ENGR0011 Section Bursic, 2:00
Group #L10
DISCREPENCIES IN ACL RECONSTRUCTION IN CHILDREN WITH
IMMATURE GROWTH PLATES AND ITS ECONOMIC EFFECT
Kyle Berkow (KAB259@pitt.edu)
THE HUMAN KNEE AND INJURIES TO
THE ACL
What Are The Problems With ACL Reconstruction?
As a freshman majoring in biomedical engineering with
a passion for athleticism and movement, one topic that
shows opportunity for plenty of advancement in the future is
the recovery from sports related injuries. Currently, I am
volunteering at Dr. Richard Debski’s Shoulder and Knee
Dynamics Lab. This lab does studies in relation to injuries
that occur both in the shoulder and the knee, allowing them
to consult with doctors and other professionals in order to
advance surgical procedures as well as day to day care.
One study that has sparked my attention is the many
ways of rebuilding or engineering a new ACL. Orthopedic
surgeons currently have a method of doing this, yet it is not
practical for the younger population of injured athletes. The
debate with this issue is simply the argument of whether or
not time and money should be spent to develop new methods
of engineering a new ACL and to then educate doctors in
these new advancements. The reasoning against the
development of a new process is that it will be costly, will
require time taken away from these practicing doctor’s
already overloaded schedules, and will develop arguments of
ethical uses over stem cell research. Still, time and money
should be spent towards allowing patients to receive the
most modern advancements in surgeries, which will
decrease reoccurring injury and benefit our society in
healthcare costs.
Personally, I see that the longer the time spent recovering
from an injury, the harder it becomes for all athletes and
individuals to return back to their normal way of life.
Simply speaking, new advancements in recovery from
surgeries caused by injuries to young athletes will allow a
quicker return to the sport along with the relief that such
injury will be less likely to occur.
Anatomy of the Knee
The knee consists of bones, tendons, ligaments, and
cartilage, all of which connect to stabilize our motion in the
knee. The femur, tibia, and patella are the bones that make
up the knee structure; these bones are held stable by the
medial collateral (MCL), lateral collateral (LCL), posterior
cruciate (PCL), and anterior cruciate (ACL) ligaments.
Cartilage sits between the femur and tibia, acting as a shock
University of Pittsburgh, Swanson School of Engineering
10/30/12
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absorber for the bones [1]. Together, these three structures
help us perform everyday physical activities.
The anterior cruciate ligament (ACL), which runs
diagonally between the femur and tibia, connects the femur
and the tibia, preventing movement out of alignment. The
ligament’s job is to prevent the tibia from going in front of
the femur, providing stability when rotating the knee during
arduous exercise and swift movements.
ACL Injuries
The most commonly injured ligament within the knee is
the ACL, amounting to hundreds of thousands of injuries
each year. The American Orthopedic Society for Sports
Medicine claims “about 150,000 ACL injuries occur in the
United States every year” [2]. Injuries to the ACL are
normally caused by a rapid or sudden change in direction, a
sudden stopping action, an incorrect landing from a jump, or
a direct contact or collision [3]. Injuries of change in motion
and mechanical movement account for about 70 percent of
ACL injuries [2]. ACL injuries are especially seen in sports
with rapid movements, such as soccer, basketball, and
hockey. ACL injuries are also seen in contact sports such as
football and rugby, which account for only 30 percent [2].
Although there is no rapid movement or contact, I am
currently focusing more on triathlon’s making both shoulder
and knee injuries for swimming and running a major interest
for myself. Also, studies have shown that females are more
prone to ACL injuries than men due to muscular
development, strength, and physical condition [3].
Signs and symptoms of ACL injuries are easily spotted.
When the ACL tears, a popping sound can usually be heard
as the knee gives out. A tear in the ACL literally causes the
ligament to split into two strands, which are then not strong
enough to keep the femur and tibia in place. This then will
cause extreme pain in everyday motions such as walking.
Alongside that, there is normally swelling, tenderness, and
loss of motion during an injury of this sort [3]. Based on the
severity of the tear, either reconstructive surgery or physical
therapy is advised. Even though I have not personally been
exposed to an ACL injury occur, I do know many peers who
have already torn this ligament and have required surgery.
Kyle Berkow
In addition, with the increase in activity, preventative
initiatives must be made more readily available. Exercises
and activity to prevent ACL injuries could potentially reduce
the number of ACL tears and also the economic impact.
Young athletes are usually unaware of the consequences of
limited strength and flexibility in certain parts of the body,
which cause these injuries. If the athletes are more
accustomed to preventative activities that will reduce these
risks, less injuries will occur. Together, a more stable
engineered ACL and preventative exercises will decrease the
risk of further injury, which will in turn promote lower costs
to the family and to the healthcare system as a whole.
ACL TEAR
The ACL above has completely torn into two pieces,
providing no stability [1]
ACL Injuries in Children and What Action We
Should Take
Treatment Options
Nonsurgical Treatment
Nowadays, children are more prone to injuries, shown by
the increase in ACL tears. While ACL tears used to be more
heavily concentrated in the 20-30s population, it has begun
to trickle down towards younger age groups. Coaches and
parents, by pushing for more strenuous training at younger
ages, have started to make all sports more and more
demanding for children. As both a swimmer and runner, I
am performing close to three or four hours a day. Firsthand,
I have seen that this push comes with greater risk, especially
with children who are underdeveloped physically. This is
key, as children have not reached skeletal maturity until “1213 [years of age for] girls and 14-15 [years of age for] boys”
[4]. It is during this period that they are experiencing the
same injuries as their adult counterparts.
Very few surgical options are available to children with
ACL injuries due to their immature growth plates, causing
higher risk for injury to the knee. New options for surgical
treatment are becoming readily available with advancements
in technology; however, this will take plenty of training for
the surgeons who are not accustomed with such methods.
These doctors need to become more knowledgeable with
other methods of treatment so that children may be treated
just as well as adults while also receiving the most advanced
method of treatment available. If these kids are not treated
with the most modern advancements in the field, they will
live without the best possible recovery. New advancements
are allowing for quicker recovery time and less of a chance
of a similar injury occurring. I have been injured in
numerous places ranging from my knee to my back, all
which have had some type of reoccurrence. Therefore,
giving these young athletes the peace of mind is more than
worth the time to train these doctors.
If the patient is older and does not wish to interact in
physical sports later on, a nonsurgical treatment is advised.
Usually, this method of treatment is recommended for elder
people with limited mobility to begin with, as surgery would
be unnecessarily difficult for a patient whose ligaments and
bones will only grow weaker after the injury. A knee brace
and physical therapy is a common form of nonsurgical
treatment in order to protect the knee’s stability as the ACL
would have done [1], [3].
Surgical Treatment
If the patient is young and wants to continue to be active
the rest of his life, reconstructive surgery is usually
recommended for an ACL injury. The process of an ACL
reconstruction is a rebuilding of the split ligament. The ACL
cannot be sewn back together because it has been proven to
tear again over time. Therefore, a new method has become
prevalent; doctors choose a location to take a piece of a
ligament from another location close to the knee and replace
the ACL [1].
The most common ligaments used to replace the ACL
are from the patellar tendon, hamstring tendon, and
quadriceps tendon. The graft can be taken from either the
injured patient or a cadaver, which is a donated portion of a
deceased body [1].
Yet, how do they replace the torn ligament? Surgeons
with drill holes into the growth plates on both sides of the
knee in a diagonal alignment and will fuse the tendon into
position. This process allows the new tendon to act as the
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Kyle Berkow
ACL does by limiting the tibia from repositioning in front of
the femur [1].
plate of a child, which can more than likely fracture the
growth plate, adding more pain than relief.
ACL TEARS IN CHILDREN WITH
IMMATURE GROWTH PLATES
ECONOMIC EFFECT OF ACL
RECONSTRUCTION AND PHYSICAL
THERAPY
Problems with Treatment Options for Children
The effect of so many injuries and surgeries plays a vital
part in our healthcare system. A reconstructive surgery can
be anywhere from $4800 to $5500 per surgery [6]. With the
number of ACL injuries close to 200,000 per year, billions
of dollars are being spent on surgery to repair ACLs. These
are only the costs for surgeries. Once a part of the body has
been injured, it is more prone to injury again. There is a
higher risk for those who have already torn their ACLs
before.
In addition to surgery, both adults and children must go
through a phase of physical therapy to work back to their
previous physical condition. Time and energy of our
healthcare professionals is spent leading these patients back
to normal lives. For a child, the choice is not clear. Either
way, our healthcare system will spend millions on the
continual care of these children injured at such a young age.
There is a solution to this increasing cost to our
healthcare system, one that could benefit not only the
children with ACL injuries. A new method of ACL
reconstruction has been found, but it requires slightly more
money and time devoted to the professionals in order to
learn a newer method. The introduction of this new method
of reconstruction is expensive in itself, yet it will be cost
efficient in the long run.
How will this new method be cost efficient? Compare
the new method of surgery to alternative energy sources.
The new method has been proven to allow quicker recovery
and a more stable ACL, yet it will be more time consuming
for the doctor’s to create and master. Our energy source has
mainly come from gasoline and oil, but our society could
benefit from alternative energy sources in the long run if an
investment cost is spent to start the process. Time and
money must be spent to better educate orthopedic surgeons
in this method of ACL reconstruction in order to minimalize
the recovery process and decrease healthcare costs for the
patient’s future.
In addition, the main goal of all engineers is to provide a
more economical way of reproducing a similar result. We
already have a method for ACL reconstruction, yet a better
method could replace it, which will be cheaper and cause
less recovery time. Therefore, research in this field and
Children are part of the category that do not fall into
either the surgical option or the nonsurgical option, creating
discrepancies in treatment choices. Children still wish to be
active later on in their own lifetime, making the procedure of
drilling through a child’s growth plates an unviable option.
Therefore, doctors argue whether they should recommend
surgery or should choose to go for a nonsurgical treatment
until the child reaches “skeletal maturity” [5].
Why is it recommended to wait until “skeletal maturity”?
The answer is that surgery requires drilling into the growth
plate of children, which can stunt growth by damaging these
plates [5]. Yet, recent research has shown that there is less
risk in damaging a growth plate than disregarding a torn
ACL altogether. The problem is clear: surgery will stunt
growth by drilling into the growth plates in the bone while
no treatment at all will cause permanent damage to the knee.
Damage caused at this young of an age will create health
issues in other parts of the body, leading to more surgeries
and extensive physical therapy. The disproportions in bone
growth will cause imbalanced walking. These young
children will be incapable of returning to normal physical
activity. I would be devastated to find out I am no longer
able to continue normal everyday physical activity if in this
position. In addition, each health risk adds to the society’s
increase in healthcare costs, which keeps rising every year.
Growth Plates
Growth plates are “the area at the end of long bones in
children and adolescents that allows the bones to grow” [4].
The “plate” refers to the cartilage cells that regenerate new
cells to make the bone longer [4]. These cells are necessary
to have normal bone growth. If the bone does not grow to
normal length, other injuries are more prone.
Injuries to the growth plate also have their own longterm effects. Any injury can cause the “separation of that
bone at the growth plate, fractures of the bone across the
growth plate, or crushing of the growth plate” [4]. ACL
reconstructive surgery drills a hole in the non-mature growth
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Kyle Berkow
education to orthopedic doctors will be beneficial physically
as well as economically.
[9]. Much can be done to reduce the healthcare cost to our
up and coming athletes of the future.
WHAT ARE THE MOST RECENT
ADVANCES IN ACL RECONSTRUCTION?
ETHICALLY, THESE DOCTORS
SHOULD PERFORM THESE TASKS
Sports Medicine doctors have created a more advanced
method to reconstruct a patient’s ACL. The earlier method
was to place a second “ligament” taken from a graft beside
the original torn ACL, adding greater stability. The problems
with this include the damage to the patient’s growth plates
and long recovery time. More recently, a modern method
called the “double bundle” repair can use a harvest of the
original ACL and place the new ligament in the “exact
center of the original position of the patients own ACL” [7].
Orthopedic surgeon Dr. John Vitolo claims that his patients
are experiencing less post-operative pain and are returning to
activities faster [8]. On the other hand, this new method
requires engineering a new strand of the original ligament,
which requires using stem cells, an extremely controversial
topic.
What needs to be done about this new method of
treatment? Doctors should be better educated about the new
treatment, which will take funding to advance their
education. Also, this new method can lead to more advanced
methods, creating room for more research to this type of
injury’s necessary recovery. A common injury such as ACL
tear should have more advancements than it already does.
Economically, this new method will benefit our system’s
healthcare needs as well. This new method has been said to
decrease the risk of developing arthritis later in life by
staying was from the bone’s growth plates [8]. The initial
push for better knowledge will not be cost efficient at first,
but it will create less health risks for the future, and
therefore, greater post-operative success.
As an engineer, another one of our goals is to perform
tasks to the best of our ability in order to help others,
whether it may be creating the ability for someone to walk or
creating a stable bridge for millions of cars to travel over
every year. We are held responsible for the “safety, health,
and welfare” of the public [10]. In the rebuilding process or
the engineering of a new ACL, these biomedical engineers
are held accountable for the health of each patient. That
means that if it is known that one method of surgery will
only provide relief for 10 to 15 years, but has a small
percentage of reoccurrence, then these engineers are still
putting each patient’s health at risk. It is true that “engineers
shall perform services only in the areas of their competence”
or “only when qualified by education or experience” [10].
Yet, I am promoting the education of such new methods to
these doctors in order to allow to best recovery possible
from such an injury. We, as humans, are limited by our
physical ability. I will never accept that a physical constraint
cannot be overcome in order to provide normal everyday
activity. Our society can always improve and make
advancements.
In my experience, the track someone takes does not
always seem to be the most appropriate, yet it happens to be
the most suitable based on financial and other influences.
For example, the most recent occurrence was the last high
school graduating class’s choice of where to attend college.
Some of the smartest and most talented students should have
attended the University of Pittsburgh and other highly
qualified four-year institutions such as the Ivy League
schools, yet their economic and familial influences did not
allow him or her to make such a choice. Similarly, these
doctors may very well agree with my opinion to promote
more research in this area and educate doctors, but in reality,
these doctors are not willing to give up their time or spend
the money to be better educated on such issues. I still stand
for these advancements because these initial investments
will provide less costly recovery from such injuries.
Therefore, our society should look ahead and take the risk of
spending and invest in our society’s future of the most
modern advancements.
Still further, our biomedical engineers are constrained by
their compliance with “legal, ethical, governmental, and
PREVENTATIVE CARE
With such a large number of injuries in one specific
field, young athletes should be educated on the methods of
preventative care for their knees. Most athletes are not very
well educated on the risks of a lack of stretching and
warming up. Considering 70 percent of ACL tears come
from noncontact movement, simple exercises could decrease
the number of patients each year, especially in young
children. Exercises in plyometrics, core stability, and
dynamic muscular control could possibly decrease the
number of injuries to young athletes will greater potential
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Kyle Berkow
other applicable research guidelines” when conducting
research for these advancements [11]. As stated previously,
the most modern method of ACL reconstruction, the “double
bundle” repair, which involves the use of stem cells and the
re-creation of already living cells. While many may call this
therapeautic cloning, others deny the sound logic in any sort
of cloning or reproduction in any cellular form. Yet, I can
still see plenty of advancement with the need to overstep any
boundaries of cloning or inappropriate use of stem cells
while reconstructing a torn ACL.
are selecting careers other than engineering”, which is most
often “attributed to low status and poor general perception
by the public for engineering” [12]. Students are often
discouraged to pursue certain careers because they are
unaware of what that career entails. By doing this project, I
can see exactly what type of research a biomedical engineer
is capable of doing, and I can decide whether this is in fact
the right field for me.
SO, WHAT SHOULD WE DO ABOUT
ACLS?
DOES OUR EDUCATION THUS FAR
RELATE TO THESE ISSUES?
Healthcare costs and costs of medical insurance are
rising tremendously over recent years. Our society can
benefit from greater care at lower costs to our hospitals and
insurance companies. More advanced surgical methods that
will reduce post-operative recovery time, as well as health
issues in the patient’s future, will come as a benefit to both
the patient and our economy. We must always strive to teach
our doctors the most efficient and effective way to treat
injured patients in order to create the greatest outcome. Time
and money must be spent furthering advancements in
surgery for ACL reconstruction as well as the education to
orthopedic surgeons in modern methods. It is our duty as
engineers and as students to help others with further
advancements through our research and education.
Furthermore, our young populations of athletes need to be
educated in the prevention of such injuries to reduce the risk.
Our economy will benefit as well as our health.
Over the last decade or so, the approach to education has
changed. No longer does good grades and a solid
background guarantee an engineer a job. Research, real life
experience, and extracurricular activities are becoming more
important as admissions workers struggle to differentiate
different applicants. Over the past year, I myself have seen
these pushes for well-roundedness when applying to colleges
and scholarships.
Within our education system, “education to improve our
future engineers is by no means new, but there is a new
found emphasis on research and other forms of scholarship
to inform engineering education activities” [12]. Very few
engineers at the University of Pittsburgh will finish all four
years without some application of his or her work, whether it
may be in getting an internship or doing research in his or
her field.
This project was worth our time and focus as freshman
engineers because our education as students depends on our
motivation. We were all encouraged to choose topics that we
have some interest in, which will then build drive and
motivation to learn more about these topics. Yet, I believe
that by researching this topic, while it opened our eyes to the
interests that we as engineers do enjoy, we are still not fully
able to understand the phenomena of the research and the
politics involved. I can research the advancements in ACL
reconstruction until I find all of the necessary information to
fully explain its processes, yet I do not know the anatomy
and physical constraints of the research, whether it may be
the political issues such as the controversy of stem cells, or
the inability for research labs to be funded due to the
economy.
Overall, this research was worth our time as a freshman
engineer because it also showed us what our future field has
to offer. It true that “in many nations, the brightest students
REFERENCES
[1] (2009). “ACL Injury: Does It Require Surgery?”
American Academy of Orthopaedic Surgeons. (Online
article). http://orthoinfo.aaos.org/topic.cfm?topic=A00297.
[2] E. Coleman. (2011). “Statistics On ACL Injuries In
Athletes.”
Livestrong.com.
(Online
article).
http://www.livestrong.com/article/548782-statistics-on-aclinjuries-in-athletes/.
[3] (2009). “Anterior Cruciate Ligament Injuries”. American
Academy of Orthopaedic Surgeons. (Online article).
http://orthoinfo.aaos.org/topic.cfm?topic=a00549.
[4] (2012). “Sports Medicine: Growth Plate Fractures.”
Childrens Medical Center Dallas, Texas. (Online article).
http://www.childrens.com/specialties/sports-medicine/whatwe-treat/growth-plate-fractures/.
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[5] J. Cluett. (2012). “Should My Child Have ACL
Surgery?” Orthopedics About.com. (Online article).
http://orthopedics.about.com/od/aclinjury/f/children.htm.
[6] S. Nagda, G. Altobelli, K. Bowdry, et al. (2009). “Cost
Analysis of Outpatient Anterior Cruciate Ligament
Reconstruction: Autograft versus Allograft.” National
Center for Biological Information. (Online article).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2853669/.
[7] A. Allen, D. Altchek, S. Rodeo. (2009). “ACL
Reconstruction: New Advances in ACL Surgery.” HSS
Sports
Medicine
Service.
(Online
Report).
http://www.hss.edu/conditions_acl-reconstruction-newadvances.asp.
[8] J. Vitolo. (2012). “Advances in ACL Surgery: Anatomic
Reconstruction.” Patch Network. (Online Report).
http://jefferson.patch.com/blog_posts/advances-in-aclsurgery-anatomic-reconstruction.
[9] L. Kramer. (2010). “Understanding and Preventing
Noncontact ACL Injuries.” Athletic Training and Sports
Health
Care.
(Online
Report).
http://www.healio.com/orthopedics/journals/ATSHC/%7B2
F894C3E-2B85-4D30-93747293CBBD4784%7D/Understanding-and-PreventingNoncontact-ACL-Injuries.
[10] (2012): “NSPE Code of Ethics for Engineers.” National
Society of Professional Engineers. (Online Article).
http://www.nspe.org/Ethics/CodeofEthics/index.html
[11] (2012): “Biomedical Engineering Society Code of
Ethics.” Biomedical Engineering Society. (Online Article).
http://www.bmes.org/aws/BMES/pt/sp/ethics
[12] M. Borrego, J. Bernhard. (2011): “The Emergence of
Engineering Education as an Internationally Connected Field
of Inquiry.” Journal of Engineering Education. (Print
Article). Vol. 100. No. 1. pp. 14-47
ACKNOWLEDGMENTS
I want to thank Beth Bateman Newborg for giving this
writing assignment, as it helped me focus on which aspects
of bioengineering I truly love and wish to pursue. I also
would like to thank Dr. Richard Debski for letting me
understand the anatomy of the knee and the issues involved
with such injuries.
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