Pediatric ACL: Evaluation and Management
Pediatric ACL: Evaluation and Management
Nonsurgical treatment of ACL injuries in skeletally immature patients typically consists of functional bracing, physical therapy, and activity modification. Most studies evaluating the efficacy of conservative treatment demonstrate poor and "unacceptable" outcomes, with high rates of recurrent instability, meniscal damage, early arthritis, and sports related disability. These poor outcomes have been attributed to both noncompliance and significantly higher activity levels observed in children.
Delay of surgical reconstruction until skeletal maturity to avoid risking iatrogenic growth disturbance also has been associated with recurrent instability and an increased incidence of associated knee pathology. In a level III cross-sectional study, Dumont et al. demonstrated a statistically significant increase in the rate of medial meniscal tears (53.5% versus 37.8%) and medial tibial cartilage injuries (7.8% versus 2.1%) when reconstruction was delayed more than 150 days. In a retrospective cohort study, Lawrence et al. demonstrated that a delay in surgical reconstruction of more than 12 wk resulted in a four-fold increase in medial meniscal injuries and six times more medial and 11 times more lateral chondral injuries. Delayed surgery also was associated with more severe medial meniscal tears and higher grade chondral injuries, suggesting progressive damage with ongoing ACL deficiency. Henry et al. determined that delay in reconstruction until skeletal maturity resulted in a higher rate of medial meniscal tears (41% versus 16%) and a higher rate of meniscectomy. The higher rate of meniscectomy observed by Henry et al. also suggests continued instability of the ACL-deficient knee results in progressive meniscal pathology.
In contrast to the growing body of evidence demonstrating poor outcomes with conservative or delayed treatment, relatively few studies support the use of nonsurgical treatment algorithms in skeletally immature patients. Even so, a recent meta-analysis overwhelmingly favored early surgical stabilization over conservative treatment or delayed reconstruction. In that study, the aggregate data of nonsurgical or delayed surgical treatment were associated with a 34-fold increase in knee instability. Furthermore, patients treated nonsurgically had a 12-fold increase in the rate of medial meniscal tears, and none were able to return to their preinjury level of play. Given the increasing evidence of poor outcomes with nonsurgical and delayed surgical treatment, our current recommendation is early reconstruction to avoid recurrent instability and associated knee pathology.
Nonsurgical Treatment/Delayed Surgical Management
Nonsurgical treatment of ACL injuries in skeletally immature patients typically consists of functional bracing, physical therapy, and activity modification. Most studies evaluating the efficacy of conservative treatment demonstrate poor and "unacceptable" outcomes, with high rates of recurrent instability, meniscal damage, early arthritis, and sports related disability. These poor outcomes have been attributed to both noncompliance and significantly higher activity levels observed in children.
Delay of surgical reconstruction until skeletal maturity to avoid risking iatrogenic growth disturbance also has been associated with recurrent instability and an increased incidence of associated knee pathology. In a level III cross-sectional study, Dumont et al. demonstrated a statistically significant increase in the rate of medial meniscal tears (53.5% versus 37.8%) and medial tibial cartilage injuries (7.8% versus 2.1%) when reconstruction was delayed more than 150 days. In a retrospective cohort study, Lawrence et al. demonstrated that a delay in surgical reconstruction of more than 12 wk resulted in a four-fold increase in medial meniscal injuries and six times more medial and 11 times more lateral chondral injuries. Delayed surgery also was associated with more severe medial meniscal tears and higher grade chondral injuries, suggesting progressive damage with ongoing ACL deficiency. Henry et al. determined that delay in reconstruction until skeletal maturity resulted in a higher rate of medial meniscal tears (41% versus 16%) and a higher rate of meniscectomy. The higher rate of meniscectomy observed by Henry et al. also suggests continued instability of the ACL-deficient knee results in progressive meniscal pathology.
In contrast to the growing body of evidence demonstrating poor outcomes with conservative or delayed treatment, relatively few studies support the use of nonsurgical treatment algorithms in skeletally immature patients. Even so, a recent meta-analysis overwhelmingly favored early surgical stabilization over conservative treatment or delayed reconstruction. In that study, the aggregate data of nonsurgical or delayed surgical treatment were associated with a 34-fold increase in knee instability. Furthermore, patients treated nonsurgically had a 12-fold increase in the rate of medial meniscal tears, and none were able to return to their preinjury level of play. Given the increasing evidence of poor outcomes with nonsurgical and delayed surgical treatment, our current recommendation is early reconstruction to avoid recurrent instability and associated knee pathology.
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