So, thanks for sticking around. Thanks for the opportunity to present today to Anna and to Dr. Kelly also. So here's my disclosures, nothing relative to this talk. So this is probably a landmark paper for pediatric ACL reconstructions, Dr. Coker's survey of the Herodicus Society and the ACL study group published back in 2002. And while it details a lot of the growth disturbances that can come from ACL reconstruction, it also has some alarming statistics for what we were doing in terms of pediatric ACL reconstruction in that era. Which is to say that when all these surgeons were surveyed, only about 16% recommended reconstruction of an ACL in an 8-year-old and only about a third still recommended reconstruction in a 13-year-old. So here we are 15 years later and having a whole hour symposium on what to do with this group. And as you'll see, it's basically fix them all. So my goals today are basically to discuss some common treatment algorithms you can use based on quote-unquote age. Before we do that, we'll review the rationale and the techniques for ACL reconstruction just so we can have a basis for discussion. So we all know ACL injuries are on the rise and kids and the popular press has certainly caught up with that. The peak incidence of ACL injuries, as you know, is in the late teens to early 20s. And that incidence is increasing. This is a paper out of Pediatrics looking at true incidence data, noting at about a 2.3 overall increase in incidence per year. And most of this increase is from these very young patients. This is a classic Dodwell paper published in 2014, noting, highlighting the trends towards operative treatment for these very young patients as well, with the 11- to 14-year-old group having significant increases as well as the older groups. So the challenges in delaying ACL reconstruction basically come down to this balancing act of delaying ACL reconstruction, as we've seen, risking meniscus tears and cartilage injuries, and early ACL reconstruction in this age group, risking growth disturbance. The trend towards earlier reconstruction, and this is not a complete list of papers, has basically been driven by this challenge in delaying ACL reconstruction and the additional injuries which accumulate in these patients if you delay reconstruction. And unfortunately, even though you might say, well, why don't you just brace them and keep them out of activities, unfortunately, kids will be kids and they'll find ways to hurt themselves. And in our study, one of the things we found was that return to activity was not an independent risk factor for hurting yourself. So you could take them out of formal sports and gym class and soccer practice, but they still walk home from school and horse around with their friends and find ways to hurt themselves. So this has all been summarized for us by a very nice paper, Current Concepts Review, which if you're taking your boards with the web-based learning, is one of your articles for this year by Dr. Fabrikant and Dr. Coker, and basically a couple of their bullet points here are that basically children and adolescents constitute the highest demographic for these injuries. ACL deficiency in children and adolescents with continued symptoms of instability results in progressive meniscal and cartilage damage. And then while growth disturbance can occur, there are FISL sparing and FISL respecting ACL reconstructions to address it. So what are your options? Your options basically span from FISL avoiding techniques to FISL respecting techniques. We adhere to some basic principles, which is basically absolute no's or no hardware should cross the FISLs and no bone plugs should cross the FISLs. And you should do with caution any large tunnels across the growth plates. You should do minimal over-the-top dissection and notchplasty because you injured that perichondral ring and now you're in real big trouble. And tensioning grafts across the growth plates should be done with caution in patients with significant growth remaining. And as we'll see, eccentric tunnels can also be an issue. So this current concept review basically presented this algorithm, which was to break down patients into two basic categories, those who are adolescents with very limited growth remaining, we see less than two years remaining. Those patients can probably be effectively treated with a trans-FISL technique, whereas those patients who are prepubescent, the Tanner 1 and 2 kids, the premenarchal females, you should consider some sort of FISL-sparing autograft ACL reconstruction in those patients. What's a trans-FISL ACL reconstruction? It's a FISL-respecting ACL reconstruction with a soft tissue graft, autograft, in this case would be either hamstrings or a soft tissue quad, where you don't have any fixation that crosses the FISLs. Typically, you'd use a suspensory fixation on the femur and some sort of interference screw or poster washer on the tibia, or an all-inside dual-suspensory type fixation. There are plenty of papers which have been published using this technique, showing it to be safe, sometimes down into even the Tanner 1 and Stage 2 patients. Unfortunately, most of that data is from small series with little growth remaining, chronologic age wasn't necessarily, sorry, physiologic age wasn't necessarily analyzed. And importantly, if you look at that ACL reconstruction from Dr. Coker, presented in his 27th paper, most of us would look at that and say, that's not how we're reconstructing our ACLs these days, and we're using more anatomic tunnels. And as you get, quote-unquote, more anatomic, what happens is that you damage more of the FISLs. So the more you come down the wall, the more FISLs you damage, and this was initially shown by Kevin Shea in some reconstructed models, and then Dr. Cruz in actual patients. So if you're going to do FISL-avoiding ACL reconstructions, the combined extra-articular-intra-articular over-the-top iliotibial band procedure, also known as a modified McIntosh, or short for McHaley procedure, has been the workhorse at many institutions for many years. And there are other techniques, also called the all-epiphyseal techniques, which we'll talk about as well. So the over-the-top procedure is well-established, it's been performed for over 30 years. Dr. Coker and McHaley recently published their large series and noted remarkably low re-tear rates and subsequent surgery rates with that procedure. It may be due to the extra-articular portion of the reconstruction being combined with the intra-articular portion as well, vis-a-vis the ALL discussion we just heard, which was excellent. All-epiphyseal ACL reconstruction is also a well-established technique. It's been performed for over 25 years, first described, or at least attributed to the late Dr. Alan Anderson. But it's more of a philosophy of technique, and multiple authors have described different ways of kind of accomplishing the same things. The principle is that no tunnels should cross the physis, they should enter and exit at the footprints, and that no fixation should also cross the physis. We currently do it fairly similar to the way Dr. Kodasko has described back in 2012. A recent narrative review was just published this past month, actually, comparing the McHaley procedure to the all-epiphyseal procedure, which found that the re-tear rate was essentially similar between these two procedures, as was the risk of growth disturbance. There's also a hybrid epiphyseal ACL reconstruction, which can be performed, which uses a growth plate avoiding procedure on the femur, and a growth respecting on the tibia. So in 2011, we published this algorithm, but I would say that that's probably even just a couple years later, maybe a little bit out of date, because in 2019, we went on and did a survey of pediatric high-volume orthopedic ACL reconstructive surgeons from the Pediatric Research in Sports Medicine Society, looking at how they would reconstruct ACLs based on bone age. They were given treatment options of no surgery or the various techniques, and interestingly, 15 years later, from Dr. Coker's landmark article, nobody picked non-operative treatment even for an eight-year-old. Here's the punchline, which is that the McKayley technique, or the over-the-top technique, is the preferred technique for the youngest of patients, and transphyseal technique is preferred in a 14-year-old male and a 13-year-old female. When we looked at these responses, what we noticed was there was basically two camps of people who reconstructed ACLs. The first were those who used just the over-the-top technique and a transphyseal technique. So if that's you, and you want to do that technique, and you want this to be you, then this is probably your algorithm, which is to say, use your over-the-top technique in a male who's 12 or younger, and once they turn 13, switch to your transphyseal technique, and if that's a female, you shift that by one year, so 11 and under, over-the-top procedure, and 12 and over, transphyseal. If, however, you like an all-epiphyseal technique, that peaks at about the 11- to 12-year-old age range, and a male, at 13, you switch to a hybrid epiphyseal, and then by 14, you're switching to the transphyseal, and that window is shifted by one year in the females. So pediatric ACL reconstruction algorithm 2019 basically breaks down like this, based on whether you like to do just an over-the-top technique, or switching to a transphyseal technique, or whether you want to do an epiphyseal tunnel as an intermediate. As a shorthand, you can also look at it this way. If you're in your office, and you get that bone age picture, and you like to do epiphyseal tunnels, then you have, if you have capping of your distal radius in a male, you know you're safe to do that transphyseal technique, and if you see the thumb IP joint is closed, you can switch in a female. More information should be coming soon from Pluto, and if you have any issues or questions or want this talk, feel free to email me. I'm happy to give it to you. Thanks.

pediatric ACL reconstructions

statistics

surgeons

ACL injuries

treatment options