Orthopaedist blasts into space
By Jennie McKee
http://www.aaos.org/news/aaosnow/oct09/youraaos3.asp
Robert L. Satcher Jr., MD, PhD, will travel to the International Space Station
Four decades after watching the grainy television images of Neil Armstrong and Buzz Aldrin landing on the moon, Robert L. Satcher Jr., MD, PhD, will go where no orthopaedic surgeon has gone before: outer space. In November, he will fulfill his life-long dream of space travel as one of six crew members on a mission to the International Space Station.
Members of the crew take a break from training to pose for a portrait. From left: Leland D. Melvin, mission specialist; Col. Charles O. Hobaugh, commander; Capt. Michael J. Foreman (Ret), mission specialist; Robert L. Satcher Jr., MD, mission specialist; Capt. Barry E. Wilmore, pilot; and Lt. Col. Randolph J. Bresnick, mission specialist. Courtesy of NASA
“Exploration—the concept of venturing out into the unknown and discovering something—excites me,” says Dr. Satcher. “Seeing the astronauts walk on the moon stirred my imagination and made me think that space exploration would be something great to do.”
Although he has always maintained a strong interest in space travel, Dr. Satcher was also drawn to medicine—specifically, orthopaedic oncology. His career as an orthopaedic surgeon and researcher has helped prepare him for what will surely be the experience of a lifetime.
The path to the starsDr. Satcher, who earned a PhD in chemical engineering from the Massachusetts Institute of Technology and a medical degree from Harvard University School of Medicine, went on to become an assistant professor of orthopaedic surgery at Northwestern University Feinberg School of Medicine in Chicago. He treated child and adult bone cancer at Northwestern Memorial and Children’s Memorial Hospitals and held a research position at Northwestern’s Robert H. Lurie Comprehensive Cancer Center and Institute for Bioengineering and Nanoscience in Advanced Medicine.
“My career was very rewarding because operating on the musculoskeletal system requires the use of many tools and engineering concepts in reconstructions,” he says.
Although he was focused on his orthopaedic career, Dr. Satcher still maintained a strong interest in space exploration, as evidenced by his research into how physical stresses affect bone.
“We know that when a person goes into outer space, gravity is removed; however, other forces continue to act on the skeleton,” he says. “Those forces are imparted primarily by the attached muscles that pull or push the bones. When people are in space, they typically lose bone mass from some of the weightbearing areas, such as the legs and spine. Presumably, the bone loss is the result of not putting weight on the legs and spine because there’s no gravity.
“What are the main components of mechanical stress that mediate these changes? Are stresses being transmitted through fluid flowing over the cells or over the substrate—or both? These important questions remain unanswered,” he says.
In 2000, Dr. Satcher applied to the National Aeronautics and Space Administration (NASA) astronaut training program. He believed his chances of being accepted were slim.
“I thought whatever consideration I got would at least make for good stories,” he says, with a chuckle.
A year later, NASA called Dr. Satcher to arrange an initial interview. He soon completed medical and psychological testing and underwent a background check by the Federal Bureau of Investigation. Three years later, the phone rang—and an official from NASA was on the line. He offered Dr. Satcher a spot in the next astronaut candidate class—the first in four years.
“It was a wonderful and surprising phone call,” remembers Dr. Satcher. “Although I was excited about starting my training at NASA, I was also sad to leave my colleagues at Northwestern University.”
In the next few days, Dr. Satcher spent a lot of time talking with his family about how all their lives would change.
“Many people have asked how my wife and family feel about what I do,” he says. “They have been overwhelmingly supportive, despite the risks and inconveniences.”
Dr. Satcher uses virtual reality hardware in the Space Vehicle Mock-up Facility at NASA’s Johnson Space Center to rehearse some of his duties on the upcoming mission to the International Space Station. Courtesy of NASA
Training for spaceDr. Satcher and his family soon moved to Houston, Texas, to be near the Lyndon B. Johnson Space Center, where he began rigorous training. He also took a position as clinical assistant professor of orthopaedic oncology at MD Anderson Cancer Center.
Dr. Satcher quickly found that the skills he possessed as an orthopaedic surgeon translated well to being an astronaut.
“I drew on my ability to maintain focus despite anything going on around me and to multitask under difficult circumstances,” he says. “Having reasonably good manual dexterity and a good understanding of engineering concepts was also helpful.”
He enjoyed nearly all of the training exercises—especially being a copilot in a T-38 supersonic jet.
“Flying in a T-38 is like being in the fastest, scariest, most dynamic ride imaginable,” he says. “The jets are very acrobatic. It’s fun to see what everything looks like from high altitudes.”
Perhaps more demanding have been training exercises that last seven to eight hours, during which Dr. Satcher wears a 300-lb space suit modified to be worn under water. He still participates in this training on an ongoing basis.
“We get in the pool at the Neutral Buoyancy Laboratory to practice space walking as well as repairing or replacing components of a full-size model of the International Space Station and space shuttle,” he says.
Dr. Satcher, who has performed this training nearly 40 times, says it’s physically and mentally exhausting.
“The tasks are very technical and detailed,” he says. “You’re doing fine manipulation in a bulky suit under a simulated zero-gravity environment.”
The missionAfter Dr. Satcher and the other crew members blast off on November 12 (launch date is subject to change), they will travel for 3 days to reach the International Space Station.
“The commander and the pilot will fly the ship,” he says.
“As a mission specialist, I will monitor the navigational and ship data and will relay that information to the commander and pilot. I will also be responsible for performing numerous tasks required for the daily operations of the shuttle.”
Dr. Satcher explains that even activities such as eating and sleeping will require careful coordination because the crew members will be in a confined space.
“When we reach our destination, we will transfer supplies and store them on the space station,” he explains.
During the 11-day mission, Dr. Satcher will go on two space walks. During the first, he will perform maintenance tasks on the International Space Station’s robotic arms. In his second space walk, the primary task will be to install a high-pressure oxygen tank that will supply breathable air to the space station.
Dr. Satcher will also operate the space shuttle’s robotic arms.
“Operating the robotic arms is similar to performing arthroscopic surgery in many ways,” he notes.
He will also serve as a proxy scientist for principle investigators whose experiments were selected by NASA, which uses a peer-review process similar to those employed by the National Institutes of Health and the Orthopaedic Research and Education Foundation.
“One of the studies will focus on how the height of a person’s spine changes in a zero-gravity environment,” he says. “We’re going to perform measurements to see if disk height changes when you go into outer space.”
Dr. Satcher says that many of his orthopaedic colleagues have expressed great interest in his upcoming space flight.
“A number of them will be attending the launch,” he says.
“I think we’re an untapped talent source, because so many of the skills an astronaut needs are the same skills surgeons need. I think more orthopaedic surgeons should become interested in being astronauts—in certain ways, it’s something we’re already trained to do.”
Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org
AAOS NowOctober 2009 Issue
Orthopaedic astronaut studies bone’s response to stress
http://www.aaos.org/news/bulletin/jul07/research1.asp
An OREF/Zimmer Career Development Award enabled Robert L. Satcher, MD, PhD, to begin studies on ways to replace destroyed bone
Too much stress can fracture bones, as any long-distance runner or orthopaedic surgeon knows. Too little stress and bone fails to develop properly. Traumatic stress and cellular stress from diseases such as cancer can also lead to bone loss.
Robert L. Satcher, MD, PhD, is among the researchers studying ways to replace lost bone. A recipient of a 2002 Career Development Award sponsored by the Orthopaedic Research and Education Foundation (OREF) and Zimmer, Dr. Satcher is also a mission specialist astronaut candidate.
Dr. Satcher’s interest in how bone responds as a whole to the various stresses thrust upon it and, conversely, how it responds to the absence of those stresses goes back to his postdoctoral work at Northwestern University’s Feinberg School of Medicine.
Dr. Satcher gets a close-up look at one of the agency’s T-38 jet trainer aircraft.
The stresses bones faceTo gain a better understanding of how various forces affect bones, Dr. Satcher—then an assistant professor of orthopaedic surgery at the Feinberg School of Medicine, a researcher at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, and an orthopaedic surgeon at Northwestern Memorial Hospital—investigated bone at the cellular level.
Bone is made up partly of living tissue and partly of an inorganic and organic matrix. Proteins make up the organic portion, while calcium and phosphates constitute the inorganic part. It is the living portion, however, that reacts to stress placed upon it.
“It’s been known for a long time that if you subject bone to physical stress, such as loading it, the bone will become larger in size,” Dr. Satcher said. “What that means is that the bone cells—the smallest living units that make up the bone—are helping to build up that bone to make it stronger in response to that physical stress.”
Using bone cells harvested from rats, Dr. Satcher and a team of researchers were able to study how bone reacts to different physical forces using several methods. In one study, Dr. Satcher observed flowing fluid across the bone cells to see how they were affected. The side of the cell exposed to the flowing fluid represented how a physical force would affect the bone.
Dr. Satcher was also able to grow cells on a deformable membrane. “When you deform the membrane that the cell is growing on, it subjects that cell to the same deformation,” he explained, “which is equivalent to a physical stress that would cause deformation in the bone.”
This enabled Dr. Satcher to test the cells’ response to controlled loading. “We can specify how much straining the cells experience, or the deformation they experience because we artificially input the load,” he said. “This lets us observe the patterns of response.”
These initial studies led Dr. Satcher to his more recent investigation of designing materials that promote bone growth and that could be used to reconstitute areas of bone lost due to trauma, surgery, or cancer.
“We took what I had learned from working on the more fundamental process of how physical stresses affect bone and applied it to practical applications,” he explained.
Robert L. (Bobby) Satcher, Jr., MD, PhD, mission specialist astronaut candidate, floats freely aboard a KC-135 aircraft as part of his early training.
Research beyond EarthDr. Satcher may someday have the opportunity to study this process in a completely different setting. He was selected as a NASA astronaut candidate in 2004.
He has nearly completed the 2-year basic training course that combined both didactic and experiential lessons. For example, classroom training covered the specifics of the space shuttle and international space station, while training in a large pool simulated the weightlessness of space.
“We also had a trip that involved leadership training, where we were put in scenarios of hostile environments and had to work together as a team to solve the problem under stressful situations,” Dr. Satcher said.
Once he has completed a technical assignment to support ongoing activities at NASA, Dr. Satcher will be eligible for assignment to either a space shuttle mission or a research project on the international space station. In either case, at least part of Dr. Satcher’s role will be that of researcher.
“Some NASA experiments have specifically studied how bone cells respond to a low gravity environment, but I won’t necessarily be conducting orthopaedic research,” Dr. Satcher said. “NASA has a review process similar to the National Institutes of Health or OREF. They accept research proposals and select the experiments that will be flown on the space shuttle and on the space station. Most likely I’ll be a proxy scientist for the principle investigator, doing some experiments that were selected by the peer-review process.”
Dr. Satcher, a mission specialist candidate in NASA’s 2004 astronaut class, poses with a T-38 jet trainer aircraft at Ellington Field.
Discovering the future of orthopaedicsDr. Satcher stresses, however, that it is important to support orthopaedic research. “Orthopaedics as a whole has been expanding throughout the years, and the capabilities of the surgeries have become better as technology has improved,” Dr. Satcher said. “As we age, most of us will need orthopaedic care, even if it’s not operative. Our joints are going to start to bother us, or our back is going to give us problems. If orthopaedics is going to continue to improve, it will be through research that is carried out intelligently and effectively. Supporting research is essential to the continuing improvement and evolution of orthopaedics.”
Each year Zimmer supports six $50,000 awards through OREF. According to Ray Elliott, Zimmer’s board chair, “When we realized that young, practicing clinicians did not have the resources that were available to residents or veteran clinicians, we decided to help these young researchers by providing funding through OREF for a new grant program. Since then, we’ve granted to OREF more than a quarter of a million dollars each year to help these younger surgeons pursue additional research, education, travel, or any legitimate endeavor to help them advance orthopaedic science or care.”
For more information on the Zimmer/OREF Career Development Awards or ways you can support research through OREF, visit the OREF Web site, www.oref.org
Tuesday, November 17, 2009
Monday, November 9, 2009
Young tennis players who play only 1 sport are more prone to injuries
http://www.eurekalert.org/pub_releases/2009-11/luhs-ytp102909.php
Single sport tennis players more prone to injuries.
According to a study presented at the International Society for Tennis Medicine and Science World Congress, playing one sport year round increases the risk of injury, particularly in young players. The study of 519 junior tennis players found that those who played only tennis were more likely to withdraw from tournaments for medical reasons, typically injuries. Athletes in the study generally began playing at age 6 and competing at age 10; they practiced an average of 16 to 20 hours per week and nearly all (93 percent) competed at least 10 months a year. Typical injuries included muscle strains, ankle sprains, hip injuries, patellar instability, spinal stress fractures, tendinitis of the wrist, and rotator cuff injuries.
Single sport tennis players more prone to injuries.
According to a study presented at the International Society for Tennis Medicine and Science World Congress, playing one sport year round increases the risk of injury, particularly in young players. The study of 519 junior tennis players found that those who played only tennis were more likely to withdraw from tournaments for medical reasons, typically injuries. Athletes in the study generally began playing at age 6 and competing at age 10; they practiced an average of 16 to 20 hours per week and nearly all (93 percent) competed at least 10 months a year. Typical injuries included muscle strains, ankle sprains, hip injuries, patellar instability, spinal stress fractures, tendinitis of the wrist, and rotator cuff injuries.
Supervised Exercise Therapy May Be Helpful for Patellofemoral Pain Syndrome
Author: Laurie Barclay, MD
http://cme.medscape.com/viewarticle/711501?src=cmemp&uac=45143PK
October 29, 2009 — Supervised exercise therapy may be helpful in treatment of patellofemoral pain syndrome in general practice, according to the results of an open-label, randomized controlled trial reported in the October 21 issue of the BMJ.
"There is no agreement concerning the aetiology of patellofemoral pain syndrome or the most appropriate treatment," write R. van Linschoten, from Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues. "There is, however, general consensus that the preferred treatment approach is non-surgical. Rest during periods of pain and refraining from pain-provoking activities are advised; this 'wait and see' approach is advocated in the Dutch national GP [general practice] guidelines and is considered usual care."
The goal of this study was to compare the efficacy of supervised exercise therapy vs usual care for 131 patients with patellofemoral pain syndrome, in recovery, pain, and function. Patients who had a new episode of patellofemoral pain syndrome were recruited by their general practitioner (GP) or sports physician and randomly selected to the intervention group (n = 65) or to usual care (n = 66).
In the intervention group, patients took part in a standardized exercise program for 6 weeks. This was tailored to individual performance and supervised by a physical therapist. In addition, patients were instructed to practice the tailored exercises at home for 3 months. Usual care consisted of a "wait and see" approach, with rest during periods of pain and avoiding activities that caused pain. Patients in both groups received written information about patellofemoral pain syndrome and general instructions regarding home exercises.
The main endpoints of the study at 3-month and 12-month follow-up were self-reported recovery on the 7-point Likert scale, pain at rest and during activity on a 0- to 10-point numeric rating scale, and function measured with a 0- to 100-point Kujala patellofemoral score.
Outcomes at 3 months were better in the intervention group vs the control group in pain at rest (adjusted difference, −1.07; 95% confidence interval [CI], −1.92 to −0.22; effect size, 0.47), pain during activity (adjusted difference, −1.00; 95% CI, −1.91 to −0.08; effect size 0.45), and function (adjusted difference, 4.92; 95% CI, 0.14 - 9.72; effect size, 0.34).
Outcomes at 12 months continued to be better in the intervention group vs the control group in pain at rest (adjusted difference, −1.29; 95% CI, −2.16 to −0.42; effect size, 0.56) and pain during activity (adjusted difference, −1.19; 95% CI, −2.22 to −0.16; effect size 0.54) but not function (adjusted difference, 4.52; 95% CI, −0.73 to 9.76).
Recovery was reported by more patients in the exercise group vs the control group (41.9% vs 35.0% at 3 months and 62.1% vs 50.8% at 12 months), but these differences were not statistically significant. Although patients recruited by sports physicians (n = 30) did not benefit from the intervention, those recruited by GPs (n = 101) had significant and clinically meaningful differences in pain and function favoring the intervention group, according to predefined subgroup analyses.
"Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice," the study authors write. "Exercise therapy did not produce a significant difference in the rate of self reported recovery."
Limitations of this study include lack of blinding, small numbers of patients recruited by sports physicians, and protocol violation by 8 patients in the control group who received physical therapy.
"Further research should aim to elucidate the mechanisms whereby exercise therapy results in better outcome," the study authors conclude.
ZON-MW (the Netherlands organization for health research and development) supported this study. The study authors have disclosed no relevant financial relationships.
BMJ. 2009;339:b407.
http://cme.medscape.com/viewarticle/711501?src=cmemp&uac=45143PK
October 29, 2009 — Supervised exercise therapy may be helpful in treatment of patellofemoral pain syndrome in general practice, according to the results of an open-label, randomized controlled trial reported in the October 21 issue of the BMJ.
"There is no agreement concerning the aetiology of patellofemoral pain syndrome or the most appropriate treatment," write R. van Linschoten, from Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues. "There is, however, general consensus that the preferred treatment approach is non-surgical. Rest during periods of pain and refraining from pain-provoking activities are advised; this 'wait and see' approach is advocated in the Dutch national GP [general practice] guidelines and is considered usual care."
The goal of this study was to compare the efficacy of supervised exercise therapy vs usual care for 131 patients with patellofemoral pain syndrome, in recovery, pain, and function. Patients who had a new episode of patellofemoral pain syndrome were recruited by their general practitioner (GP) or sports physician and randomly selected to the intervention group (n = 65) or to usual care (n = 66).
In the intervention group, patients took part in a standardized exercise program for 6 weeks. This was tailored to individual performance and supervised by a physical therapist. In addition, patients were instructed to practice the tailored exercises at home for 3 months. Usual care consisted of a "wait and see" approach, with rest during periods of pain and avoiding activities that caused pain. Patients in both groups received written information about patellofemoral pain syndrome and general instructions regarding home exercises.
The main endpoints of the study at 3-month and 12-month follow-up were self-reported recovery on the 7-point Likert scale, pain at rest and during activity on a 0- to 10-point numeric rating scale, and function measured with a 0- to 100-point Kujala patellofemoral score.
Outcomes at 3 months were better in the intervention group vs the control group in pain at rest (adjusted difference, −1.07; 95% confidence interval [CI], −1.92 to −0.22; effect size, 0.47), pain during activity (adjusted difference, −1.00; 95% CI, −1.91 to −0.08; effect size 0.45), and function (adjusted difference, 4.92; 95% CI, 0.14 - 9.72; effect size, 0.34).
Outcomes at 12 months continued to be better in the intervention group vs the control group in pain at rest (adjusted difference, −1.29; 95% CI, −2.16 to −0.42; effect size, 0.56) and pain during activity (adjusted difference, −1.19; 95% CI, −2.22 to −0.16; effect size 0.54) but not function (adjusted difference, 4.52; 95% CI, −0.73 to 9.76).
Recovery was reported by more patients in the exercise group vs the control group (41.9% vs 35.0% at 3 months and 62.1% vs 50.8% at 12 months), but these differences were not statistically significant. Although patients recruited by sports physicians (n = 30) did not benefit from the intervention, those recruited by GPs (n = 101) had significant and clinically meaningful differences in pain and function favoring the intervention group, according to predefined subgroup analyses.
"Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice," the study authors write. "Exercise therapy did not produce a significant difference in the rate of self reported recovery."
Limitations of this study include lack of blinding, small numbers of patients recruited by sports physicians, and protocol violation by 8 patients in the control group who received physical therapy.
"Further research should aim to elucidate the mechanisms whereby exercise therapy results in better outcome," the study authors conclude.
ZON-MW (the Netherlands organization for health research and development) supported this study. The study authors have disclosed no relevant financial relationships.
BMJ. 2009;339:b407.
Friday, November 6, 2009
Anatomic Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Is It Possible?
By Daniel Rueff, MD; Robert Royalty, MD; R. Gina Yarnell, CST; Darren L. Johnson, MD
ORTHOPEDICS 2009; 32:839
This article describes a technique that allows for an anatomic anterior cruciate ligament reconstruction that restores normal translational and rotational kinematics to the knee with minimal disruption to the physis.
Reconstruction of the anterior cruciate ligament (ACL) has become one of the most common procedures performed by orthopedic surgeons today with nearly 300,000 performed in the United States each year.1 Intrasubstance ACL ruptures are a common injury in the adult population but traditionally have been thought to be a relatively rare occurrence in skeletally immature patients. However, injuries to the ACL are being increasingly recognized and reported in pediatric and adolescent patients with open growth plates.2-6 This is postulated to be the result of several factors, including the increased participation of young athletes in competitive high level sporting activities and the improved clinical and diagnostic modalities available to evaluate suspected intra-articular injuries in the pediatric and adolescent patient population.7,8
Controversy exists regarding the optimal management of ACL injuries in skeletally immature patients. Nonoperative treatment consisting of physical therapy, bracing, and activity modification has been reported in many studies to lead to an increased incidence of chondral and meniscal injury and continued knee instability.9-13
To allow for a return to sport and prevent further intra-articular damage to the knee, many surgeons advocate early operative treatment of ACL injuries in the skeletally immature.9,11,14-16 However, concern exists regarding physeal injury during surgical reconstruction with complications such as limb-length discrepancy, angular deformities, and premature physeal closure.17-19 Several reports of such growth disturbances following ACL reconstruction have been reported in the literature.20,21
In an effort to prevent injury to the growth plate, extra-articular and modified physeal sparing reconstructions have been developed; however, these are “nonanatomic” techniques and do not replicate the normal ACL anatomy or function.22-25 Long-term follow-up on these nonanatomic techniques is needed to determine how they function over time.
Anatomic ACL reconstruction is thought to decrease anterior tibial translation and increase rotational stability compared to nonanatomic techniques.26-28 Restoration of knee stability and elimination of the pivot shift are essential in young patients due to their increased activity levels and longer postsurgical exposure to sporting activities than their older counterparts. This article presents a surgical technique that provides for anatomical reconstruction of the ACL while minimizing physeal injury via a transepiphyseal femoral tunnel.
Case Report
A 14-year-old female high school/select year-round soccer athlete sustained a noncontact twisting injury to her left knee during practice. Following her injury, she reported continued swelling and instability and was unable to return to competition.
One month post-injury, Lachman’s and pivot shift testing were found to be positive. Knee radiographs revealed open growth plates and magnetic resonance imaging confirmed complete rupture of the ACL. Clinical examination revealed the patient was pre-menarchal, and she desired to return to soccer as soon as possible.
Delaying surgical reconstruction and return to competitive sports was not a viable option for the athlete or her family. As the patient was skeletally immature, she underwent anatomic ACL reconstruction using hamstring autograft with a femoral physeal sparing technique.
Surgical Technique
The patient is placed supine and general anesthesia is administered. The operative leg is placed in an arthroscopic leg holder with the hip flexed to allow for extreme hyperflexion of the knee. After tourniquet insufflation the semitendinosus and gracilis tendons are harvested through a 4-cm longitudinal incision. The tendons are then fashioned into a quadruple bundle graft on the back table and a 15-mm Endobutton CL (Smith & Nephew, Mansfield, Massachusetts) is affixed for femoral sided fixation.
“High and tight” anterolateral and “low and tight” anteromedial portals are created and the knee is surveyed in the usual standard fashion. The ACL tibial remnant is minimally debrided, retaining important tissue for revascularization and reinnervation of the graft. After a limited notchplasty is performed, a far accessory anteromedial portal is created under direct visualization using a spinal needle. This portal allows for anatomic placement and drilling of the femoral tunnel on the lateral femoral wall.
The knee is placed in 90° of flexion and the starting point for the femoral tunnel is marked with an awl through the accessory anteromedial portal. The starting point is positioned directly between the anteromedial and posterolateral bundle attachments on the bifurcate ridge. This mark is placed low on the lateral wall, centered in the area below the lateral intercondylar ridge
A Steinmann pin is placed at the femoral starting point and the knee is then hyperflexed (~140°) to allow for a pin trajectory that remains distal and nearly parallel to the femoral physis A high knee flexion angle is essential to ensure the pin remains below the physis during insertion and eventual tunnel drilling. Proper patient positioning that allows for knee hyperflexion must be confirmed before the start of the surgical procedure. The pin is drilled under fluoroscopic imaging followed by the Endobutton and single fluted femoral tunnel reamers (Figure 3). The tibial footprint is then viewed from the anterolateral portal and the tibial guide placed near the posterior aspect of the footprint. The tibial tunnel is drilled in a more vertical orientation (~65°) than usual, which results in a smaller circular defect in the growth plate compared to the larger elliptical shape produced from drilling the tibial tunnel in a more oblique angle. The graft is then passed and the Endobutton secured against the lateral femoral wall (Figure 4). Fluoroscopic imaging may be used to confirm placement of the Endobutton and femoral tunnel below the physis. The knee is then placed in full extension, and tibial fixation is provided by a screw and washer construct distal to the tibial physis. Alternatively, an anatomic femoral tunnel can be drilled below the femoral physis using an “outside-in” drilling technique with the knee positioned in 90° of knee flexion .
The wounds are closed and a cyrocuff and hinged knee brace are applied. The patient is made weight bearing as tolerated with the brace locked in full extension. The patient is seen within 1 week postoperatively and formal physical therapy including unlimited range of motion, quadriceps strengthening, and patella mobilization are initiated.
Discussion
The participation of children and adolescents with open physis in competitive athletic activity year-round has increased significantly in the past 15 years. Subsequently, so has the incidence of ACL injuries in this patient population. Nonoperative treatment of these injuries leads to further meniscal damage and recurrent instability and hastens early arthrosis of the knee.
Anterior cruciate ligament reconstruction has been shown to reliably restore knee stability while preventing further meniscal and chondral injury in skeletally immature patients in short-term follow-up. However, complications may arise with disruption of the open growth plates during surgical reconstruction.
We have described a surgical technique that allows for an anatomic ACL reconstruction restoring normal translational and rotational kinematics to the knee with minimal disruption to the vulnerable physis.
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Higuchi T, Hara K, Tsuji Y, Kubo T. Transepiphyseal reconstruction of the anterior cruciate ligament in skeletally immature athletes: An MRI evaluation for epiphyseal narrowing [published online ahead of print July 18, 2009]. J Pediatr Orthop B.
Kocher M, Saxon H, Hovis W, Hawkins R. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002; 22(4):452-457.
Salzmann G, Spang J, Imhoff A. Double-bundle anterior cruciate ligament reconstruction in a skeletally immature adolescent athlete. Arthroscopy. 2009; 25(3):321-324.
Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients: A preliminary report. J Bone Joint Surg Am. 2003; 85(7):1255-1263.
Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am. 1985; 67(2):257-262.
Micheli L, Rask B, Gerberg L. Anterior cruciate ligament reconstruction in patients who are prepubescent. Clin Orthop Relat Res. 1999; (364):40-47.
Parker A, Drez D Jr, Cooper JL. Anterior cruciate ligament injuries in patients with open physes. Am J Sports Med. 1994; 22(1):44-47.
Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002; 30(5):660-666.
Gabriel M, Wong E, Woo S, Yagi M, Debski R. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res. 2004; 22(1):85-89.
Zantop T, Kubo S, Petersen W, Musahl V, Fu F. Current techniques in anatomic anterior cruciate ligament reconstruction. Arthroscopy. 2007; 23(9):938-947.
Authors
Drs Rueff, Royalty, and Johnson and Ms Yarnell are from the Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky.
Drs Rueff, Royalty, and Johnson and Ms Yarnell have no relevant financial relationships to disclose.
Correspondence should be addressed to: Darren L. Johnson, MD, Department of Sports Medicine, K431 Kentucky Clinic 0284, 740 S Limestone St, Lexington, KY 40536.
ORTHOPEDICS 2009; 32:839
This article describes a technique that allows for an anatomic anterior cruciate ligament reconstruction that restores normal translational and rotational kinematics to the knee with minimal disruption to the physis.
Reconstruction of the anterior cruciate ligament (ACL) has become one of the most common procedures performed by orthopedic surgeons today with nearly 300,000 performed in the United States each year.1 Intrasubstance ACL ruptures are a common injury in the adult population but traditionally have been thought to be a relatively rare occurrence in skeletally immature patients. However, injuries to the ACL are being increasingly recognized and reported in pediatric and adolescent patients with open growth plates.2-6 This is postulated to be the result of several factors, including the increased participation of young athletes in competitive high level sporting activities and the improved clinical and diagnostic modalities available to evaluate suspected intra-articular injuries in the pediatric and adolescent patient population.7,8
Controversy exists regarding the optimal management of ACL injuries in skeletally immature patients. Nonoperative treatment consisting of physical therapy, bracing, and activity modification has been reported in many studies to lead to an increased incidence of chondral and meniscal injury and continued knee instability.9-13
To allow for a return to sport and prevent further intra-articular damage to the knee, many surgeons advocate early operative treatment of ACL injuries in the skeletally immature.9,11,14-16 However, concern exists regarding physeal injury during surgical reconstruction with complications such as limb-length discrepancy, angular deformities, and premature physeal closure.17-19 Several reports of such growth disturbances following ACL reconstruction have been reported in the literature.20,21
In an effort to prevent injury to the growth plate, extra-articular and modified physeal sparing reconstructions have been developed; however, these are “nonanatomic” techniques and do not replicate the normal ACL anatomy or function.22-25 Long-term follow-up on these nonanatomic techniques is needed to determine how they function over time.
Anatomic ACL reconstruction is thought to decrease anterior tibial translation and increase rotational stability compared to nonanatomic techniques.26-28 Restoration of knee stability and elimination of the pivot shift are essential in young patients due to their increased activity levels and longer postsurgical exposure to sporting activities than their older counterparts. This article presents a surgical technique that provides for anatomical reconstruction of the ACL while minimizing physeal injury via a transepiphyseal femoral tunnel.
Case Report
A 14-year-old female high school/select year-round soccer athlete sustained a noncontact twisting injury to her left knee during practice. Following her injury, she reported continued swelling and instability and was unable to return to competition.
One month post-injury, Lachman’s and pivot shift testing were found to be positive. Knee radiographs revealed open growth plates and magnetic resonance imaging confirmed complete rupture of the ACL. Clinical examination revealed the patient was pre-menarchal, and she desired to return to soccer as soon as possible.
Delaying surgical reconstruction and return to competitive sports was not a viable option for the athlete or her family. As the patient was skeletally immature, she underwent anatomic ACL reconstruction using hamstring autograft with a femoral physeal sparing technique.
Surgical Technique
The patient is placed supine and general anesthesia is administered. The operative leg is placed in an arthroscopic leg holder with the hip flexed to allow for extreme hyperflexion of the knee. After tourniquet insufflation the semitendinosus and gracilis tendons are harvested through a 4-cm longitudinal incision. The tendons are then fashioned into a quadruple bundle graft on the back table and a 15-mm Endobutton CL (Smith & Nephew, Mansfield, Massachusetts) is affixed for femoral sided fixation.
“High and tight” anterolateral and “low and tight” anteromedial portals are created and the knee is surveyed in the usual standard fashion. The ACL tibial remnant is minimally debrided, retaining important tissue for revascularization and reinnervation of the graft. After a limited notchplasty is performed, a far accessory anteromedial portal is created under direct visualization using a spinal needle. This portal allows for anatomic placement and drilling of the femoral tunnel on the lateral femoral wall.
The knee is placed in 90° of flexion and the starting point for the femoral tunnel is marked with an awl through the accessory anteromedial portal. The starting point is positioned directly between the anteromedial and posterolateral bundle attachments on the bifurcate ridge. This mark is placed low on the lateral wall, centered in the area below the lateral intercondylar ridge
A Steinmann pin is placed at the femoral starting point and the knee is then hyperflexed (~140°) to allow for a pin trajectory that remains distal and nearly parallel to the femoral physis A high knee flexion angle is essential to ensure the pin remains below the physis during insertion and eventual tunnel drilling. Proper patient positioning that allows for knee hyperflexion must be confirmed before the start of the surgical procedure. The pin is drilled under fluoroscopic imaging followed by the Endobutton and single fluted femoral tunnel reamers (Figure 3). The tibial footprint is then viewed from the anterolateral portal and the tibial guide placed near the posterior aspect of the footprint. The tibial tunnel is drilled in a more vertical orientation (~65°) than usual, which results in a smaller circular defect in the growth plate compared to the larger elliptical shape produced from drilling the tibial tunnel in a more oblique angle. The graft is then passed and the Endobutton secured against the lateral femoral wall (Figure 4). Fluoroscopic imaging may be used to confirm placement of the Endobutton and femoral tunnel below the physis. The knee is then placed in full extension, and tibial fixation is provided by a screw and washer construct distal to the tibial physis. Alternatively, an anatomic femoral tunnel can be drilled below the femoral physis using an “outside-in” drilling technique with the knee positioned in 90° of knee flexion .
The wounds are closed and a cyrocuff and hinged knee brace are applied. The patient is made weight bearing as tolerated with the brace locked in full extension. The patient is seen within 1 week postoperatively and formal physical therapy including unlimited range of motion, quadriceps strengthening, and patella mobilization are initiated.
Discussion
The participation of children and adolescents with open physis in competitive athletic activity year-round has increased significantly in the past 15 years. Subsequently, so has the incidence of ACL injuries in this patient population. Nonoperative treatment of these injuries leads to further meniscal damage and recurrent instability and hastens early arthrosis of the knee.
Anterior cruciate ligament reconstruction has been shown to reliably restore knee stability while preventing further meniscal and chondral injury in skeletally immature patients in short-term follow-up. However, complications may arise with disruption of the open growth plates during surgical reconstruction.
We have described a surgical technique that allows for an anatomic ACL reconstruction restoring normal translational and rotational kinematics to the knee with minimal disruption to the vulnerable physis.
eferences
Cohen S, Sekiya J. Allograft safety in anterior cruciate ligament reconstruction. Clin Sports Med. 2007; 26(4):597-605.
Bales C, Guettler J, Moorman III C. Anterior cruciate ligament injuries in children with open physes: evolving strategies of treatment. Am J Sports Med. 2004; 32(8):1978-1985.
Kannus P, Järvinen M. Knee ligament injuries in adolescents: eight year follow-up of conservative management. J Bone Joint Surg Br. 1988; 70(5):772-776.
Aichroth P, Patel D, Zorrilla P. The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents: A prospective review. J Bone Joint Surg Br. 2002; 84(1):38-41.
Johnston DR, Ganley TJ, Flynn JM, Gregg JR. Anterior cruciate ligament injuries in skeletally immature patients. Orthopedics. . 2002; 25(8):864-871.
McCarroll J, Rettig A, Shelbourne K. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988; 16(1):44-47.
Shea KG, Pfeiffer R, Wang JH, Curtin M, Apel PJ. Anterior cruciate ligament injury in pediatric and adolescent soccer players: An analysis of insurance data. J Ped Orthop. 2004; 24(6):623-628.
Söderman K, Pietilä T, Alfredson H, Werner S. Anterior cruciate ligament injuries in young females playing soccer at senior levels. Scand J Med Sci Sports. 2002; 12(2):65-68.
Henry J, Chotel F, Chouteau J, Fessy MH, Bérard J, Moyen B. Rupture of the anterior cruciate ligament in children: Early reconstruction with open physes or delayed reconstruction to skeletal maturity? Knee Surg Sports Traumatol Arthrosc. . 2009; 17(7):748-755.
Mizuta H, Kubota K, Shiraishi M, Otsuka Y, Nagamoto N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995; 77(6):890-894.
Millett P, Willis A, Warren A. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: Does a delay in treatment increase the risk of meniscal tear? Arthroscopy. 2002; 18(9):955-959.
Graf B, Lange R, Fujisaki C, Landry G, Saluja R. Anterior cruciate ligament tears in skeletally immature patients: Meniscal pathology at presentation and after attempted conservative treatment. Arthroscopy. 1992; 8(2):229-233.
McCarroll J, Shelbourne K, Porter D, Rettig A, Murray S. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes: An algorithm for management. Am J Sports Med. 1994; 22(4):478-484.
Mohtadi N, Grant J. Managing anterior cruciate ligament deficiency in the skeletally immature individual: A systematic review of the literature. Clin Sports Med. 2006; 16(6):457-464.
Dorizas J, Stanitski C. Anterior cruciate ligament injury in the skeletally immature. Orthop Clin North Am. 2003; 34(3):355-363.
Janarv PM, Nyström A, Werner S, Hirsch G. Anterior cruciate ligament injuries in skeletally immature patients. J Ped Orthop. 1996; 16(5):673-677.
Koman J, Sanders J. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am. 1999; 81(8):711-715.
Ono T, Wada Y, Takahashi K, Minamide M, Moriya H. Tibial deformities and failures of anterior cruciate ligament reconstruction in immature rabbits. J Orthop Sci. 1998; 3(3):150-155.
Higuchi T, Hara K, Tsuji Y, Kubo T. Transepiphyseal reconstruction of the anterior cruciate ligament in skeletally immature athletes: An MRI evaluation for epiphyseal narrowing [published online ahead of print July 18, 2009]. J Pediatr Orthop B.
Kocher M, Saxon H, Hovis W, Hawkins R. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002; 22(4):452-457.
Salzmann G, Spang J, Imhoff A. Double-bundle anterior cruciate ligament reconstruction in a skeletally immature adolescent athlete. Arthroscopy. 2009; 25(3):321-324.
Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients: A preliminary report. J Bone Joint Surg Am. 2003; 85(7):1255-1263.
Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am. 1985; 67(2):257-262.
Micheli L, Rask B, Gerberg L. Anterior cruciate ligament reconstruction in patients who are prepubescent. Clin Orthop Relat Res. 1999; (364):40-47.
Parker A, Drez D Jr, Cooper JL. Anterior cruciate ligament injuries in patients with open physes. Am J Sports Med. 1994; 22(1):44-47.
Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002; 30(5):660-666.
Gabriel M, Wong E, Woo S, Yagi M, Debski R. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res. 2004; 22(1):85-89.
Zantop T, Kubo S, Petersen W, Musahl V, Fu F. Current techniques in anatomic anterior cruciate ligament reconstruction. Arthroscopy. 2007; 23(9):938-947.
Authors
Drs Rueff, Royalty, and Johnson and Ms Yarnell are from the Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky.
Drs Rueff, Royalty, and Johnson and Ms Yarnell have no relevant financial relationships to disclose.
Correspondence should be addressed to: Darren L. Johnson, MD, Department of Sports Medicine, K431 Kentucky Clinic 0284, 740 S Limestone St, Lexington, KY 40536.
ACL Reconstruction in Adolescent and Preadolescent Patients
By Theodore J. Ganley, MD
http://www.orthosupersite.com/view.asp?rID=44983
ORTHOPEDICS 2009; 32:833
In this issue of Orthopedics, Dr Theodore Ganley discusses the pros and cons of delaying anterior cruciate ligament reconstruction in skeletally immature patients.
What are the major concerns regarding performing anterior cruciate ligament (ACL) reconstruction in skeletally immature patients?
Early ACL reconstruction primarily risks damaging the growing physis and inducing a growth disturbance.
Describe the surgical approach in prepubescent patients vs that in adolescent patients?
Theodore J. Ganley
Surgical options include transphyseal, epiphyseal, and extra-articular procedures. For prepubescent and younger adolescent patients, I perform an all-epiphyseal ACL reconstruction. Epiphyseal tunnels are placed by way of a tibial docking technique and a femoral outside-in technique (Figure). This procedure avoids the physis and allows for customized tunnel placement proximally and distally. For older adolescent patients with a closing physis, I perform a transphyseal ACL reconstruction with hamstring autograft and fixation adjacent to but not at the level of the growth plates.
What are the benefits of delaying ACL reconstruction?
In the all-epiphyseal ACL reconstruction technique, epiphyseal tunnels are placed by way of a tibial docking and femoral outside-in technique.
Patients are frequently given a brief period of several weeks or, at times, over a month to regain motion preoperatively. Surgery can also be delayed for prolonged periods of time. If there is a delay until skeletal maturity, the risk of growth plate disturbance can be removed altogether.
What are the risks of delaying ACL reconstruction?
Delaying ACL reconstruction risks ongoing intra-articular damage due to knee instability. I conducted a study with my colleague, Todd Lawrence, MD, PhD, to quantify these risks and to identify independent risk factors for patients 14 years and younger.1 Using logistic regression models we found that time to reconstruction was significantly associated with medial meniscus tears and chondral injuries in the group with delay greater than 12 weeks. For medial meniscus tears, time to reconstruction and a history of instability were identified as independent risk factors. The odds ratio for delaying treatment was 4 and 11 for instability. Treatment delay was also associated with an increase in tear severity including irreparable tears.
When is nonoperative management indicated?
Nonoperative management is indicated when a patient’s physical, mental, or social situation precludes them from surgical treatment or from participating in rehabilitation. Nonoperative treatment is also indicated if families prefer activity restriction over reconstruction.
Does potential growth disturbance caused by ACL reconstruction outweigh complications that stem from nonoperative management?
Because a delay in treatment was associated with a several-fold increase in medial meniscus tears and severe lateral compartment cartilage injuries, the risks of delaying surgery outweigh the risks to the growth plates, especially given current techniques. To further minimize risk, I currently use computer navigation to guide tunnel placement in preadolescents. Image guidance is not a prerequisite for all-epiphyseal procedures; however, I currently use it as an extra precautionary measure to accommodate for the undulating nature of the physes. This is especially useful in younger patients with potentially as much as 12 to 18 inches of growth remaining.
How big of a role does chronological, skeletal, and physiological age play in determining the management of ACL injuries in adolescents?
Chronological age and skeletal age can be markedly different in the same patient. We base decision making on the status of the growth plates at the time of surgery.
Explain why management in preadolescents is more problematic than in any other adolescent group.
From a physiologic and anatomic standpoint, prepubescent patients frequently have an extensive amount of growth remaining, a considerably smaller knee, and physes that are undulating in the coronal and sagittal planes. Compliance with postoperative rehabilitation is more challenging, and it is therefore useful to have an initial team of therapists and nurses who are comfortable treating these younger patients. A postoperative protocol that accommodates for these potential differences in compliance is also helpful. I require preadolescent patients to undergo formal testing to monitor strength progression. These patients are also required to refrain from a return to sports for at least 3 months longer than older adolescents.
Reference
Lawrence JTR, Ganley T. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment. Paper presented at: Annual Meeting of the American Orthopaedic Society for Sports Medicine; July 8-12, 2009; Keystone, CO.
Author
Dr Ganley is Sports Medicine Director, The Children’s Hospital of Philadelphia and Associate Professor of Orthopedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Dr Ganley has no relevant financial relationships to disclose.
http://www.orthosupersite.com/view.asp?rID=44983
ORTHOPEDICS 2009; 32:833
In this issue of Orthopedics, Dr Theodore Ganley discusses the pros and cons of delaying anterior cruciate ligament reconstruction in skeletally immature patients.
What are the major concerns regarding performing anterior cruciate ligament (ACL) reconstruction in skeletally immature patients?
Early ACL reconstruction primarily risks damaging the growing physis and inducing a growth disturbance.
Describe the surgical approach in prepubescent patients vs that in adolescent patients?
Theodore J. Ganley
Surgical options include transphyseal, epiphyseal, and extra-articular procedures. For prepubescent and younger adolescent patients, I perform an all-epiphyseal ACL reconstruction. Epiphyseal tunnels are placed by way of a tibial docking technique and a femoral outside-in technique (Figure). This procedure avoids the physis and allows for customized tunnel placement proximally and distally. For older adolescent patients with a closing physis, I perform a transphyseal ACL reconstruction with hamstring autograft and fixation adjacent to but not at the level of the growth plates.
What are the benefits of delaying ACL reconstruction?
In the all-epiphyseal ACL reconstruction technique, epiphyseal tunnels are placed by way of a tibial docking and femoral outside-in technique.
Patients are frequently given a brief period of several weeks or, at times, over a month to regain motion preoperatively. Surgery can also be delayed for prolonged periods of time. If there is a delay until skeletal maturity, the risk of growth plate disturbance can be removed altogether.
What are the risks of delaying ACL reconstruction?
Delaying ACL reconstruction risks ongoing intra-articular damage due to knee instability. I conducted a study with my colleague, Todd Lawrence, MD, PhD, to quantify these risks and to identify independent risk factors for patients 14 years and younger.1 Using logistic regression models we found that time to reconstruction was significantly associated with medial meniscus tears and chondral injuries in the group with delay greater than 12 weeks. For medial meniscus tears, time to reconstruction and a history of instability were identified as independent risk factors. The odds ratio for delaying treatment was 4 and 11 for instability. Treatment delay was also associated with an increase in tear severity including irreparable tears.
When is nonoperative management indicated?
Nonoperative management is indicated when a patient’s physical, mental, or social situation precludes them from surgical treatment or from participating in rehabilitation. Nonoperative treatment is also indicated if families prefer activity restriction over reconstruction.
Does potential growth disturbance caused by ACL reconstruction outweigh complications that stem from nonoperative management?
Because a delay in treatment was associated with a several-fold increase in medial meniscus tears and severe lateral compartment cartilage injuries, the risks of delaying surgery outweigh the risks to the growth plates, especially given current techniques. To further minimize risk, I currently use computer navigation to guide tunnel placement in preadolescents. Image guidance is not a prerequisite for all-epiphyseal procedures; however, I currently use it as an extra precautionary measure to accommodate for the undulating nature of the physes. This is especially useful in younger patients with potentially as much as 12 to 18 inches of growth remaining.
How big of a role does chronological, skeletal, and physiological age play in determining the management of ACL injuries in adolescents?
Chronological age and skeletal age can be markedly different in the same patient. We base decision making on the status of the growth plates at the time of surgery.
Explain why management in preadolescents is more problematic than in any other adolescent group.
From a physiologic and anatomic standpoint, prepubescent patients frequently have an extensive amount of growth remaining, a considerably smaller knee, and physes that are undulating in the coronal and sagittal planes. Compliance with postoperative rehabilitation is more challenging, and it is therefore useful to have an initial team of therapists and nurses who are comfortable treating these younger patients. A postoperative protocol that accommodates for these potential differences in compliance is also helpful. I require preadolescent patients to undergo formal testing to monitor strength progression. These patients are also required to refrain from a return to sports for at least 3 months longer than older adolescents.
Reference
Lawrence JTR, Ganley T. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment. Paper presented at: Annual Meeting of the American Orthopaedic Society for Sports Medicine; July 8-12, 2009; Keystone, CO.
Author
Dr Ganley is Sports Medicine Director, The Children’s Hospital of Philadelphia and Associate Professor of Orthopedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Dr Ganley has no relevant financial relationships to disclose.
The Effects of Anterior Cruciate Ligament Lesion on the Articular Cartilage of Growing Goats
By Francesco Falciglia, MD, PhD; Giuseppe Mastantuoni, MD; Vincenzo Guzzanti, MD, PhD
ORTHOPEDICS 2009; 32:812
Abstract
Treatment of anterior cruciate ligament (ACL) injury in skeletally immature patients is controversial. The growth plate could be damaged if treated with the reconstruction techniques used to treat instability in adults. For this reason, many authors postpone surgical treatment until skeletal maturity, but the acceptable length of time that treatment can be postponed without causing irreversible damage to the articular cartilage in children with ACL injury is unknown. Until now, no studies have described the pathological findings and the evolution of the lesions of the articular cartilage during the growing period. For this reason, an experimental study on 16 6-month-old, skeletally immature goats was performed. A complete ACL lesion was achieved by removing the ligament. Two animals per group were sacrificed at intervals of 1, 3, 6, and 9 months postoperatively, and macroscopic and microscopic evaluations were performed. The presence of meniscal injury and articular cartilage lesions with progressive aspects were hystologically underlined. The hystological observations showed that the complete ACL lesion causes irreversible articular cartilage alterations in growing goats 3 months after injury. These experimental data suggest that ACL reconstruction in growing patients with ACL injury and instability should be indicated without waiting until skeletal maturity.
Anterior cruciate ligament (ACL) injury in teenagers is now seen so frequently that it is the subject of much attention.1-18 In adults, the problem of therapy is approached with a careful selection of the cases to be treated conservatively.19 Some authors strongly believe that the results of conservative treatment in young patients with complete ACL lesion are not satisfactory and that valid alternative therapeutic solutions is necessary.9,10,13,20-22 Because the greatest problems encountered are associated with the presence of the growth plate, ACL isometric reconstruction is performed when skeletal maturity is complete.
ORTHOPEDICS 2009; 32:812
Abstract
Treatment of anterior cruciate ligament (ACL) injury in skeletally immature patients is controversial. The growth plate could be damaged if treated with the reconstruction techniques used to treat instability in adults. For this reason, many authors postpone surgical treatment until skeletal maturity, but the acceptable length of time that treatment can be postponed without causing irreversible damage to the articular cartilage in children with ACL injury is unknown. Until now, no studies have described the pathological findings and the evolution of the lesions of the articular cartilage during the growing period. For this reason, an experimental study on 16 6-month-old, skeletally immature goats was performed. A complete ACL lesion was achieved by removing the ligament. Two animals per group were sacrificed at intervals of 1, 3, 6, and 9 months postoperatively, and macroscopic and microscopic evaluations were performed. The presence of meniscal injury and articular cartilage lesions with progressive aspects were hystologically underlined. The hystological observations showed that the complete ACL lesion causes irreversible articular cartilage alterations in growing goats 3 months after injury. These experimental data suggest that ACL reconstruction in growing patients with ACL injury and instability should be indicated without waiting until skeletal maturity.
Anterior cruciate ligament (ACL) injury in teenagers is now seen so frequently that it is the subject of much attention.1-18 In adults, the problem of therapy is approached with a careful selection of the cases to be treated conservatively.19 Some authors strongly believe that the results of conservative treatment in young patients with complete ACL lesion are not satisfactory and that valid alternative therapeutic solutions is necessary.9,10,13,20-22 Because the greatest problems encountered are associated with the presence of the growth plate, ACL isometric reconstruction is performed when skeletal maturity is complete.
Mending Meniscals In Children, Improving Diagnosis And Recovery
Mending Meniscals In Children, Improving Diagnosis And Recovery
The meniscus is a rubber-like, crescent moon-shaped cartilage cushion that sits between the leg and thigh bone. Each knee has two menisci: one on the inside of the knee joint and one on the outside. In recent years, more children have been diagnosed with tears to this area (meniscal tears); however, according to a literature review published in the November 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), prospects for a full recovery are high. "Seventy-five to 90 percent of children who have meniscal tears heal successfully when they are treated appropriately. In adults, the success rate is often less than 50 percent," said study co-author Dennis Kramer, M.D., an attending orthopaedic surgeon at Children's Hospital Boston and instructor in Orthopaedic Surgery at Harvard Medical School. "A child's physiology is different than an adult's-they are growing and therefore have a greater blood flow to the meniscus. This helps in the healing process." How Meniscal Tears OccurMeniscal tears often occur when a child twists his or her knee while playing sports (the area becomes painful and swollen and tears are sometimes dismissed as knee sprains). Children can continue to experience pain, but often do not seek help because they do not want to miss out on sporting events or have to go to the doctor. Additionally, a small percentage of children are born with abnormally shaped "discoid" menisci that are larger and therefore more prone to tearing. If your child complains of a "snapping" or "popping" knee, it may be due to a discoid meniscus. According to the study, several factors are contributing to the increase in diagnosis of meniscal tears in children: - more children are participating in sports, where knee injuries often occur; - more healthcare professionals are aware of and recognize the signs of meniscal tears; and - the use of magnetic resonance imaging (MRI) helps physicians to better diagnose them. Early Treatment Important for Long-Term HealthDr. Kramer stresses that although meniscal tears in children can often be repaired successfully, they should be treated quickly. "Tears that are repaired within three months seem to heal better than those treated at a later time," he said. "Additionally, if a child has a meniscal tear that cannot be repaired but instead has to be removed, studies indicate that it can lead to arthritis later in life." Diagnosing and Treating a Tear in a ChildIf you believe your child has a meniscal tear, visit your doctor. Dr. Kramer suggests parents may expect the following: 1. The doctor will conduct a simple physical. Your child will be asked to bend and twist the leg in a certain way to cause stress to the meniscus, as well as push on the area of the knee where the meniscus is located to determine if it is injured. 2. The doctor will attempt to perform the exam to minimize any pain. Ask if your physician knows how to make these modifications. If he or she is not comfortable making this assessment, you may want to visit an orthopaedic surgeon or physician who specializes in sports medicine who has experience conducting these tests. 3. If the physical tests indicate there is a tear, your doctor may schedule an MRI. Dr. Kramer notes that pediatricians, radiologists or physicians specializing in sports medicine may be better equipped to interpret the results of your child's MRI. 4. If the MRI indicates that your child has a meniscal tear, your child may need arthroscopic surgery. This is a minimally invasive surgical technique using small incisions and tiny pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the knee. Smaller Injuries Can Progress, So Talk to Your Doctor"Smaller injuries can progress and get worse if left untreated, said Dr. Kramer. "If you suspect your child has a meniscal tear, talk to your doctor and discuss treatment options as soon as possible." SourceUniversity of Michigan Health System
The meniscus is a rubber-like, crescent moon-shaped cartilage cushion that sits between the leg and thigh bone. Each knee has two menisci: one on the inside of the knee joint and one on the outside. In recent years, more children have been diagnosed with tears to this area (meniscal tears); however, according to a literature review published in the November 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), prospects for a full recovery are high. "Seventy-five to 90 percent of children who have meniscal tears heal successfully when they are treated appropriately. In adults, the success rate is often less than 50 percent," said study co-author Dennis Kramer, M.D., an attending orthopaedic surgeon at Children's Hospital Boston and instructor in Orthopaedic Surgery at Harvard Medical School. "A child's physiology is different than an adult's-they are growing and therefore have a greater blood flow to the meniscus. This helps in the healing process." How Meniscal Tears OccurMeniscal tears often occur when a child twists his or her knee while playing sports (the area becomes painful and swollen and tears are sometimes dismissed as knee sprains). Children can continue to experience pain, but often do not seek help because they do not want to miss out on sporting events or have to go to the doctor. Additionally, a small percentage of children are born with abnormally shaped "discoid" menisci that are larger and therefore more prone to tearing. If your child complains of a "snapping" or "popping" knee, it may be due to a discoid meniscus. According to the study, several factors are contributing to the increase in diagnosis of meniscal tears in children: - more children are participating in sports, where knee injuries often occur; - more healthcare professionals are aware of and recognize the signs of meniscal tears; and - the use of magnetic resonance imaging (MRI) helps physicians to better diagnose them. Early Treatment Important for Long-Term HealthDr. Kramer stresses that although meniscal tears in children can often be repaired successfully, they should be treated quickly. "Tears that are repaired within three months seem to heal better than those treated at a later time," he said. "Additionally, if a child has a meniscal tear that cannot be repaired but instead has to be removed, studies indicate that it can lead to arthritis later in life." Diagnosing and Treating a Tear in a ChildIf you believe your child has a meniscal tear, visit your doctor. Dr. Kramer suggests parents may expect the following: 1. The doctor will conduct a simple physical. Your child will be asked to bend and twist the leg in a certain way to cause stress to the meniscus, as well as push on the area of the knee where the meniscus is located to determine if it is injured. 2. The doctor will attempt to perform the exam to minimize any pain. Ask if your physician knows how to make these modifications. If he or she is not comfortable making this assessment, you may want to visit an orthopaedic surgeon or physician who specializes in sports medicine who has experience conducting these tests. 3. If the physical tests indicate there is a tear, your doctor may schedule an MRI. Dr. Kramer notes that pediatricians, radiologists or physicians specializing in sports medicine may be better equipped to interpret the results of your child's MRI. 4. If the MRI indicates that your child has a meniscal tear, your child may need arthroscopic surgery. This is a minimally invasive surgical technique using small incisions and tiny pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the knee. Smaller Injuries Can Progress, So Talk to Your Doctor"Smaller injuries can progress and get worse if left untreated, said Dr. Kramer. "If you suspect your child has a meniscal tear, talk to your doctor and discuss treatment options as soon as possible." SourceUniversity of Michigan Health System
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