular deformity

54. Physeal-Sparing: All Epiphyseal Anderson JBJS Am 2005 12 patients Average age 13.3 Mean f/u 4.1 years Quad HS graft, femoral/tibial tunnels through epiphyses Mean IKDC 96.5 KT-1000 mean side-to-side difference 1.5 mm IKDC objective: 7 normal, 5 nearly normal No LLD or angular deformities Mean growth surgery to f/u 16.5 cm

55. Physeal-Sparing: All Epiphyseal Lawrence, Ganley CORR 2010 3patients Ages 10-12, All Male F/U 1 year Quad HS graft, femoral/tibial tunnels through epiphyses, Retro-drill on Tibia Lachman and Pivot Normal KT-1000 less than 1 mm side-to-side difference @ MMD All returned to sport in functional brace No LLD or angular deformities @ minimum f/u 1 year

56. Physeal-Sparing: All Epiphyseal Guzzanti, Stanitski AJSM 2003 Anderson JBJS Am 2005 Lawrence, Ganley CORR 2010 Quad HS graft, femoral/tibial tunnels through epiphyses NormalLachman + Pivot Mean IKDC > 95 KT-1000 mean side-to-side difference < 1.5 mm IKDC objective: normalor nearly normal No LLD or angular deformities

57. Partial Transphyseal Transphyseal 6-8mm tibial tunnel, central & vertical Femoral position Over the top (Lo, Andrews) Epiphyseal (Lipscomb & Anderson) Avoids more common valgus deformity Tanner Stage 2 or 3

58. Partial Transphyseal Lipscomb and Anderson JBJS Am 1986 24 patients, age 12-15 Tibia transphyseal, femur epiphyseal 20/24 returned to same activity level, no objective instability One LLD 2 cm Andrews et al. AJSM 1994 8 patients, age 9-15 Tibia transphyseal, femur over the top, facia lata or achilles allograft No objective instability No significant LLD Lo et al. Arthroscopy 1997 5 patients, age 8-14 Tibia transphyseal, femur over the top No objective instability No LLD/Angular deformity

59. Complete Transphyseal Femoral & Tibial Transphyseal tunnels Soft tissue grafts Central, more vertical Paletta, HSS Alumni meeting ‘09, AAOS ‘10

60. Complete Transphyseal Liddle et al JBJS Am 2008 17 patients, Tanner I/II Avg age 12 (9.5-14) One failure One valgus angular deformity Kocher et al JBJS Am 2007 61 patients, Tanner III Avg age 14.7 (11-16.9) 3% revision rate Lachman/pivot shift all normal/ nearly normal Mean height increase 8.2 cm No angular deformity/LLD Cohen et al Arthroscopy 2009 26 patients, 5 Tanner I/II, 21 II/IV Avg age 13.3 3 failures No angular deformity/LLD

61. ACL Reconstruction Failure in Children/Adolescents Shelbourne et al AJSM 2009 Risk of retear 8.7% if <18 Risk of retear 1.7% if >18 Kaeding et al (MOON Cohort) AOSSM 2008 Highest re-tear rates in 10-19 yo Risk of re-tear decreases by factor of 2 with each decade Must Counsel Parents Regarding Higher Potential for Failure

62. Revision ACL Reconstruction in Adolescents 36 patients, Age 12-17, 22 Female, 14 Male Interval between Primary and Revision: Average 18 months Physeal Status @ Primary: Open 10, Partially Open 3, Closed 21 Primary Graft: BTB 15, HS 13, Allograft 8 Reason for Failure: Non-Contact 23, Contact 7, Persistent Instability 5, Infection 1 Revision: Complete Transphyseal in all F/U 2 years: Lachman Negative or 1A in 91%, Pivot Negative 96% Mean IKDC subjective score: 89.1 Only 57% returned to the same or higher level of activity sport 8% required additional revision Reinhardt et al ISAKOS 2011

63. Case: All Epiphyseal Technique Age: 13y 10m Bone Age: 13y

64. Case: All Epiphyseal Technique Age: 11y 10m Bone Age: 12y

65. Femur: Flip Cutter - 2.75 cm tunnel Tibia: Retrodrill – 2cm Tunnel

66. Graft Passage: Femur Retrograde, Tibia Anterograde Graft Fixation: Femur Tight-Rope, Tibia Retro-screw

67. Case: All Epiphyseal All Inside

69. All-Epiphyseal, All Inside Technique

70. Physeal-Sparing: Modified McIntosh

71. Partial Transphyseal9 year old girl

72. Adolescent with Growth Remaining Tanner Stage 2 or 3 Males 13-16 Females 12-14 Partial Transphyseal Femoral Epiphyseal Over-The-Top Complete Transphyseal with Metaphyseal Fixation 13 year old girl

73. Older Adolescent with Closing Physes Tanner Stage 4 or 5 Males > 16, Females > 14 BTB Autograft an option Adult-Type Transphyseal Reconstruction with Epiphyseal Fixation (Interference Screws) an option

74. Summary ACL injuries on the rise (Adult, Adolescent and Pediatric) Non-Operative Treatment possible but Requires strict activity limitation, Bracing: Compliance ? Natural History: Non-Operative Treatment results in High Failure Rate and High rates of meniscus/cartilage injury with Delayed Reconstruction Allografts Not Recommended (Higher Failure Rates)

75. Summary Prepubescent, Tanner 1 or 2, M<12 F<11: Physeal Sparing:All Epiphyseal, All-Inside Physeal Sparing: Modified McIntosh (Kocher) Partial/Complete Transphyseal (Paletta) Adolescent with Growth Remaining, Tanner 2 or 3, M:13-16, F12-14 Partial Transphyseal Femur over the top or epiphyseal Older Adolescent with Narrowed Physis, Tanner 4 or 5, M>16, F>14: Complete Transphyseal, BTB Autograft Younger age = Higher risk of Failure regardless of technique

76. Thank You