The Risk of Transphyseal Drilling in Skeletally Immature Patients With Anterior Cruciate Ligament Injury

Faunø, Peter; Rømer, Lone; Nielsen, Torsten Grønbech; Lind, Martin

doi:10.1177/2325967116664685

Cited by 30 publications

(34 citation statements)

References 35 publications

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“…14 Iatrogenic physeal damage during ACL reconstruction remains a concern, as the risk for growth arrest and resultant angular and length deformities after an intraoperative physeal injury has been well documented. 6,13,26,34 Because of this risk, several new techniques for ACL reconstruction in the pediatric and adolescent populations have emerged. 1,5,12,15 Although controversy remains about the optimal treatment of pediatric and adolescent ACL injuries, there is consensus emerging that surgical reconstruction is superior to nonoperative treatment in active patients.…”

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confidence: 99%

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Shea

Burlile

Richmond

et al. 2019

Orthopaedic Journal of Sports Medicine

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Background:The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest.Purpose:To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest.Study Design:Descriptive epidemiology study.Methods:Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT.Results:The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella.Conclusion:The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex.

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confidence: 99%

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Shea

Burlile

Richmond

et al. 2019

Orthopaedic Journal of Sports Medicine

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“…Additionally, despite its history of good to excellent results, more recent data have called into question the safety of transphyseal drilling for patients 2 to 3 years away from achieving skeletal maturity. In a recent study by Fauno et al, 15 24% of patients who underwent transphyseal ACLR experienced either a compensated growth disturbance or leg-length discrepancy of ≥10 mm. Several other studies and reviews have reported premature physeal closure, angular deformities, and leg-length discrepancies with transphyseal ACLR.…”

Section: Discussionmentioning

confidence: 94%

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Willson

Kostyun

Milewski

et al. 2018

Orthopaedic Journal of Sports Medicine

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Background:Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.Purpose:To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.Study Design:Case series; Level of evidence, 4.Methods:Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.Results:Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.Conclusion:The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

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“…Seventy-seven articles reporting the clinical outcomes of pediatric and adolescent patients undergoing ACL reconstruction were analyzed. 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 ,…”

Section: Resultsmentioning

confidence: 99%

Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

Fabricant

Brusalis

Schachne

et al. 2020

Arthroscopy, Sports Medicine, and Rehabilitation

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Purpose To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger. Methods A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded. Results We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies. Conclusions There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently. Clinical Relevance A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

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The Risk of Transphyseal Drilling in Skeletally Immature Patients With Anterior Cruciate Ligament Injury

Cited by 30 publications

References 35 publications

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

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