Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study

Abstract

There is limited scientific knowledge on ACL injuries in children 12 years or younger. Substantial controversy exists on treatment algorithms and there are no published data on performance-based functional outcome. Classification of adult ACL injured subjects as copers and non-copers is common, but no study has classified knee function in children using performance-based functional test after ACL injury. The aim of the present study was to evaluate the medium-term functional outcome among children with ACL injury and to classify them as copers and noncopers. Children 12 years or younger who were referred to our institution from 1996 to 2004 with an ACL injury were included. Twenty non-operated subjects (21 knees) and six ACL reconstructed subjects (7 knees) were examined at a minimum of 2 years after ACL injury or reconstruction. Four single-legged hop tests, isokinetic muscle strength measurements, and three functional questionnaires (IKDC 2000, KOS-ADLS and Lysholm) were used as outcome measurements. Children who had resumed their pre-injury activity level and performed above 90% on all hop tests were classified as copers following non-operative treatment and ACL reconstruction. The 26 children were on average 10.1 years at the time of injury. Of the non-operated children, 65% had returned to pre-injury activity level, and 50% were classified as copers. Copers scored significantly better than non-copers on single hop for distance, IKDC 2000, and Lysholm score. Of the non-operated children, 9.5% had suffered a secondary meniscus injury. Of the ACL reconstructed subjects, 67% were classified as copers at follow-up. Non-operated ACL-deficient children demonstrated excellent knee function on performance-based single-legged hop tests and 65% had returned to pre-injury activity level. Delayed ACL reconstruction resulted in success for a majority of the ACL-reconstructed children. Treatment algorithms for ACL-injured children are discussed.

Pediatric anterior cruciate ligament reconstruction

“…Compared to a control group who received acute reconstructions, they reported no increase in intra-articular injuries despite a mean delay of 70 weeks until ACL reconstruction. Moksnes et al [29] delayed ACL reconstruction in young patients until skeletal maturity with extensive rehabilitation and return to activities as tolerated with brace wear. They reported 65% of children were able to return to previous activities without reconstruction and only 9.5% suffered a secondary meniscus injury.…”

Management of Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals

“…Woods and O'Connor 107 reported that the incidence of meniscus injuries at the time of surgery (46%) in the 13 included children was similar to the incidence in 116 skeletally mature adolescents treated with transphyseal reconstruction. Moksnes et al 82 reported 3 medial (11%) and 3 lateral (11%) meniscus injuries in 26 children during a follow-up period of 2 to 9 years, while Mizuta et al 80 reported 1 additional meniscus injury in a study of 18 skeletally immature patients (6%). Graf et al 40 reported 7 new meniscus injuries (88%) in 8 children who underwent delayed ACL reconstruction due to knee instability.…”

“…To our knowledge, no well-designed studies on nonoperative management have been published, and the rates of secondary meniscus injuries in 3 of 4 case series were low. 80,82,107 There is an immense need for well-designed prospective studies with well-described inclusion criteria and long-term follow-up to develop evidence-based criteria for the treatment of skeletally immature individuals.…”

“…In studies on primary nonoperative treatment, the rehabilitation programs are insufficiently described. 40,80,82,107 There seems to be a consensus on the use of a knee brace during sports activities, although no RCT has been published that studies bracing and ACL injuries in children. Woods and O'Connor 107 followed the strictest algorithm, recommending bracing and activity limitations until surgical treatment at skeletal maturity, while Mizuta et al 80 and Moksnes et al 82 advocated bracing only when performing pivoting sports.…”

“…Our previous study showed that approximately half the children with ACL injuries could be classified as copers (resumed preinjury activity level and had singleleg hop test indexes greater than 90% of the uninjured limb) without a high risk of secondary meniscus injuries. 82 Children with ACL injuries should be monitored and assessed by an orthopaedic surgeon and a physical therapist working together, and ACL reconstruction should not be considered before it has been established that a structured rehabilitation program was not successful in returning functional stability of the knee.…”