ACL reconstruction for 13 year-old

[jgderber]

My daughter tore her ACL almost three years ago (yes, at 10 years-old). She has had good stability until recently and now needs reconstruction. We have consulted with 2 top surgeons (one benefit of living in a ski town). One will do autograft the other allograft. Anyone have experience with adolescent patients? She has a little more growing yet to do.

[kingdom-tele]

In 12 years have only seen 1 adolescent girl with ACL repair, we are rural though so our numbers are generally low, it was an elected allograft and med meniscus repair after she went 18 months with occasional instability. Other than the overwhelming emotional component early on she did great ( pretty hefty scars to stare at) - just passed 18 months p/op and she is playing soccer this fall without concerns

consider a pre surgical PT appointment - assessing hip strength and early thigh ex ed will be helpful and get her involved early vs. scared to move p/op

a candid surgeon is helpful - if your daughter can take it, look at post surgical pics so when the bandages and brace come off the next morning she is ready

the enjoyable part, at least from a PT perspective, was the lack of short term memory, adolescents don't seem to dwell on the negatives for long.

Is just ACL?

Good Luck

[jgderber]

Great advice. She not great about strengthening on her own.

Initially, no other damage. There is probably some meniscus damage now.

What was the reason your patient chose allograft over autograft?

[kingdom-tele]

Yeah - finding a 12 y/o excited about leg lifts is pretty rare, for a good reason, boring, but necessary.

It was surgeon comfort that she ended up with an allograft as far as I know.

A majority of ACL repair we see are hamstring grafts, she was an anomoly in that regards - outcomes for both have been great though.

[Alaskan Rover]

I don't think she needs to worry nowadays. I had my first ACL surgery after a ski-racing accident when I was 20. That was an autograft back then (shit...now I can't even remember where the took the tissue from on me) and it was a full open surgery with quite long incisions. Took some time to recover from it too. Tom Baker, team surgeon for the Syracuse Orangeman did the fancy cutting on my knee, and he had a fantastic sports therapy group then so I was lucky.

I re-injured the same knee while doing some mountain climbing back in 1998...and was lucky enough to get Dr. Pedegana to do the surgery, who at the time was team surgeon for the Seattle Mariners baseball team. He elected to do a allograft via arthroscopic surgery.

The difference between the two methods is incredible!! Allografts are great, the dead person's tissues are soon replaced by your own tissue and arthoscopic surgery barely leaves any scarring...only a few small incision holes. The recuperation time after modern arthroscpopic surgery is also MUCH shorter compared to the open-surgery that used to be the norm.

Allografts and Arthroscopies are now the norm...I wish that was the case during my first surgery!! Now eleven years after surgery and LOTS of active use, I still have near normal strength/stability and absolutely normal range of motion. NOTE: Not even the best ACL surgery will beget 100% pre-injury stability, but 95% is pretty damn good!

Good luck to the kid and I wish a good recovery!

EDIT: I forgot to mention: Make sure you get the best SPORTS surgeon you can find. I had good luck finding team doctors that do work outside their own team members. A lot of orthopedic surgeons spend so much time dealing with non-active older folks that they are not used to dealing with athletes. A real sports-oriented surgeon that is used to dealing with athletes makes all the difference in the world!! I know it harder with insurance problems nowadays, but most cities still have quite a few good sports orthopedists that deal strictly w/ athletes and the young.

[jgderber]

Thanks! Fortunately, we live where the US Ski & Snowboard team is based and have great doctors that are very experienced with athletes. I think at least 1/4 of the people living here have had acl surgery, although none that I know were young as my daughter.

My choices are Dr. Vern Cooley (autograft) and Dr. Eric Heiden (allograft or autograft). Both are highly respected.

[Alaskan Rover]

Thanks! Fortunately, we live where the US Ski & Snowboard team is based and have great doctors that are very experienced with athletes. I think at least 1/4 of the people living here have had acl surgery, although none that I know were young as my daughter.

My choices are Dr. Vern Cooley (autograft) and Dr. Eric Heiden (allograft or autograft). Both are highly respected.

I've heard NOTHING but good about Dr. Eric Heiden!!! He has also opened up a practice in Utah and another somewhere else. If ANYBODY knows the requirements of the athletic body it would be him...being the winningest Gold Medal winner in Winter Olympic history. He still skates now, although not competively anymore.

[drmark]

The big issue here is not the skill or noteriety of the doctors, but the fact that this is a 13 year old. Despite the presence of secondary sexual characteristics and closing growth plates, she is still a child.

After ACL surgery, patients have to power their way through a painful rehabilitation period and not all 13 year olds are ready for that. And return to sports for this season is not mandatory, and ACL surgery is about as "elective" as elective can get.

A signifigant amount of psychological preparation will be necessary.

[jgderber]

That is certainly one of my concerns. She has a pre-op appointment with a pt to discuss what will be required after surgery. The doctors have suggested 2 pt/ week, but I think I will go with 3/wk initially. Getting her to work on it on her own will be a challenge. She is not one of my toughest kids. I will order ice and cpm machines. Fortunately, the timing is such that come the first of the year she will get 20 more pt visits with insurance.

The onset of puberty has caused significant increase in looseness. Now, if she moves wrong while sitting in her desk, her knee pops. I had hoped that she could continue to hold off on surgery by working on strengthening her supporting muscles.

Back to the allograft vs. autograft. I have not been able to find anything on which is better for a skeletally immature patient. Maybe the pros and cons are the same as adults. I know the bigger issue the placement and attachment of the graft.

[keipow]

For the question of graft choice, it is a long debate and should be with your chosen surgeon.

Another several questions to ask yourself:
1. Aesthetics. Autograft requires more incisions.
2. Graft acceptance and what will happen in the future. Do you expect her to grow much taller? What are the parents' and siblings' bone/joint sizes?
3. Puberty is the last time when a person grows in the number of muscle cells. Recovery speed is of importance.
4. Do you have enough resources to initiate PT months prior to surgery to build her strength, and I don't mean just the leg but overall body? If you are electing surgery, what is the feasibility of having the surgery on the last few days of the fall semester so that she can stay home without missing school? In the mean time, it might be good to start her on pre-op PT.
5. Do you have enough resources and ability to push her through daily rehab activities?
6. At her age, it is quite likely that medical advances will allow doctors to make her grow new tissue sometime in the future. Does the chosen method preclude this? This one is an argument for allograft. In other words, keep her body working and as intact as possible until some day modern medicine gets an even better fix. Don't weaken her patella or hamstring for a short-term (less than 10 to 15 years) fix. Surgeons are growing ACL's with silk webbing base from stem cells experimentally now.
7. How well can you muster support from her friends during the recovery? Given that you live in a ski town, that is really important. No one should be making fun of her during the recovery. Perhaps you can organize some parties for various milestones such as first PT, stitch removals, etc.
8. With her bones growing, what will the surgeon's choice of screw material be? Will the choice of material have the possibility of requiring removal later (titanium) or causing weird growth (bio-absorbable)?

I do not work in a medically-related field, but have talked to several teenagers who had the same surgery during my PT. They seem to be recovering well.

[jgderber]

Thanks! Those are great questions and suggestions.