Physeal sparing distal radio-ulnar joint ligament reconstruction in children

Background: Return to sports (RTS) is often the primary concern of patients following anterior cruciate ligament reconstruction (ACLR). Unfortunately, RTS at the preinjury level is not commonplace in pediatric patients despite advances in rehabilitation and measures of recovery, and second injury rates are highest among the young adolescent population. RTS criteria have become more rigorous in recent years. The impact of these new RTS assessments (RTSA) is still unfolding, and their application in a mixed pediatric and adolescent population is unclear. Purpose: To assess whether adolescent patients who undergo standard ACLR pass a rigorous RTSA sooner than those undergoing pediatric ACLR. Methods: This study was a retrospective chart review of patients ages >5 and <18 with primary, unilateral ACL tear who underwent ACLR from January 2017 to December 2019. Subjects were identified using current procedural terminology codes from the hospital electronic medical record then grouped based on ACL reconstruction technique: Adolescent (transphyseal approach) and Pediatric (complete or partial physeal-sparing approach). All subjects underwent a rigorous and standardized RTSA used by the operating surgeons to guide clearance to RTS. The primary outcome measure was post-operative time to clearance for RTS, with secondary analyses controlling for sex, concomitant pathology at the time of ACLR, number of RTSAs prior to clearance, and physical therapy provider. Parametric and nonparametric statistical comparisons were respectively performed via unpaired Student t-tests and Mann-Whitney U tests (p<0.05). Results: Of 426 identified ACLR patients, 97 (84 Adolescent, 13 Pediatric) met the inclusion criteria for the final analysis (39 M, 58 F; Adolescent mean age 16.44 ± 1.7 years, Pediatric mean age 13.21 ± 1.4 years). There were no significant differences in gender distribution or concomitant pathology between the groups. Median post-operative time to clearance for RTS was 12.2 months in the Pediatric group (95% CI: 10.9-12.7) and 9.3 months in the Adolescent group (95% CI: 8.9-9.8) (p<0.001). This difference in time to RTS between groups remained statistically significant after adjusting for the secondary variables described above (all p≤0.002). Conclusions: When applying a rigorous and standardized RTSA to determine readiness for RTS, Pediatric subjects who underwent a partial or complete physeal-sparing technique took nearly 3 months longer to be cleared than Adolescent subjects who underwent a standard transphyseal approach. Notably, Adolescent subjects averaged more than 9 months of rehabilitation prior to RTS. These findings help inform patient expectations for a safe recovery period following ACLR.

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Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of Transphyseal Versus Physeal-Sparing Techniques

The American Journal of Sports Medicine ◽

10.1177/0363546516638079 ◽

2016 ◽

Vol 45 (2) ◽

pp. 488-494 ◽

Cited By ~ 34

Author(s):

Todd P. Pierce ◽

Kimona Issa ◽

Anthony Festa ◽

Anthony J. Scillia ◽

Vincent K. McInerney

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Leg Length ◽

Cruciate Ligament Reconstruction ◽

Growth Disturbances ◽

Anterior Cruciate ◽

Physeal Sparing ◽

Angular Deformities

Background: Anterior cruciate ligament reconstruction is becoming more common in skeletally immature individuals, and it may be performed with transphyseal or physeal-sparing techniques. A number of studies have assessed the outcomes of these techniques, but there is a need to systematically evaluate the pooled data from these studies. Purpose: To compare the differences in demographics and outcomes of transphyseal and physeal-sparing techniques by assessing (1) demographics, (2) incidence of growth disturbances, and (3) graft survivorship in the pediatric population. Study Design: Systematic review. Methods: A thorough review of 3 databases was performed to identify all studies that evaluated outcomes after pediatric reconstruction based on transphyseal or physeal-sparing techniques. After completing our search and cross-referencing for additional sources, 43 reports were identified for this review. Reports were analyzed for differences in demographics as well as incidence of leg-length discrepancies, angular deformities, and graft survivorship. After review of manuscripts, 27 studies were included for review (21 transphyseal and 6 physeal-sparing studies). Results: Those who had transphyseal reconstruction were more likely to be female (39% vs 20%; P = .0001), while those with the physeal-sparing surgery were younger (12 vs 13.5 years of age; P = .0001). The transphyseal and physeal-sparing cohorts demonstrated similar incidence rates of leg-length discrepancies (0.81% vs 1.2%, respectively; P = .64) and angular deformities (0.61% vs 0%, respectively; P = .36). The transphyseal and physeal-sparing cohorts also showed similar rates of rerupture (6.2% vs 3.1%, respectively; P = .11). Conclusion: Although the study groups were not well matched with regard to age and sex, our results show that these surgical techniques have no differences in incidence of growth disturbances or graft survivorship. Younger males tend to undergo physeal-sparing reconstruction. Future research should focus on long-term outcome metrics with the physeal-sparing techniques, as there remains a paucity of studies regarding them.

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