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A New Approach in ACL Reconstruction Helps to Reduce Re-injury in High Risk Population

A New Approach in ACL Reconstruction Helps to Reduce Re-injury in High Risk Population

by | Nov 27, 2019 | Sports Medicine

Recently, Assistant Chief of Staff Philip L. Wilson, M.D., and pediatric orthopedic surgeon Henry B. Ellis, M.D., published a novel technique for treating an anterior cruciate ligament (ACL) injury. 

Too many young and growing athletes who have an ACL injury and reconstruction reinjure the same leg or have a new injury in the opposite leg within two years of the initial reconstruction. In fact, the rate of re-injury can be as high as one out of every four (25%). “Young children and adolescents are the most challenging to treat after an ACL injury because their growth plates are still open,” says Wilson. “Because of this and their commitment to returning to a high level of activity, they require special techniques to both allow continued growth and give them the best chance of not re-tearing.” 

Since 2012, our team has been studying the results of a unique approach for this surgery. Our experts have combined a surgery intended for younger children (less than 12 years old) with a commonly used procedure for an older child. This approach has resulted in a reduced rate of re-injury to approximately 5% compared to 25%.

While allowing for uninterrupted function of the growth plates, the technique provides additional support when compared to other treatments for this rapidly growing population. The technique adds both additional lateral knee support as well as added ACL graft size, both of which have been demonstrated to reduce the risk of ACL reinjury. The reduced rate of secondary ACL injury in the study are less than half of any other reported results in a similar group. In many cases, ACL injuries take very young athletes out of play for a year. This important step in reducing the risk of secondary injury helps to ensure that athletes can stay active once they are cleared to return. 

“This surgical technique is very promising,” says Ellis. “As an institution committed to innovation, we are proud of the work that has gone into this project. It is rewarding to help athletes get them back to doing what they love and know that they have a much lower risk of re-injury.”

This research study was presented at the 2019 annual meetings of two prestigious organizations: Pediatric Orthopedic Society of North America and the American Orthopedic Society of Sports Medicine. The manuscript has also published in a highly rated, peer-reviewed journal American Journal of Sports Medicine. The data include outcomes from this procedure in almost 60 athletes (age 11-16 years) collected over a five-year period. The combined TPH/ITB technique has a low re-injury rate (5.3%) and high return to sport rate (91%) and a low risk of minor growth-related changes (5.5%).

Learn more about the ongoing research in the Center for Excellence in Sports Medicine.

Physician Leadership: As health care moves to value, more leaders going to PROMs

Physician Leadership: As health care moves to value, more leaders going to PROMs

by | Apr 17, 2019 | General News, Press Coverage

Patient-reported outcome measures (PROM), which are stored in the clinical record, help physicians optimize treatment. These surveys can shed light on important factors following treatment, such as how the patient feels about their quality of life after treatment and whether everyday activities have improved.

Henry B. Ellis, M.D., a pediatric orthopedic surgeon at Scottish Rite Hospital, recently spoke with the American Association for Physician Leadership about the use of PROMs and how they help him and his team.

“PROMs really help us quantify the results of our treatment,” Ellis says. “And it will quantify their activity level following their treatment as well.”

Read the full story here.

Adolescent Idiopathic Scoliosis

Adolescent Idiopathic Scoliosis

by | Jun 18, 2018 | Scoliosis & Spine

Article originally published by staff orthopedist Amy L. McIntosh, M.D., in first quarter, 2018 issue of Pediatric Society of Greater Dallas newsletter. 
What is scoliosis?
Scoliosis is a rotation in the spinal column that creates a “C”-shaped single curve or an “S”-shaped double curve, when viewed from behind (Figure 1). Some cases worsen with time and can result in serious problems such as abnormal appearance in posture, increasing back pain as one ages, and in the worst cases, interference with heart and lung function. Idiopathic (no underlying cause) scoliosis occurs in 2 to 3% of the adolescent population, usually affecting young people between the ages of 10 to 16. Scoliosis onset is usually earlier in girls than in boys—generally, ages 10 to 14 for girls and 12 to 16 for boys.


Figure 1

When should I screen patients for adolescent idiopathic scoliosis (AIS)?
Scoliosis screening is designed to identify adolescents with abnormal spinal curvature. Screening can detect scoliosis at an early stage, when the curve is mild. Most curves can be treated without surgery if detected before becoming too severe. Therefore, early detection is the key to controlling spinal deformities. Ideally, spinal screening should be conducted as a part of the annual examination for females at age 10 and 12 years, and males once at age 13 or 14 years. Signs to watch for include (see Figure 2):

  • One shoulder higher than the other. One shoulder blade higher or more prominent than the other
  • One hip higher than the other.
  • Space between arms and body greater on one side.
  • Leaning to one side.
  • Head not centered directly above the pelvis.
  • When bending forward, thoracic rib prominence or lumbar fullness that is asymmetric to the opposite side. (+ Adams forward bend test) (Figure 3)​

If any of these signs are present, then the child should be referred to a pediatric orthopedic surgeon. Texas Scottish Rite Hospital for Children has a low dose X-ray machine (EOS) that obtains high quality images with significantly less radiation exposure to the patient. For that reason, please do not obtain X-rays. Just refer the patient if clinical signs of scoliosis are apparent on physical exam. The orthopedic surgeon will obtain standing, full length (posterior-anterior and lateral) spine X-rays to measure the cobb angle in both the frontal and sagittal planes. The Cobb angle measurement and the skeletal maturity of the child will determine the treatment.
What are the treatment options for AIS?
Observation:
Routine rescreening or observation by the physician is a form of treatment for mild curves (11-20 degrees). This observation period consists of regular clinical exams and spine X-rays throughout the rapid growth years of adolescence until the spine is mature. It is important to note that more than 90 percent of patients with scoliosis require no treatment other than observation. 

Brace: 
For curves greater than 20 degrees in patients that are still growing rapidly, a brace is prescribed. The brace can prevent the curve from progressing and may eliminate the need for spinal surgery. However, the brace cannot correct the curve that already exists. Bracing is generally recommended for curves between 20 to 40 degrees in adolescent patients with significant growth remaining. The main factor in achieving a high rate of bracing success is the number of hours a day that the brace is worn. Various spinal orthoses are available, with the most common being a Thoracolumbo Sacral Orthosis (TLSO). The TLSO is named by the areas it is designed to stabilize: the thoracic, lumbar and sacral parts of the spine. It is cosmetically acceptable as it can be covered well by clothing. Wearing a brace is not an easy treatment for an adolescent. Even covered by clothing, it is hot, hard and can make the student feel self-conscious. Getting into a daily routine of wearing the brace while participating in activities helps with compliance, which is key to successful treatment.

Surgery: 
Some patients present with severe spinal deformity, and other patients scoliosis worsens despite compliant brace wear.  In these specific patients, surgery can reduce a portion of the curve and prevent it from increasing in the future. Usually, surgery is reserved for adolescents and pre-adolescents who already have a curve of 45 to 50 degrees or more. The most common surgical procedure is a posterior spinal fusion with instrumentation and bone graft.

This type of surgery involves attaching rods to the spinal column to help straighten it. The bone graft between the affected vertebrae encourages fusion to prevent further progression of the curve. Instrumentation refers to the various rods, screws, hooks or wires that are used to hold the spine in the corrected position while the bone fusion occurs. The instrumentation is rarely removed. Following surgery, the fused section is no longer flexible. The average hospital stay is about two to three days, and the student can usually return to school in approximately four weeks. During the first six months after surgery, some limits will be placed on strenuous physical activity. After this healing phase, the surgeon will usually release the patient for all activities, including competitive, low-contact sports.
Does physical therapy help treat scoliosis?
The Schroth method is a nonsurgical option for scoliosis treatment. It uses exercises customized for each patient to return the curved spine to a more natural position. The goal of Schroth exercises is to de-rotate, elongate and stabilize the spine in a three-dimensional plane. This is achieved through physical therapy that focuses on:

  • Restoring muscular symmetry and alignment of posture
  • Breathing into the concave side of the body
  • Teaching you to be aware of your posture

This approach to scoliosis treatment was developed by Katharina Schroth and further popularized by her daughter Christa. Born in Germany in the late 1800s, Katharina Schroth had scoliosis that was unsuccessfully treated with bracing. She developed her own breathing technique and exercises to manage her scoliosis. She and her daughter opened a clinic, where they treated more than 150 patients at a time.
A Schroth-trained physical therapist or specialist should guide you in learning this program. The duration of this treatment varies and the patient is expected to continue exercises at home to keep scoliosis in check.

Scottish Rite Hospital is currently investigating the use of Schroth physical therapy alone and combined with brace treatment for patients with mild scoliotic curves.

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