Timing of Pediatric ACL Reconstruction

Author

Study type

Patients

Outcomes

Newman (AJSM 2015) [21]

Cohort study (LOE 3)

Older cohort (14–19 y/o; (n = 165)

Younger cohort (<14 y/o; n = 66)

Significant relationship between time to ACLR and irreparable meniscal pathology in both groups

Young cohort:

Time to surgery correlated to severity of chondral injury

Delay in surgery >3 months predictive of the presence of an injury that required additional operative procedures

Older cohort:

Return to activity before surgery and obesity predictive of an injury that required additional operative procedures

Anderson (AJSM 2015) [3]

Cohort study (LOE 3)

Acute group (ACLR < 6 weeks; n = 62; median 14 y/o)

Subacute group (ACLR 6–12 weeks; n = 37; median 13 y/o)

Chronic Group (ACLR > 12 weeks; n = 36; median 12 y/o)

Subacute and chronic groups had 1.45 and 2.82 times higher odds, respectively, of LMTs severity compared with acute reconstruction

Chronic group was significantly more likely to have increased severity of MMTs

Time to surgery was a significant risk factor for increased incidence and grade of chondral injury

Fundahashi(AJSM 2014) [6]

Cohort study (LOE 3)

Non-op group (n = 24; mean age 12.9)

Delayed ACLR group (n = 47; mean age 13.5 y; mean time to surgery 16.6 months)

Delayed ACLR group:

No significant difference in meniscal/chondral injury if ACLR was delayed <1 year vs. >1 year

57 % had meniscal and 51 % had meniscal and chondral injuries at the time of surgery

Patients had average of 4.6 “new encounters” for new pain or swelling

Found a positive association between the number of new encounters and likelihood of combined chondral and meniscal injuries

Ramski (AJSM 2014) [13]

Meta-analysis (LOE 3)

6 studies compared operative to non-op (total patients, n = 217)

5 studies compared early to delayed ACLR (total patients, n = 353)

Nonoperative or delayed treatment was associated with a 34-fold increase in knee instability

2 studies demonstrated patients were over 12 times more likely to have a MMT after nonoperative treatment compared to ACLR

2 studies reported none of the patients in the nonoperative groups returned to their previous level of play compared with 85.7 % of patients in the operative groups

Dumont (AJSM 2012) [4]

Cross-sectional study (LOE 3)

Early ACLR (<150 days; n = 241)

Delayed ACLR (>150 days; n = 129)

Significantly increased MMTs (53.5 % vs. 37.8 %; OR 1.8) and medial tibial cartilage injuries (7.8 % versus 2.1 %) were observed in the delayed treatment group

Similar incidence of LMTs was observed between groups

Chondral injury was significantly associated with the presence of meniscal tear in the same compartment of the knee

Lawrence (AJSM 2011) [14]

Cohort study (LOE 3)

Early ACLR (<12 weeks; n = 41)

Delayed ACLR (>12 weeks; n = 29)

Mean age 12.9 y

Time to surgery >12 weeks was independently associated with MMTs (odds ratio 4.1), as well as medial (OR 5.6) and lateral (OR 11.3) chondral injuries

Delay in treatment of >12 weeks was associated with an increase in the severity of MMTs

Henry (KSSTA 2009) [9]

Cohort study (LOE 2)

Early ACLR (mean 13.5 months; n = 29; mean age 11.5 y)

Delayed ACLR (mean 30 months; n = 27; mean age 13.3 y)

Delayed ACLR group had higher rate of medial meniscal tears (41 % vs. 16 %) and higher rate of meniscectomy

Both groups had similar rate of lateral meniscus tears

Lower subjective IKDC scores (83.4 vs. 94.6) were observed with delayed ACLR

Millett (Arthroscopy 2002) [17]

Cohort study (LOE 3)

Acute (<6 week until ACLR; n = 17)

Chronic (>6 weeks until ACLR; n = 22)

Mean age 13.6 y

Found significantly increased meniscus tears when ACLR delayed >6 weeks (36 %) compared to ACLR <6 weeks (11 %)

No difference between groups regarding lateral meniscal tears

LOE level of evidence, ACLR anterior cruciate ligament reconstruction, LMT lateral meniscus tear, MMT medial meniscus tear, OR odds ratio

Ramski et al. [23], in a meta-analysis, systematically analyzed aggregated data from the literature to determine if superiority of treatment outcomes exists for nonoperative or early operative treatment for ACL tears in pediatric patients. They found six studies (217 patients) that compared operative to nonoperative treatment and five studies (353 patients) that compared early to delayed ACL reconstruction. Three studies reported that posttreatment instability occurred in 13.6 % of patients after operative treatment and 75 % of patients after nonoperative treatment (p ≤ 0.01). Two studies found symptomatic medial meniscal tears were 12 times more likely after nonoperative treatment (p = 0.02). Two additional studies reported return to activity; none of the patients in the nonoperative group returned to previous activity level of play compared to 85.7 % of patients who were treated operatively (p ≤ 0.01). The authors concluded that multiple trends favor early surgical stabilization over nonoperative or delayed treatment in pediatric ACL tears.

6.3 Growth Disturbance

Although there is a growing body of evidence indicating that nonoperative treatment is associated with meniscal and chondral injuries and sports-related disability, the decision to perform surgery depends on the risk and efficacy of the alternative, surgical reconstruction. Most authors have not reported growth disturbance after physeal sparing ACL reconstruction in pediatric patients; however, Frosch et al. [5], in a meta-analysis of 55 studies including 935 patients who had either a physeal sparing, partial physeal sparing, or transphyseal reconstruction, found that the risk of leg-length discrepancy or angular deformity after surgical treatment was 1.8 %. In the systematic review of 31 studies (n = 479 patients), Vavken and Murray [24] found that three patients developed angular defects and two had leg-length discrepancies. They also analyzed the literature to determine if surgical treatment was the best option for pediatric ACL tears. Nine studies with evidence level 2 or 3 compared surgical treatment to nonsurgical treatment (n = 6), immediate with delayed reconstruction (n = 2), and surgical treatment with mature versus immature patient (n = 1). These studies unanimously reported significantly better clinical scores and knee laxity after surgical reconstruction compared to nonoperative treatment. They also found no difference in the risk of growth disturbance.

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