ACL in Kids

Question 1

treatment strategie

Answer 1

Conservative Mx until skeletal maturity vs physeal sparing surgery

Question 2

algorthim of ACL management in skeletaly immature patient

Answer 2

Question 3

Hx, phys, XR, MRI

Answer 3

1. R/o OC lesions
2. R/o extension block
3. Maturity assessment: bone age, Tanner, menses,

Question 4

Risk factors for failed non-op Mx of partial ACL tears:

Answer 4

1. >50% of the midsubstance ligament width,
2. tears predominantly involving the posterolateral bundle,
3. a mildly positive pivot shift test,
4. older chronologic and skeletal age

Question 5

Indications for non-op Mx:

Answer 5

1. aged <14 years
2. near normal Lachman and pivot shift tests

Question 6

any suportive letrature for surgical treatment in adoulecent

Answer 6

Vavkin systematic review:

“in the skeletally immature patient with a complete ACL rupture, surgical intervention produces superior clinical outcomes with regard to future stability and secondary injury prevention”

Question 7

Risk factors for growth disturbance in transphyseal ACL recon:

Answer 7

• fixation hardware across the physis,
• large tunnels (³12 mm),
• lateral extra-articular tenodesis,
• dissectionin proximity to the perichondrial ring of LaCroix,
• suturing near the tibial tubercle

Question 8

Tunnel size important in reducing physeal injury

Answer 8

with 8-mm tunnels, <3% of the cross-sectional area of the physis

Question 9

Options for repair:

Answer 9

1. Physeal-sparing
   
   • all-intraepiphyseal
   • physeal-sparing combined extra- and intra-articular anterior
     cruciate ligament reconstruction using autogenous iliotibial band
2. Partial Transphyseal
   
   • hybrid of physeal-sparing reconstruction
     and traditional transphyseal
     procedures performed in adult
3. Complete Transphyseal

Question 10

list treatment options

Answer 10

1. All transphyseal (standard)
2. Physeal spaing intra-articular (Anderson, see lower pic)
3. IT band Physeal sparing combined intra and extra-articular (upper pic, modified version of the McIntosh procedure)
4. Partial transphyseal (e.g trans tibial physis tunnel + epiphyseal femur)
5. Primary repair of ligament (high failure)

Don’t uses PBTB if crossing physis in kid that still has to grow! Use SemiT and Grac.

Question 11

4 scenarios:

Answer 11

1. Young, tear <50% = non op
2. <12 yo M or <11yo F = IT band physeal sparing intra and extra-articular recon
3. 12-14yo G, 13-16yoM = transphyseal quadrupled hamstrings with metaphyseal fixation (don’t put hardware across physis)
4. >16yo M, >14yoF = Adutl type ACL recon, hamstrings or PBTB