Jeremy Frank, MD, Pediatric Sports Medicine Surgeon at Joe DiMaggio Children’s Hospital talks about repairing ACL’s in children.
Interview conducted by Ivanhoe Broadcast News in August 2018.
You see a lot of kids, obviously. Are you seeing ACL injuries in kids a lot?
Dr. Frank: ACL injuries in kids with open growth plates represent a large percentage of my practice. The rate of ACL injury in kids and adolescents has risen nearly 400% over the last 10 to 15 years as a result of a variety of factors. Kids only play one sport nowadays. They’re not playing a variety of sports because they’re not looking to be three sport athletes. The institution of Title Nine brought an influx of women into the sports world and girls tear their ACL four to six times more common than men. We have scouting at advanced ages, travel teams, all-star teams, showcase events, etc. Kids are playing one sport more intensely and getting injured more frequently. As a result, we’re getting better at treating ACL injuries in young athletes.
Explain to those who don’t know: what is an ACL injury and how can it be repaired? Does it need to be completely replaced?
Dr. Frank: The ACL is the critical ligament on the inside of the knee that gives stability to your knee. Without your ACL you could likely sit, walk, swim, and ride a bike without a problem. However if you tried to run, jump, cut, pivot, or play sports, you’d be at risk of your knee buckling and therefore injuring cartilage, the protective surfaces on the end of the bones, or the meniscus, the shock absorbing cushion in your knee. ACLs do not heal on their own. There is some new data to suggest that we may be able to repair some of the ACLs based on studies from Boston’s Children Hospital where I did my training, but we’re not yet at the point to be able to do that. The vast majority of sports medicine surgeons around the world reconstruct an ACL, meaning they take out the torn ACL and they replace it with new tissue to build a new ACL.
When you’re talking about children, younger patients compared to adults with an ACL tear, are the procedures different? What do you do to replace them or to fix the injury?
Dr. Frank: There’s a big difference between doing an ACL surgery on someone who no longer has growth plates because they’ve completed puberty and growth and they’re now an adult versus a young child whose growth plates are still open. Plus, there are differences in growing kids, so you can have someone who is completely prepubescent, someone who is in the middle of puberty, and someone who is almost done with puberty, almost an adult. You have to treat those three subsets of patients differently and protect their growth plates when you’re doing ACL surgery so that you don’t injure their growth plates and cause one leg to be longer than the other or even grow at an abnormal angle.
Are they at risk for anything later in life like arthritis?
Dr. Frank: Everyone who gets ACL surgery, whether you’re a child or an adult, has higher incidence of arthritis in the knee. That said, if you don’t get your ACL reconstructed at all, your chances of developing arthritis in your knee are virtually 100%. As far as the safety of doing ACL surgery on kids whose growth plates are open, we’ve developed a very specific technique to do these surgeries and protect the growth plates simultaneously.
Talk about the technique and what you do that’s different.
Dr. Frank: With kids whose growth plates are open, we really have to determine what level of growth and what stage of puberty they are in to determine what the right surgery is for each individual patient. In prepubescent patients, we perform a technique originally developed at Harvard where you take a strip of tissue from the outside of the knee and wrap it around the knee and through it to reconstruct and rebuild the ACL without drilling through the growth plates whatsoever. This is only done on patients who are completely prepubescent and have the highest risk of injury to a growth plate if you were to drill through it.
So this technique is only for younger patients?
Dr. Frank: Correct. This is for prepubescent patients. For patients in the middle of puberty, we use a different technique where we can drill small holes through the growth plate safely. The technique where we bypass drilling through the bone happens only in prepubescent males and females.
And this is the specific one that we’re talking about today?
Dr. Frank: Yes.
Tell us what it’s called and describe to us how it works and why it’s better to do it this way and what the recovery is from that.
Dr. Frank: The recovery is very similar to a standard ACL procedure, though there are some minor differences in the early weeks after surgery. What we’re doing is taking a strip of tissue from the side of the thigh. That tissue is called the iliotibial band or IT band. We take that tissue and wrap it around the thigh bone, through the knee, and then stitch it into the top of the shin bone. Therefore, we’re not drilling any holes whatsoever in the bones and not risking any injury to the growth plate. The safety of this technique is remarkable in the fact that there’s zero risk to the growth plate so kids will continue to grow safely, and there’s long term studies that show that this is a one-time definitive procedure. This is not a procedure that we do until the kids reach skeletal maturity, meaning their growth plates are closed. This is one and done and this will reconstruct their ACL for good and they’ll be able to get back to sports safely and effectively.
Give us an idea of the age you’re talking about. What’s the age group here?
Dr. Frank: It’s usually boys under about 12 years of age and girls under about 11 years of age, but it’s not exclusively based on their chronologic age. One 12 year old boy and another 12 year old boy could be completely different on the puberty scale, so you can’t just assess their chronologic age. You have to assess what their physiologic age is, meaning how they look and how much puberty they have gone through. Then we can also get a bone age by taking an x-ray of their hand and wrist and we combine all that data to make an appropriate assessment.
Are you saying once you’re over the age of 11 or 12, those growth plates are already set?
Dr. Frank: No, they’re not closing once you’re above 11 or 12, but it’s safer then to actually do a procedure where you drill through the growth plates with smaller holes. It just depends. Prepubescent patients get the IT band ACL surgery while mid-prepubescent patients get a surgery where you use their hamstring tendons to build their own ACL and we drill through the growth plates. For patients who are very old or maybe even young adults, we perform adult type ACL reconstructive surgery on them.
So, with the IT band ACL surgery, you said recovery is pretty much the same. Just give us an idea of what that is.
Dr. Frank: For the first couple of weeks after surgery, they’ll be on crutches. They’ll start therapy usually within a week after surgery and they’ll continue for about three months where they go two or three times a week for about 45 minutes to an hour. After three months, we’ll let them start doing some light stuff like jogging, swimming, or biking. It usually isn’t until somewhere between six months or at the most nine months before we allow them to go back to competitive sports and cutting and pivoting activities.
Basically, you’re saying if you’re in soccer or baseball or football, you can go back to that sport.
Dr. Frank: Absolutely, and the return to sport rate is very high for kids who get this procedure and then return back to their sport at their given level.
Just bullet point the benefits of this procedure over what was done previous.
Dr. Frank: About 20 years ago, when a young kid with open growth plates tore their ACL, the adult sports medicine doctors would say to them, we can’t do your ACL surgery right now, there’s too much risk that we would injure your growth plate, you’re going to have to wear a brace, minimize your sports and activities, and wait until you’ve gone through puberty and your growth plates close. What we learned over the last 10 to 20 years is that that’s not true. We can safely and effectively do this surgery on young patients, give their knee stability with a new ACL, allow them to return to sports, and allow them to be a part of their normal social and athletic circles. This maintains their self-esteem, self-confidence, and provides a very low risk to any arthritis or premature closure of the growth plate.
Are there any risks to the procedure itself?
Dr. Frank: There’s always risk to every procedure, but this particular one has no more than any other. There could be some infection after surgery, but kids usually get antibiotics beforehand. Bleeding is really a non-factor, we’re not operating on any significant nerves, and we’re not operating on the growth plate. So there’s really no high risk of complications after this surgery and people often do exceedingly well.
So the bottom line here, because this will go out nationally, is if your child suffers from an ACL injury, you should research and try to find a pediatric orthopedic surgeon who is doing this type of procedure.
Dr. Frank: Around the country now, there’s a host of very well qualified and well trained pediatric sports medicine doctors in almost every major metropolitan area that can perform a growth plate sparing, meaning they’re not drilling through the growth plate, surgery to reconstruct the ACL. If you have a young child who is either prepubescent or in the middle of puberty, it would be very smart to find a pediatric sports medicine doctor who’s qualified to perform these techniques so that your child can get their ACL reconstructed. Get a stable knee, return back to sports, and have very low, if any, risks to injury in the growth plate.
Should we say what might cause that injury on the field? Go ahead.
Dr. Frank: ACL injuries can happen from usually one of two techniques. One is a non-contact pivoting technique. You might see in the NFL a wide receiver or a running back catching a pass turning up field and then pivoting and they immediately injure their ACL and go down on the ground complaining of knee pain. Another possibility is a contact injury. If two female soccer players collide knee to knee, or one person slide tackles into another player’s knee, they can tear their ACL that way. So there are non-contact and contact ACL type injuries.
So if a child suffers that type of injury, it could even be from skiing.
Dr. Frank: Absolutely. In almost every sport we see ACL injuries. Very common sports are girls’ soccer, girls’ basketball, football, skiing; these are all injuries where the foot is usually set in a binding, like in skiing and the pivot point is the knee, or female sports where landing problems are really the culprit for ACL tears like in girls’ basketball and girls’ soccer. So it happens in every single sport across the board, but there are some sports that are more likely to produce ACL injuries.
Where is the injury?
Dr. Frank: The ACL is a ligament deep within the central portion of the knee that couples the end of the thigh bone to the top of the shin bone and provides stability from the knee rotating and translating forward and backwards. When that’s torn, patients usually experience a pop along with pain and often times they have a large amount of swelling in their knee and they can’t put weight on it.
END OF INTERVIEW
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