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pediatric acl: a new technique

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 ageCorrelates with the increasing number of ACL injuries. Treatment Options. Conservative treatment:BracingPhysical therapy to strengthen the quadriceps and hamstringsCounselingActivity modification.

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pediatric acl: a new technique

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    1. Pediatric ACL: A New Technique Koco Eaton, M.D.

    2. 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

    3. Treatment Options Conservative treatment: Bracing Physical therapy to strengthen the quadriceps and hamstrings Counseling Activity modification

    4. 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

    5. 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

    6. 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

    7. 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

    8. The Million $$$ Question: What is the best option for a patient with a torn ACL and open growth plates? ACL Repair with Semitendinosus Augmentation

    9. 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

    10. The New Technique Clinical Orthopaedics, George A. Paletta, and Carl L. Stanitski; Ch. 63, p.779

    11. The New Technique Three #1 PDS sutures are passed through the remaining stump of the ACL

    12. The New Technique ACL stump is freed up from adhesions to PCL, to increase excursion

    13. 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

    14. The New Technique Double-looped passing suture is placed through the gaffe and brought out through the medial portal

    15. 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

    16. The New Technique Incision is made over the hamstrings, semitendinosus is harvested

    17. 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

    18. The New Technique

    19. 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

    20. The New Technique The graft and sutures are tied down over a 6.5mm screw and spiked ligament washer

    21. The New Technique Graft in full extension:

    22. 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

    23. 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

    24. X-rays Pre-op Post-op

    25. Graft at Later Arthroscopy Initial surgery 1 year later

    26. 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

    27. 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

    28. Comparative X-rays 12 years old 14 years old

    29. 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

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

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