Sports - Paeds (Complete) Flashcards
What injuries is a knee hemarthrosis associated with in skeletally immature patients?
[JAAOS 2018;26:e50-e61]
- ACL
- Patella dislocation
- Chondral shear injury
- Tibial eminence fracture
What investigation is recommended to assist in selecting appropriate surgical technique for ACL reconstruction in a pediatric patient?
[JAAOS 2018;26:e50-e61]
Wrist/hand radiograph
- Determines Sanders bone age
What is the risk of delaying ACL reconstruction or treating nonoperatively in skeletally immature patients?
[JAAOS 2018;26:e50-e61]
- Meniscal and chondral injury
- Psychological effects resulting from activity restrictions
What are risk factors for physeal injury in ACL reconstruction?
[JAAOS 2018;26:e50-e61]
- Proportion of physis violation
* <5% = low risk - Location of tunnel within physis
* Central = low risk of arrest (compared to peripheral) - Orientation of tunnel
* Vertical tunnel = low risk due to lower proportion
What are indications for nonoperative and operative intervention for an ACL injury in a pediatric patient?
[JAAOS 2018;26:e50-e61]
- Nonoperative
- Partial tear
- Normal or near normal physical exam
- Operative
- Older patients
- Instability on physical exam
What are the surgical ACL reconstruction options available in the skeletally immature patient?
[JAAOS 2018;26:e50-e61]
- Intra-articular extraphyseal
- All-epiphyseal
- Partial transphyseal
- Physeal-respecting transphyseal
- Traditional transphyseal
What ACL reconstruction options should be considered based on age?
[JAAOS 2018;26:e50-e61]
- Bone age ≤8
* Intra-articular extraphyseal - Bone age >8 and ≥2 years of growth remaining
* All-epiphyseal - <2 years of growth remaining (approaching skeletal maturity)
- Partial transphyseal
- Physeal-respecting transphyseal
- Skeletally mature
* Traditional transphyseal
What is the intra-articular extraphyseal technique for ACL reconstruction?
[JAAOS 2018;26:e50-e61]
Iliotibial band reconstruction (Kocher technique)
- Nonanatomic
- Over constrains rotation wrt normal ACL
- Midsubstance slip of the IT band was looped posterolaterally over the lateral femoral condyle then passed through the intercondylar region, through the joint, and under the intermeniscal ligament to form a new ACL
- A trough is placed under the intermeniscal ligament to allow for more anatomic graft placement without causing direct physeal injury
- Proximally, the autogenous graft is sutured to the periosteum of the lateral femoral condyle at the insertion of the intermuscular septum
- Distal to the joint, the graft is sutured to periosteal flaps at the proximal anterior tibia with the use of heavy nonabsorbable sutures
What is the all epiphyseal technique for ACL reconstruction?
[JAAOS 2018;26:e50-e61]
Anderson procedure
- Tunnels are drilled in femoral and tibial epiphysis under fluoroscopy visualization
- Hamstring autograft is fixed on the femoral side with a cortical button or interference screw
- Fixation on the tibial side can be with a cortical button or interference screw or distally over a post
What is the partial transphyseal (hybrid) technique for ACL reconstruction?
[JAAOS 2018;26:e50-e61]
- All-epiphyseal femoral tunnel
- Avoidance of physis is suggested due to:
- More longitudinal growth from the distal femoral physis compared to the proximal tibial physis
- Femoral tunnel is more peripheral – higher risk of angular deformity
- Central transphyseal tibial tunnel
What is the transphyseal technique for ACL reconstruction?
[JAAOS 2018;26:e50-e61]
Femoral and tibial tunnels are transphyseal
What practices can be used to avoid physeal injury in transphyseal ACL reconstruction techniques?
[JAAOS 2018;26:e50-e61]
- Vertical tunnel
- Tunnel diameter ≤8mm
- Central tunnels (avoid peripheral tunnels)
- Avoid the perichondral ring
- Hardware and bone should not be placed across the physes
- Soft tissue grafts preferred
- Heat necrosis should be avoided by hand drilling or slow drilling speeds
What is the recommended graft choice for pediatric ACL reconstruction?
[JAAOS 2018;26:e50-e61]
All soft tissue and Autograft
***Note - If BPTB graft is used avoid placement of bone at the level of the physis, which may increase the risk of bony bridging across the physis
What is the risk of graft failure and retear in skeletally immature ACL reconstructions?
[JAAOS 2018;26:e50-e61]
15-25%
NOTE: follow pts annually with repeat XRs until skeletal maturity to assess for growth disturbance
