Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis

Abstract

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non–English language manuscripts, multiligamentous injuries, and nonclinical studies. Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences ( P = .413) or proportion with difference ≥3 mm ( P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

Sensitivity and Specificity of MRI in Diagnosing Concomitant Meniscal Injuries With Pediatric and Adolescent Acute ACL Tears

“…This is important because of the propensity for new meniscal tears (especially on the medial side) to occur before surgery, a trend that has been described extensively in recent literature. 1 , 6 , 21 , 31 , 37 , 38 …”

Wide Variability of Pediatric Knee Arthroscopy Case Volume in Orthopaedic Surgery Residency

“…16 Similarly, ACL reconstruction within 12 weeks of injury is associated with a lower incidence of secondary meniscal injury and a higher rate of return to sports when compared to nonoperative management or delayed surgery. 17 Technical differences among adult and pediatric knee arthroscopy exist and serve as important aspects of arthroscopy education for orthpaedic residents. The pediatric knee joint is smaller in size and involves neighboring growth plates, requiring adapted techniques with miniaturized equipment.…”

“… 16 Similarly, ACL reconstruction within 12 weeks of injury is associated with a lower incidence of secondary meniscal injury and a higher rate of return to sports when compared to nonoperative management or delayed surgery. 17 …”

Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

“…Current practice has evolved to favor early surgery with good functional outcomes, decreased meniscal and articular cartilage injuries, and improved rate of return to sports with minimal risk of growth disturbance. 11,14,[32][33][34][35] Surgical treatment for the skeletally immature includes physeal sparing, partial transphyseal, and transphyseal techniques. 10,12 Despite these advancements in surgical treatment, there is currently a lack of evidence-based rehabilitation protocols after ACLR specific to the youth athlete.…”

“…skeletally immature patient, restoring knee stability, decreasing risk of subsequent injury to the knee, improving rate of return to play, and providing favorable long-term outcomes. [11][12][13][14] Although pediatric athletes return to sports at a high rate after ACL reconstruction (ACLR), 15 subsequent ACL injuries to the ipsilateral or contralateral leg are reported to be as high as 32%. 16,17 Recent studies of revision ACLR in pediatric and adolescent populations have reported lower functional outcomes, lower return to sport rates, significant risk of contralateral ACL injury, and high rates of revision graft injury 18,19 compared to primary ACLR.…”