Sports Medicine Research: In the Lab & In the Field: Early Surgery May Be Better in Pediatric ACL Injuries (Sports Med Res)
Wednesday, January 8, 2014

Early Surgery May Be Better in Pediatric ACL Injuries

Anterior Cruciate Ligament Tears in Children and Adolescents: A meta-analysis of nonoperative versus operative treatment

Ramski DE, Kanj WW, Franklin CC, Bladwin KD, & Ganley TJ. American Journal of Sports Medicine. Published Online First December 4, 2013 doi:10.1177/0363546513510889

Take Home Message: Pediatric patients may benefit over the short term from early surgical management of ACL injuries.  However, we need more clinical trials and additional information to determine the long-term implications of our treatment decisions on the growth plate.

The frequency of anterior cruciate ligament (ACL) injuries is increasing within the skeletally immature population.  Clinicians are uncertain about how to appropriately manage an ACL tear in a young patient due to concerns about potential growth plate complications.  Therefore, these authors conducted a meta-analysis to compare outcomes (i.e., laxity, symptomatic meniscal tears, clinical outcomes scores, repeat surgery, and return to activity) of immediate surgery versus nonsurgical or delayed surgical management among children and adolescents.  Following a systematic search of the literature the authors identified 6 studies that compared operative to nonoperative treatments and 5 studies comparing early and delayed ACL reconstructions. Of the included studies, 4 were prospective, 7 retrospective, and 1 was a case-control study.  Overall, the authors found better outcomes for early surgery for pediatric ACL injuries.  Nonoperative or delayed operative patients had a significantly greater likelihood of having a meniscal tear (67%) and instability episodes (75%) in comparison to the early surgical group (4% and 13.6%; respectively).  A young patient treated with nonsurgical or delayed surgical management may be over 33 times more likely to have instability episodes (“episodes of giving way”) and 12 times more likely to have a medial meniscus tear compared with a young patient treated with an early ACL reconstruction.  Early operative management also resulted in a greater rate of return to pre-injury activities. 

While short-term outcomes favor early surgical management for ACL injuries in the pediatric population, these results should be interpreted with caution.  None of the studies reported enough information to make conclusions regarding the status of the growth plate or any potential complications resulting from surgery.  Furthermore, there are a few different surgical techniques that may mitigate the potential growth plate issues, and there was not enough information to look at these techniques independent of one another.  The results of this meta-analysis reinforce that more high-quality research is needed within the pediatric ACL injured population.  The authors indicated that the included studies could be subject to selection bias as there was no randomization regarding treatment options.  However, the results of this meta-analysis appear to favor early surgical management of ACL tears in the pediatric population.      

Questions for Discussion:  What are your thoughts in dealing with the pediatric patient with an ACL injury?  Are there any other concerns that you might have in dealing with this population?  
 
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Ramski DE, Kanj WW, Franklin CC, Baldwin KD, & Ganley TJ (2013). Anterior Cruciate Ligament Tears in Children and Adolescents: A Meta-analysis of Nonoperative Versus Operative Treatment. The American Journal of Sports Medicine PMID: 24305648

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