>> Hi, I'm Jay Lee, I'm here to talk to you
about pediatric knee injuries, specifically the ACL today.
My interest is pediatric sports medicine.
I do have a disclosure, I do get research support
in terms of my ACL biomechanic testing.
And so today's case is a 10-year-old male
who sustained a injury during basketball.
He jumped, he landed, his knee twisted,
and he had some pain and swelling.
He gave it about a week and then returned
to basketball and noted his knee felt unstable
and it gave way again.
When he saw us, we noticed that he had
a large mountain of swelling in his knee.
The ACL test, the Lachman's Test demonstrated
some asymmetry between the right and the left knee,
and we also noted he was small compared to his parents.
He was prepubescent, he hadn't gone
through puberty and his growth spurt yet.
He got some X-rays, these X-rays don't show too much,
except for in this case, you could really make out
the growth plate which is here in the femur,
and here in the tibia.
And that's a concern when you're thinking
about treating a patient with an ACL tear
who's not yet done growing.
We got an MRI, and this X-ray here
is just for orientation, this is looking
at the knee from the side.
These MRI images are looking, again, from the side.
In this case, the femur is up here at the top,
tibia is down below.
And here is the PCL, the sister ligament of the ACL.
The ACL in this case is missing,
typically you would see the ACL coursing
across in this direction.
And so, he was diagnosed with an ACL tear.
And so, what do we do for a 10-year-old with an ACL tear?
You can consider starting some physical therapy,
you can fit him with one of the many ACL braces
that we have on the market.
You can start with both one and two,
or you can consider ACL surgery.
So what is the ACL?
We all know the ACL is important for pivoting and cutting,
it actually prevents shift of the tibia or shinbone,
anteriorly or forward in relationship
to the femur or thighbone.
It's also important for rotation,
and for varus and valgus stress.
It protects the knee and protects
the meniscus and the cartilage.
It's important for preventing arthritis.
And so what are the symptoms of an ACL tear?
Well the signs and symptoms are pretty similar
to what this patient experienced.
Oftentimes, there'll be a contact
or a non-contact injury with some twisting of the knee.
The patient will oftentimes note of pops
and deep pain and swelling.
And oftentimes if they return to play,
they'll find that their knee is unstable.
On exam, you'll notice a large amount
of swelling or a fusion like we did in this patient,
and you'll have your Lachman's and pivot shift test
to determine whether or not the knee is stable.
In terms of our pediatric patients,
I find that the Lachman's is probably
the easier of the two tests.
That pivot shift requires a completely relaxed patient
and it's more useful in the operating room.
Why do we get an X-ray?
So, the X-ray's more useful for determining
if there are other injuries or a different injury
masquerading as an ACL tear.
We use it to rule out fractures around the knee.
At Hopkins, we've also described
a way to determine how skeletally mature a patient is,
meaning how much growth do they have left
based off of the appearance
of the growth plates on the X-ray.
Why do we get an MRI?
The MRI is also useful for, again,
determining whether or not a patient
has an ACL tear.
Again, the absent ACL on this MRI.
Also, notice the bruising pattern.
The bruising pattern here is characteristic
of an ACL tear.
Other reasons to get an MRI is to rule out other injuries.
In this one patient's case, they also had
a tear to one of the collateral ligaments, the LCL.
And again, at Hopkins, we've described ways
to look at the growth plate on MRI as well
to determine how much growth a patient has left.
So what are our treatment options?
Well, for nonsurgical treatment, oftentimes,
are partial ACL tears, patients who have part
of their ACL still intact will benefit
from bracing and some activity modification.
We tell our patients to avoid cutting and pivoting sports,
and some of our low-demand patients, 15 to 20%
of them actually do pretty well, those are our copers.
In terms of surgery, historically we recognize
that patients are still growing,
and the techniques that we had in the past required
us to delay surgery, because in this case
of a 17-year-old, their growth plates are no longer there.
They're not as visible, and they're quite visible
on this 10-year-old here.
But, we found that if we delayed surgery,
oftentimes our patients would present later
once they were done growing for their ACL surgery
and have a significant amount
of meniscus and cartilage damage.
They would essentially have some arthritis already.
This is a traditional treatment for an ACL tear.
This is what we still do in some adults.
In this case, we drilled tunnels and put in screws
in the femur and in the tibia.
In between, we've passed a new ACL.
In our 10-year-old, this concept wouldn't work
because the screws and the tunnels would
be across their growth plate.
This would a leg to grow at an angle.
Instead, we have other options for treating an ACL.
This here utilizes the IT band.
This IT band is passed outside of the knee
and then slid through without any tunnels,
without any sockets, without any screws.
This here is called an all-pivot seal reconstruction.
In this case, the sockets are drilled here and drilled here.
This preserves the growth plate and avoids
or minimizes any growth plate disturbance.
And so currently, our current approach
to patients who have an ACL tear who are still growing,
we oftentimes will not delay the ACL reconstruction.
And then, we'll utilize one of these techniques
to avoid disruption to the growth plate.
These patients will oftentimes require
us to continue following them as they continue to grow
just to make sure they don't have any growth disturbance.
So back to our patient.
Our patient's 10, still growing, and enjoys being active,
playing basketball and baseball.
He does a lot of cutting and pivoting,
and so which of these options is the right one for him?
It's actually a combination of all of them.
Physical therapy's important even before
an ACL injury, because it's been found
to improve coordination, balance and strength,
and in that way reduce the risk
of an ACL tear to begin with.
It's also important after an injury,
because retear rates are pretty high,
and physical therapy can help reduce that rate.
In terms of bracing, bracing's useful before surgery just
to remind the patient to take it easy
and prevent any further injury.
It's also useful after surgery.
Even though it's not enough to prevent
a future ACL tear, it may benefit
a patient in terms of helping them move better.
And by moving better, we think the risk
of an ACL tear is less.
So, what is ACL surgery?
ACL surgery is typically outpatient.
You miss about five days of school,
you use crutches for a little bit,
and then you wait and rehab your knee
and get back to sports,
typically around that nine-month mark.
So in terms of addressing the ACL,
there's lots of different ways to go about it.
In this case, this is in our fluoroscopic picture.
In this patient, we decided to leave the ACL alone.
He had a meniscus tear that we treated
at the same time, but his knee was otherwise stable.
This here, this is the ACL, and this is sort
of a schematic of what we're looking at.
We're looking at the thigh bone here in the background.
And down here would be the shinbone or tibia.
So in terms of replacing the ACL, we talked
about lots of different techniques,
but in this case, this patient was missing
an ACL, which should course across there.
And we took an IT band from this patient's knee
and replaced that ACL.
You can also supplement an ACL.
In this case here, we have a patient with a torn ACL,
at least a portion of it, and in the background,
you actually have intact tissue.
So in this case, we took out this torn portion here
and left the intact tissue in place.
We think this might have some proprioceptive benefit.
And if you look here, we have new graft supplementing
his native tissue, so you have the best of both.
You have the robust structure from the additional graft,
but you also preserve some of the nerve endings
that comes through the native tissue.
In terms of repairing an ACL, there are certain situations
where actually fixing the native tissue does well.
Again, this is a normal knee, this is somewhat
a confusing picture because in this case,
in this one patient, the ACL actually tore
off of the tibia.
The whole piece is elevated, it's bloody.
We actually see some exposed bone underneath.
And the ACL itself is up here, it's intact,
but its attachment is not.
And in this case, you can take this whole piece
and bring it down.
By bringing it down, you retension that ACL.
And here is the final option, this is actually why
I have a disclosure in this presentation.
So we're looking at retensioning here at Hopkins,
and I put a question mark here
because we're still studying it.
In this particular case, there was a torn ACL
which we created, and some intact ACL here.
What we did is we went ahead and then detached
this intact ACL, and we went ahead
and took this core, this tissue here,
and we reoriented the native tissue.
By taking that core, we rotated it to recenter the ACL,
and we pulled it to recreate the tension.
And that, as we found so far,
does recreate the biomechanics of the knee.
The benefit of this would be that
the native tissue is still intact.
And again, we believe that keeping the native tissue
preserves the nerves and maybe some proprioception.
So back to our patient.
We were able to get him back to basketball and baseball.
He's now grown and post-pubescent,
and he had an IT band reconstruction,
this construction here.
This is his picture, which I had shown before,
this is his new ACL.
This is his IT band.
And this is his most recent X-ray.
I'll continue to follow him for another year or two
as he continues to grow, but this picture here
shows that his growth plates
are symmetric, right versus left.
So for our patient, we were able to get him back
to basketball and baseball and get him back
to the sports that he loves without any issues with growth.
If you're a patient or if you have
a patient with an ACL tear
and you have questions, please reach out.