+ Serious A.C.L. Injuries on the Kids’ Playing Fields

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An article by Gina Kolata in the Times says young athletes’ big-time injuries are being recognized. 

Collin Link was 11 years old last year when he was tackled as he went in for a touchdown in pee-wee football.His mother said, “He didn’t get up. He kept saying his knee hurt real bad.”But Crystal Link was not overly concerned, thinking it was just a sprain.When the family was getting ready to go to church near their home in Texas next morning, Collin said he could not walk. And on  Monday, a doctor told the Links that Collin had an injury which doctors used to think almost never occurred in children.

He had torn the anterior cruciate ligament, or A.C.L., in his left knee.  The A.C.L. is the main ligament that stabilizes the joint.

The standard and effective treatment for such an injury in adults is surgery, and it poses a greater risk for children and adolescents who have not finished growing.  The operation involves drilling into a growth plate, an area of still-developing tissue at the end of the leg bone.

Although there are no complete or official numbers, orthopedists at leading medical centers estimate that several thousand children and young adolescents are getting A.C.L. tears each year.  The number being diagnosed has been soaring recently.

Centers that used to see only a few such cases a year are now seeing several each week.

The old belief that boys are more prone to the injury than girls has been disproved:  as many as eight times more girls than boys are suffering the tears, doctors report.

This is not an overuse injury from playing one sport too intensively, like shoulder injuries in young pitchers.  Instead, doctors say, the injury occurs simply from twisting the knee. 

Diagnoses are on the rise — partly because it can now be easily detected.  But also, partly because the very nature of youth sports has changed.

Dr. Theodore J. Ganley, director of sports medicine at the Children’s Hospital of Philadelphia and a spokesman for the American Academy of Orthopedic Surgeons, says that in the old days a child would develop a “trick knee”, making  sports difficult.   But the real reason was not understood.  Most doctors — thinking children did not get A.C.L. tears —  did not suspect the real reason.

These days almost every child with a hurt knee gets a magnetic resonance imaging.  Doctors are finding the ligament tears on a regular basis.

The other reason for the reported surge in A.C.L. tears, doctors speculate, is that the best athletes are more or less constantly at risk.

Kids play year-round and on multiple teams with frequent games of high intensity.  The risk of injury is higher than it is in in practice exercises because of the intensity of play.

“The kids are playing at really highly competitive levels at earlier and earlier ages,” says Dr Mininder Kocher, the associate director of the division of sports medicine at Children’s Hospital in Boston.

The increase in diagnoses — whatever the reason — has created a new problem: what to do about the injury.

Every orthopedist is familiar with A.C.L. tears in adults. It is “the most common and most dreaded injury in professional sports,” Dr. Kocher said.

The well-established operation to repair it often results in a full return to function. And doctors often recommend that adults have the operation because without the ligament, the knee is not stable.

Any sport that can twist the knee (soccer or basketball) is dangerous after such a tear. Without an anterior cruciate ligament, even everyday activities can injure the smooth, shock-absorbing cartilage that caps the knee joint.

And then you’re headed for arthritis, says Kocher.

The Danger of the Surgery for Children 

With its drilling into the growth plate, the standard A.C.L. repair operation may cause permanent damage to the still-growing bones of young children.

After drilling, surgeons replace the torn ligament with a tendon ( like the hamstring) taken from elsewhere in the body or from a cadaver. But if the drilling damages a child’s growth plate, the leg bone will not develop normally.

Dr. Freddie H. Fu, an orthopedic surgeon at the University of Pittsburgh, saw this happen with a 14-year-old boy recently referred to him. A year after the operation, the leg with the repair was bowed 20 degrees on one side.  It was also shorter than the other leg.

“I had to go in on the other side and stop the growth,” Dr. Fu said. “Now, about six months later, the leg is still crooked. There still is a two-inch difference in length which I have to fix.” The boy, he said, “will be a little bit shorter” as a result, although both legs will be the same length.

Doctors often suggest putting a brace on the injured knee and limiting a child’s activities in order to delay surgery until the child finishes growing.

But the children who tear A.C.L.’s tend to be highly competitive athletes, not occasional game players.  They chafe under the restrictions.

Parents of young soccer stars often want them to keep playing, says Ashley Hammond, owner of Soccer Domain, a facility in New Jersey.   In addition, these  children were the type who would forget to wear a brace — or resist instructions — putting their knees at risk.

“All kids feel they are indestructible,” Mr. Hammond said. “The kids want to play no matter what we say.”

And so the result can be injury to their knee cartilage, and the attendant risk of arthritis in young adulthood.

Some surgeons are developing new and technically demanding methods to repair A.C.L. tears in children.  They drill holes to create little tunnels in bone that is already finished growing and thread tendons around the growth plate.

Different surgeons have different versions of the technique, Dr. Ganley said.

But then the tendons are not anchored where they would normally be.  The long-term effects of the operation are not known.

Dr. Kocher has studied 59 young patients and has perhaps the most extensive data.  His results are encouraging; the implanted ligaments failed in only two patients and no patients had severe growth abnormalities.  However, the patients have been followed less than four years.

The long-term results, 20, 30 years out are not known.  Are these children  going to end up with arthritis? Some doctors feel there’s a chance of that, but others believe that surgery lessens the chance.

It is because of the new increase in diagnosed A.C.L. tears in children, orthopedists say, that they discovered how mistaken they once were about this injury.

Doctors used to think that such tears did not occur, or that they were extremely rare in children because children’s ligaments were stronger than their bones.

 They thought an injury that would rip an adult’s A.C.L. would, in children, instead result in a broken bone.

A second myth is that A.C.L. tears arise mostly in contact injuries  (a tackle in football) and that they almost exclusively affect boys.  It now appears that girls are more susceptible, although no one really knows why.

Doctors have also learned that contact injuries are not the most common cause of A.C.L. injuries. Rather, tears occur more often from twisting and jumping. A child can be running and step in a hole, twisting a leg. They can fall off a bike.  A young athlete might tear an A.C.L. by coming down from a rebound in basketball, or by accelerating and decelerating.

Now, with doctors looking for the injury and surgeons finding new ways to repair it without touching the growth plate, parents like the Links face difficult decisions.

Mrs. Link says the first orthopedist told her that Collin should wear a knee brace and wait to have the operation until he stopped growing, which could take five years or more.

“He told Collin he was completely out of sports — soccer, basketball, baseball and football,” Mrs. Link said. “They were his whole life. That was devastating to him.”

So they took Collin to Children’s Hospital in Dallas, where they saw another orthopedist. This doctor said he could operate on Collin; that he had operated on a few children with A.C.L. tears, using one of the new methods that could avoid the growth plate.

But first, he wanted to put a brace on Collin’s leg and see how he did before trying the surgery.

The Links finally traveled to Boston where Dr. Kocher operated on Collin.  It was the best of a bad set of choices.

In addition, the surgery and its aftermath were more difficult than they anticipated.  Collin, in intense pain and on a morphine drip after the operation, then spent much of the next six weeks lying down.  His leg was in a machine that moved his knee slowly through a range of motions.

That was followed by six months of physical therapy, which was often painful and always physically and emotionally difficult, relates Mrs. Link.

Mrs. Link said that having the operation was a difficult decision to make. “But if they can play sports, it’s the only option.”

A year after the operation, Collin is now starting to play a nontackle form of football.  He is worried about injury if he played regular football and got tackled again.

And he is running track.

sole source: article by Gina Kolata in the NY Times on 2/18/08.  www.nytimes.com

tutoring in Columbus OH:   Adrienne Edwards   614-579-6021   or email  aedwardstutor@columbus.rr.com

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