Moiss Cohen 1980 REMEMBER... The children are not a miniature adult - - PowerPoint PPT Presentation

ISAKOS EDUCATION TRAINING CENTER UNIVERSIDADE FEDERAL DE SAO PAULO - BRASIL

Moisés Cohen

Medical Director Medical Board

FIFA MEDICAL CENTRE OF EXCELLENCE DIRECTOR

Chairman Chairman Medical Director

1980

REMEMBER... The children are not a miniature adult Children

• Body changes
• Muscles hypertrophied
• Bones grow
• Ligaments are more requested

Lausanne – Oct. 2017

GRAFT BEHAVIOUR

Astur,D. ........Cohen M.,KSSTA 2016

• Quadruple hamstring graft decreases a mean 25.3 %

(range from 12.9 to 33.3 %) in diameter from time of ACL reconstruction surgery until reassessment period after surgery in skeletally immature patients

2016

Astur DC, Cachoeira CM, Vieira TS, Debieux P, Kaleka CC, Cohen M.

2017

24.6 % 17.5 % 9.2 %

< 16 years old 16 and 18 years old > 18 years old

Astur DC, Cohen M. KSSTA. 2017

Tanner I < 8-9 years-old Totally open physis Tiny graft Minimal epiphysis thickness

Type 1 Type 2

Symptomatic Asymptomatic Unstable Stable

Non surgical treatment Extra-articular Surgery

Tanner I, II, III < 12-13 years-old Open physis Small graft Eminent epiphysis

Viable femoral epiphysis Viable femoral and tibial epiphysis Partial trans ephyseal reconstruction Totall trans ephyseal reconstruction

Type 3 e 4

Tanner III and IV > 15-16 years-old Phyisis in closing Medium graft Developed epiphysis

Transphyseal reconstruction Type 3 Type 4 + vertical tunnel Anatomical tunnel

t t

TANNER STAGE GUIDELINES

JWL, male, 4 y.o. Frequent falls and Left Knee instability since 1 year

February, 2011

• Cabinet fall on left knee
• Emergency Room – “Left Tibia fracture with no

displacement . Cast Immobilization for 25 days”.

• During 1 year the mother

said the patient didn’t complaint but he dropped down many times and he couldn’t run and play soccer with the collegues at the school.

April, 2012

• The mother says that she saw the “boy's

knee dislocating”

• He usually dislocated the knee by himself

just kidding to show to his friends December 2012

• The patient came to visit us.

• Lachman +++/3+
• Anterior Drawer +++/3+
• Pivot Shift +++/3+
• No articular swelling
• No pain
• Spontaneous subluxation of the left knee
• Tanner

I

Immature skeleton with no bone changes

ANTEROPOSTERIOR LATERAL OBLÍQUE

NORMAL

Sagital T2

?

Surgical technique

Kocher, M.S.,JBJS, 2006

2015

ANTEROPOSTERIOR LATERAL

 GRAFT TRAJETORY

Axial T2 fat Sat 1 2 3 4 5 6 7 8 Inferior Superior  M L M L M L M L M L M L M L M L

Fixação tibial

Lateral  Sagital T2 fat Sat Medial 1 2 4 5 6 3

Fixação tibial

1 2 3 4 5 6 Anterior Posterior  M L M L M L M L M L M L

Fixação tibial

Coronal T2 fat Sat

 GRAFT TRAJETORY

2017 – P.O 56 months – 9 years old Good Evolution, Very happy Normal activities together with the school colleagues

• FUTURE ?????
• More Normal Childhood
• We need to know better about the evolution

and the complications

• Clarify and Share the problem with the family

SUMMARY

Thank You