A Promising New Technique for a Season-Ending Injury

Michael Siroty knew something was wrong when he heard a pop.

As the team’s pitcher, he had just chucked the ball toward the catcher’s mitt. His right hand lurched forward, his left leg kicked out, the ball rolled off his fingers, just like in practice. Except this time, there was the dreaded noise—and the pain shooting down his leg.

Afterward, Michael told his dad, David, that he probably hurt his hamstring. Aching but unconcerned, he went on to play a soccer game that afternoon.

In fact, the Siroty family didn’t give the injury much thought until the next day, when Michael’s knee ballooned and he couldn’t fully extend his leg. Imaging showed a tear in his meniscus and a torn anterior cruciate ligament (ACL). Doctors at the Hospital for Special Surgery Lerner Children’s Pavilion said Michael would need two surgeries and 12 months of recovery time before he could play ball again.

He was nine years old.

Knee Injuries on the Rise

Once the concern of professional athletes, ACL injuries are becoming surprisingly common-place in high-performing young athletes like Michael. According to a study by HSS researchers, there’s an “epidemic” of ACL injuries among tweens and teens, especially those who play sports that require cutting and pivoting, like soccer, basketball, football, skiing and lacrosse.

Experts chalk up the rise to children and teenagers starting sports at a younger age and playing for longer periods of time and with greater intensity. They also found that kids who play only one sport year-round overtax the same group of muscles and ligaments, as opposed to kids who cross train by playing a variety of sports.

But perhaps even more troubling is the likelihood that young athletes will require a second knee surgery down the line. In the same study, researchers discovered that eight percent of patients with a primary ACL reconstruction had another ACL surgery either on the same or opposite knee. Fourteen percent had a second non-ACL knee surgery in that same time frame. Meanwhile, researchers warn that those numbers may not offer a complete picture, as the data they analyzed didn’t include patients who opted not to have a second surgery.

A New Technique Just for Young Athletes

Reconstructing a child’s torn or ruptured ACL is tricky business. Typically, in adults, a surgeon will remove the torn ligament from the knee, drill holes through the ends of the thighbone and shinbone, and insert a tissue graft in place of the removed ligament.

But that approach won’t work in young patients, because it would involve crossing the graft over the growth plate—something doctors are hesitant to do because of the potential damage it could cause. (Think limbs of uneven lengths or angular deformities.)

Now, young athletes have more options, thanks to Frank Cordasco, MD, member of the Sports Medicine Service at HSS, and Daniel Green, MD, a pediatric orthopedic surgeon at the HSS Lerner Children’s Pavilion. The doctors pioneered a technique, called All-Inside, All-Epiphyseal ACL Reconstruction (AE), which restores knee stability and preserves the growth plate.

It’s a technically demanding, complex procedure that’s been refined over the last 10 years and is performed at only a handful of hospitals, including HSS Lerner Children’s Pavilion. Moreover, its success rate underscores the importance of seeing a specialist with expertise in this area.

Practically speaking, AE is similar to an adult reconstruction, except here the ligament is only attached to the rounded ends of the thighbone and shinbone and does not cross into the growth plate. But, Dr. Green stresses, all treatment is individualized for growth spurts and age.

The Choice to Have Surgery

In Michael’s case, the Siroty family had already done their own research and knew that there were a few viable options. “We also knew that there aren’t many kids younger than Michael who have undergone the surgery,” mom Jill says. “He was 62 pounds and nine years old.”

Still, the family was confident in the surgeons’ plan. “We were putting our faith in Dr. Green and Dr. Cordasco,” she says. “There’s not a lot of literature on ACL tears in children, but ironically, their names came up on any that we could find.”

To allay any fears or concerns, the team sent Michael home with a folder of information detailing what happens during a pediatric surgery at the hospital, including a DVD that showed him what the various rooms looked like. On the morning of his surgery, in November, he chose to walk into the operating room carrying his own IV bag, smiling ear to ear.

The Long Road to Recovery

The AE procedure went off without a hitch, though rehab would be long and arduous. Michael started physical therapy near his Westfield, N.J. home five days after surgery and continued going through the fall. The normally active nine-year-old wore a locked knee brace 24/7 for two months, then spent three months on crutches. To avoid reinjury, doctors advised him to stay inside during recess and sit out the entire season of basketball.

Still, Jill says the good has far outweighed the bad, starting with the family’s time at HSS Lerner Children’s Pavilion. “I have to say, our experience at HSS has been amazing,” she adds. “The inpatient experience was so great, and Dr. Green is so kind. After the surgery, he kept coming in and checking on Michael himself. He even gave me his cell phone number, just in case. The nurses were so great, too. In fact, every time we go back to see Dr. Green, we stop by to say ‘Hi’ to the nurse who took care of him.”

It also helped that Michael found ways to make the most of his recovery time. As soon as he was out of crutches, he started shooting hoops while his dad rebounded the ball. He attended basketball practices and games, even though he wasn’t allowed to play. (During the final seconds of the last game of the season, his coach asked him take the final shot, so long as the rest of the players agreed not to go anywhere near him.) In May, he was finally able to join his friends outside during recess.

That said, Michael isn’t out of the woods—yet. “He’s still not 100 percent pain-free,” Jill says. “He still goes to physical therapy twice a week. He can run and jump. He shoots baskets in the driveway, but he can’t play in a game. But at the end of September, they’ll have travel basketball tryouts again. Our hope is to get him well enough so that he can try out again. The season starts in November. That’s been our plan all along.”