Pediatric ACL: A New Technique

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Pediatric ACL A New Technique

• Koco Eaton, M.D.

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Injuries in Younger Patients

• Why are kids tearing their ACLs at such a young
  age?
• Increasing number of children playing organized
  sports at a younger age
• Correlates with the increasing number of ACL
  injuries

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Treatment Options

• Conservative treatment
• Bracing
• Physical therapy to strengthen the quadriceps and
  hamstrings
• Counseling
• Activity modification

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Treatment Options

• Conservative treatment
• Various authors have reported poor outcomes with
  non-operative treatment
• Bracing may not prevent instability
• Further episodes of instability will most likely
  result in new meniscus tears and early arthritis

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Treatment Options

• Primary repair
• May be attempted if ligament is avulsed from
  femoral or tibial insertions may heal to
  provide temporary stability
• Repair of midsubstance tears has resulted in
  persistent instability and decreased activity
  level

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Treatment Options

• Extraarticular tenodesis
• May provide anterior tibial stability and
  eliminate the pivot shift
• Not an anatomic reconstruction
• Overloaded lateral joint compartment may undergo
  premature degenerative changes

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Treatment Options

• Intra-articular reconstruction
• Should be avoided in young patients with open
  growth plates
• Involves drilling through growth plates, which
  may cause physeal injury and growth arrest

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The Million Question

• What is the best option for a patient with a torn
  ACL and open growth plates?
• ACL Repair with Semitendinosus Augmentation

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The New Technique

• Semitendinosus is detached proximally, remains
  intact at the insertion
• Passed under the intermeniscal ligament, running
  alongside the remaining stump of the ACL
• Passed over the top of the femur
• Held in place with screw and ligament washer
  proximal to physis

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The New Technique

• Clinical Orthopaedics, George A. Paletta, and
  Carl L. Stanitski Ch. 63, p.779

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The New Technique

• Three 1 PDS sutures are passed through the
  remaining stump of the ACL

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The New Technique

• ACL stump is freed up from adhesions to PCL, to
  increase excursion

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The New Technique

• Gaffe is introduced into the lateral portal,
  passed intra-articularly to locate the
  over-the-top position
• Skin incision made over the gaffe
• IT band is split

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The New Technique

• Double-looped passing suture is placed through
  the gaffe and brought out through the medial
  portal

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The New Technique

• Sutures from the ACL are then brought out through
  a cannula placed in the medial portal
• ACL sutures are then passed through the
  double-looped passing suture to the over-the-top
  position

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The New Technique

• Incision is made over the hamstrings,
  semitendinosus is harvested

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The New Technique

• 2-0 Ticron is placed through the detached
  proximal end of the semitendinosus
• A 60 suture passer containing the Tycron is
  placed through the incision and under the
  intermeniscal ligament into the knee joint

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The New Technique
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The New Technique

• The harvested semitendinosus is then pulled
  through the knee joint, also to the over-the-top
  position alongside the remaining stump of the ACL

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The New Technique

• The graft and sutures are tied down over a 6.5mm
  screw and spiked ligament washer

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The New Technique

• Graft in full extension

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After Surgery

• Typically 3-5 days on crutches
• Physical therapy is initiated as soon as possible
  after surgery
• Most patients report less pain after ACL repair
  with semitendinosus augmentation than with
  traditional intra-articular ACL reconstruction

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Results

• Since 1993, 13 patients have undergone this
  procedure
• No growth arrest or angular deformity is present
  post-operatively
• 100 of patients have returned to pre-injury
  activities

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X-rays

• Pre-op

• Post-op

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Graft at Later Arthroscopy

• Initial surgery

• 1 year later

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Case Study

• 12-year old female gymnast falls off balance
  beam, tears her ACL
• Growth plates wide open on x-ray
• Undergoes successful ACL repair with
  semitendinosus augmentation

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Case Study

• Same female, now age 14, tears her ACL in
  opposite knee running bases
• Growth plates are now closed
• Undergoes traditional ACL reconstruction with
  bone-tendon-bone autograft

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Comparative X-rays

• 12 years old

• 14 years old

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Case Study

• Comparing knees, patient reports
• Easier recovery and quicker return to activity
  with repair
• Equal strength bilaterally
• Full range of motion bilaterally
• Equal stability bilaterally

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Summary

• ACL repair with semitendinosus augmentation is a
  safe and effective procedure in patients with a
  torn ACL and open growth plates
• QUESTIONS?