Please enable JavaScript.
Coggle requires JavaScript to display documents.
ACL Reconstruction - Coggle Diagram
ACL Reconstruction
Skeletal Age
Assessing and documenting the child’s skeletal age, in addition to his or her chronological age, is necessary to individualising treatment of ACL injuries.(Ardern, 2018) :check:
Five Considerations for Skeletal Age Assessment (Ardern, 2018)
-
Use imaging of the knee to determine if the femoral and tibial physes, and the tibial tubercle apophysis are open. If the growth areas are closed, then, independent of chronological age, the child can be treated as an adult.
None of the specific methods for skeletal age determination in isolation is sufficient to accurately determine skeletal age :check:
Use a multifaceted clinical approach to determine skeletal age that includes whether or not the child has had an adolescent growth spurt, the relative heights of the child’s parents and Tanner staging :check:
The most common method of skeletal age assessment is via posterior-anterior left hand and wrist X-ray. This can be compared with a skeletal atlas (eg, Gilsanz and Ratib75 or Greulich and Pyle76) or using a smart-phone application (eg, the Bone Age app for iPhone). :check:
Many studies fail to assess the skeletal age of included participants (Ardern, 2018) (Wong, 2019) (Brusalis, 2017) :check:
Many PRiSM members (91%) assess skeletal age (Popkin, 2018)
Follow-Up to maturity
53% of French surgeons did (Gracia, 2019) :check:
Only 56% of surgeons followed patients up to skeletal maturity (Accadbled, 2019) :check:
Methods to measure
Tanner stage is often used, however its unreliable in orthopoedic surgeons (Slough, 2013), (Knapik, 2020) :check:
Many use menarche to indicate skeletal age in females, and only state that physeal status has to be recorded in males, as they don't have this proxy (Seabol, 2021)
Mostly measured using Greulich-Pyle Bone Age atlas, which is considered as the most accurate way in skeletally immature patients (Knapik, 2020) (Fabricant, 2013)
Could use knee MRI (Meza, 2020)
PROM
No peads-specific ACL PROM available, and there should be a priority to generate such (Ardern, 2018) :check:
Recommendations of which to use (Ardern, 2018)
► Use a generic measure of health-related quality of life; ► Use either the Pedi-IKDC or KOOS-Child to assess self-re- ported knee function;
► Use the Pediatric Functional Activity Brief Scale to assess self-reported activity level
Most commonly used PROMs were IKDC subjective knee form, lysholm, tenger (Zebis, 2019)
Adult PROMs are more commonly used than paeds-specific ones (Zebis, 2019) (Brusalis, 2017) :check:
None used consistently across studies (Zebis, 2019) :check:
Paediatric simple knee value could be a good scale to use in the future; one question, shown to be comparable to paed-IKDC in 10-15yr olds 6month post ACL reconstruction (Marot, 2021)
Trends
Increase in paeds ACL tears in last 20 years <18yrs old - US (Beck,2017)
Increase in surgical treatment in last 20 years - US (Beck, 2017)
An explanation of the increase could be due to sports specialisation; focusing on one sport, year round training and increased training volumes (Bell, 2018) :check:
Increase in incidence in Italy for <14yr olds (Longo, 2020)
Increase in US (Tepolt, 2019) <18yrs in 10yrs
Increase in UK in <20yrs old in last 20yrs (Nogaro, 2020) :check:
How to treat
Non-surgical treatment can be a permanent treatment option for those who do not develop functional instability, or a short-term option to delay ACL reconstruction until the child has reached skeletal maturity (Ardern, 2018) :check:
Little previous consensus on a consistent way to treat (Ardern, 2018)
Non op management can lead to re- current instability, meniscal injury, and chondral injury, potentially leading to early osteoarthritis with non- operative or delayed reconstruction (Fabricant, 2013) (Dingel, 2019) :check:
Delay of surgery by 1 day reduces the odds of return to sport by 1.3% (Fones, 2020) :check:
Aims of ACL treatment
To restore a stable, well-functioning knee that enables a healthy, active lifestyle across the lifespan (Ardern, 2018)
To reduce the impact of existing or the risk of further meniscal or chondral pathology, degenerative joint changes and the need for future surgical intervention. (Ardern, 2018)
To minimise the risk of growth arrest and femur and tibia deformity (Ardern, 2018)
Post op complications
Second ACL rupture
Prevalence of 32% (Dekker, 2017)
Prevalence of ipsilateral or contra of ~30% (Kay, 2018) :checK:
8.7% (Wong, 2019) :check:
Most commonly reported complication (Knapik, 2020) :check:
Reported by 40% of studies examined (Zebis, 2019)
reinjury rate of 24.3% for adolescent athletes at a minimum of 2 years after ACLR (Fones, 2020) :check:
Growth Disturbance
Growth disturbances may be a result of hardware, bone plugs at the physis, extra-artic- ular tenodesis or use of over-the-top femoral position. (Ardern, 2018) :check:
Monitoring
Monitor height 6 monthly (Ardern, 2018) :check:
Pre-Op Radiographs
Only 54% of surveyed surgeons did preop radiographs (Accadbled, 2019)
Pre-op radiographs can be unreliable at times to assess LL, possible due to an inability to fully straighten the leg - if a radiograph is being taken, it has to be in full extension and weightbearing (Heath, 2020)
72% of French surgeons surveyed did long leg preop radiographs (Gracia, 2019)
A US surgeon cosensus agreed that pre-op standing, AP, PA flexion, lateral and long-leg alignment views as well as left hand film for bone age are required (Seabol, 2021) :check:
Ensuring that preoperative standing alignment radiographs are performed only after the patient has regained the ability to fully straighten the knee will increase the accuracy and precision of longitudinally measured changes (Fabricant, 2019) :check:
Post-Op Radiographs
66% of PRiSM members said they followed up with 3 view x rays post op in skeletally immature patients (Popkin, 2018) :check:
Routine clinical and radiological measurement of LL in the first 12 months post op is important, and if skeletally immature, annually until maturity (Ardern, 2018) :check:
Fewer than a third of changes seen radiologically were seen clinically (Fabricant, 2019) (Bayomy, 2019) :check:
Often reported as Growth disturbances defined as greater than 1-cm limb length discrepancy (LLD) and/or more than 5◦ of malalignment (Gracia, 2019)
Types of GD (Ardern, 2018) :check:
► Localised physis injury resulting in a bone bridge leading to growth arrest and possible malalignment (type A);
-
► Undergrowth process arising from a graft traversing a physis under tension during growth and leading to a tethering effect (type C).
Valgus is the most common angular growth deformity (Wong, 2019) :check:
Observed to a similar extent in all techniques (Wong, 2019) :check:
More LLD in all epiphyseal repair compared to extraphyseal (Knapik, 2020)
Reported by 69% of studies included (Zebis, 2019)
Low rates of subsequent surgery to address growth disturbance (Nogaro, 2020)
Reported by 7% of respondants in French survey, however this is probably an underestimate, as not all of them were followed up (Gracia, 2019)
-
Speculation that LLD can predispose to ACL injury (Lazaro, 2017) :check:
Less of a concern in children with open physis but near skeletal maturity - 13yr female, 15yr male (Fabricant, 2013)
Long-term
No studies have examined long term outcomes such as knee osteoarthritis (Zebis, 2019) :red_flag: check current literature
Rehab
Bracing
The effective- ness of bracing following ACL injuries or reconstruction in paediatric patients is unknown. Other considerations related to the use of a brace might be to prevent knee hyperextension or knee valgus/varus, to enhance the child’s awareness of his or her injury and as a protective signal to others the child might encounter (Ardern, 2018) :check:
Substantial variability of published hospital rehab guidelines and milestones vs IOC statement vs each other (Forrester, 2019) :check:
Most guidelines don't consider skeletal age (Forrester, 2019) :check:
RTS
consider advising the child athlete not to return to pivoting sport until at least 12 months following ACL reconstruction (Ardern, 2018) :check:
Meniscus injury
Meniscal repair should be performed whenever possible in the paediatric patient because of the deleterious effects of menis- cectomy and the positive outcomes of meniscal repair (Ardern, 2018)
-
ACL anatomical background (Fabricant, 2013)
Sudden varus or valgus force with knee twisting. Often have popping sensation or sound. (Fabricant, 2013) :check: