Athletic participation by children and adolescents leads to an estimated 3 million emergency department visits in the United States each year, with pediatric orthopeadists seeing increasing numbers of patients for injuries such as dislocations and ligament tears, types previously more common in adults.
However, disagreement continues over proper management of adolescent and pediatric cases based on concerns about growth-plate development and high rates of follow-up injury, especially in younger patients.
Seeking to establish guidelines for best practices, Kevin Dale, M.D., a pediatric orthopaedic surgeon at Monroe Carell Jr. Children’s Hospital at Vanderbilt, reviewed outcomes of patients following treatment and post-surgical rehabilitation regimens, including increased restrictions on resumption of athletic activities.
“We try to tell these high school athletes who dislocate their shoulder to do rehab and they will be fine, but we also know when they go back to their activities, they will have a greater risk for secondary dislocation,” Dale said.
“In the shoulder, the labrum acts as a suction cup to keep it in place. If that doesn’t heal like it is supposed to, and then someone tackles them on the field, the shoulder suffers more damage.”
In a 2017 study, he and colleagues found that a third of all young patients treated for anterior cruciate ligament (ACL) injuries would incur a second ACL tear or graft rupture, and that a swift return to athletic activities is the best predictor of a secondary ACL injury.
Surgically repaired labrum injuries are similar. ACL injuries without surgery also require young athletes to wear braces and take more time off from their sport.
The potential impact on growth plates, which remain active in males through age 16 and females through age 14, has been considered a reason to defer surgery for children and younger adolescents.
Orthopaedic surgeons must work around the physis of the distal femur and the proximal tibia to preserve natural growth of bones and cartilage.
“In the past, we didn’t do surgery on younger kids because of concern that it might impact the growth plates,” Dale said.
“We’ve found that kids are not able to effectively modify their activities or consistently wear a brace, making them vulnerable to subsequent meniscus tears or other injuries,” he said.
“Now, we can do it in a way to avoid drilling through the growth plates.”
One new surgical approach shown to be successful in even prepubescent children uses iliotibial band autograft and avoids tunnel reaming.
“In really young kids, less than 10 years old with a lot of growth remaining, this new surgery to wrap the iliotibial band through the knee to recreate the ACL can be a great option,” Dale explained.
In shoulder surgery, arthroscopic techniques are used, when possible, to remove damaged tissue and reanchor the labrum onto the bone. Smaller incisions and, when needed, either allograph or autograph bone grafts have proven successful, Dale said.
Conducting surgery more swiftly after injury also has provided positive results.
“We want to do shoulder surgery quicker, after the first or second incident, to repair soft tissues or, when it does involve the bone and cartilage, to do open surgery. The longer we wait to do surgery, the higher chance of recurrent shoulder instability even after surgery.”
Risks of the Game
Key to the long recovery period are the risks inherent in engaging in athletic activity, particularly following a significant injury.
Females have higher risks due to differences in bone alignment that create a tendency to land with knees pointed inward, as well as some differences in collagen makeup.
Regardless of age, anyone who undergoes ACL reconstruction has approximately a 5 percent chance of tearing the graph after surgery, according to Dale.
For patients below the age of 18, the risk jumps to 30 percent for ACL reconstructions. The risk of recurrent instability after shoulder surgery is also 20 percent. What’s more, younger patients also incur a 10 percent higher likelihood of sustaining an injury in a previously uninjured limb.
Measuring the length of a patient’s recuperation time after orthopaedic surgery remains highly predictive of the risk of future injury, the surgeon emphasized.