Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Abstract

Background:Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.Purpose:To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.Study Design:Systematic review; Level of evidence, 4.Methods:All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.Results:Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.Conclusion:Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Outcome Measures After ACL Injury in Pediatric Patients: A Scoping Review

“…53 Furthermore, a 2017 review on reporting trends in youth ACL reconstructions found diverse definitions of skeletal maturity, inconsistently reported objective outcome measures, and the use of patient-reported outcome measures (PROMs) that were developed and validated for adults. 10 Inconsistent and nonstandardized outcome reporting reduces the possibility of comparing and interpreting results across different studies. It is unknown if the high variability in outcome measures seen in adults and adolescents is present in the literature on pediatric ACL injuries.…”

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

“…The lack of high-quality evidence in studies identified in the present systematic review is consistent with prior investigations into the literature concerning pediatric and adult ACL reconstruction. 13 , 114 The vast majority of studies were conducted retrospectively, which constrains the data available for analysis and precludes use of newer PROMs, which have greater applicability to pediatric populations. It is important to consider that many studies were conducted prior to the development of survey instruments validated in pediatric populations.…”

“…However, a recent study evaluating the pediatric ACL literature from 2010 to 2016 in a limited number of journals demonstrated significant heterogeneity in clinical outcomes reporting, consistent with the findings of the current review. 13 …”

“… 9 , 10 , 11 Several recent studies have focused on the utility of such outcome measures in pediatric sports medicine. 12 , 13 , 14 To date, the plethora of reported outcome measures raises concern that data heterogeneity across the literature may impede meaningful data pooling that allows researchers to draw conclusions and to guide clinical practice. 13 Moreover, outcome measures must be validated in the patient populations of interest in order to ensure the accuracy and validity of information being collected, a challenge when studying children and adolescents.…”

Editorial Commentary: We PROMIS…One More Patient-Reported Outcome Questionnaire!

“…Third, we need to understand how to apply the pediatric PROMIS domains to our pediatric and adolescent patients, especially in sports medicine that has very few age-appropriate PROMs despite experiencing a large increase in the incidence of youth sports injuries and treatment methods. [17][18][19][20][21][22] Finally, we need to work with our institutions and specialty societies to guide the conversation around how these data will be used by the government and thirdparty payers. As PROMs such as PROMIS become linked to reimbursement, we as a profession want a seat at the table as these policies are being created.…”