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

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?  
by: Nicole Cattano
by: Jeffrey Driban

Related Posts:

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