Management of ACL injuries in the skeletally immature patient

36 Pages·2014·3.34 MB·English

5th course of advanced surgery of the knee
Val d’Isère, 02-2014
Management of ACL injuries in
the skeletally immature patient
Prof. Romain Seil, MD, PhD
Orthopaedic Centre Hospitalier
Surgery de Luxembourg
Centre de Recherche
Sports Medicine
Public – Santé,
Research Laboratory
Luxembourg
Disclosures
None !
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Types of pediatric ACL lesions
Cartilaginous Bony Midsubstance
avulsions avulsions tears
Chotel, KSSTA 2013
0 8 14
years
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In-house ACL registry: 2011-2012
 30%
rerupture
: 32%
risk
: 68%
4-5%
Frobell RB, Scand J Med Sci Sports 2007
Granan LP, Am J Sports Med 2009
Renstrom P, Br J Sports Med 2012

Few precise epidemiological data

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Growth and maturation of knee joint
Boys
Girls
d
e
e
p
s
h
Growth speedtw
o
r
G
lower extremity
Gicquel P, 2007
6
5
)
m
m
( y 4
tix
a
Knee laxityl e 3
e
n
K 2
(mm)
1 Baxter MP, 1998
140
r
a
e 120
y
/ s 100
e
ir
e 80
g
r
u
s 60
fo
No. of surgeries r 40
e
b
m 20
per year
u
N
0
9 10 11 12 13 14 15 16 17 18 19 20 21 Swedish ACL registry 2010
Age (years)
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Treatment
Surgery Nonoperative
Meniscal tears
Growth changes
Signs of OA
MFC
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Treatment
Low treatment evidence
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Nonoperative treatment debate
Hypothesis:
• children < 12 years, no surgery • children < 14 years, surgery
Hypothesis:
• 65% returned to pre-injury level of sport • more medial meniscus & cartilage lesions

iTf shurege rey >a 3r lmieonrt htsh aefte rs inujurryg ery,
Lawrence J, AJSM 2011
Moksnes H, KSSTA 2008
> 40 % of children do not
the lower secondary meniscus
need surgery !
and cartilage lesions.
• Tanner I or II (median 11 years)
• higher MMT rate in late surgery group
• 42 % of conservatively treated children
did not need surgery over a 5-years period
• 58 % developed instability and received
an ACL-reconstruction

Streich NA, KSSTA 2010 Henry J, KSSTA 2009
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Nonoperative treatment debate
Functional tests
Patients’ & families’ adherence to:

• Less active lifestyle
• Damocles sword of later surgery and
subsequent meniscus tear / cartilage
lesions
• Level II sports
• Brace
Reliability ?
Sensibility ?
Limited option for some patients & their family
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Operative treatment debate
3 pathophysiological types of growth changes
Growth arrest
Arrest Boost deCeleration
Chotel F, KSSTA 2010
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