Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment?
Lawrence JT, Argawal N, Ganley TJ. Am J Sports Med. 2011 Dec;39(12):2582-7.
With nearly 38 million children playing organized sports annually in the United States, and countless more engaging in recreational sports, the opportunity for serious knee injury is more prevalent than ever. While much research has been done to determine the best approach for treating anterior cruciate ligament (ACL) injuries in adults, the same cannot be said for skeletally immature patients. Therefore, Lawrence et al. compared the effect of immediate ACL reconstruction and a delayed ACL reconstruction on meniscal and chondral injuries among patients 14 years of age or younger. The authors performed a retrospective review to identify 70 ACL reconstructed knees in 69 patients with an average age of 12.9 years (range 10 to 14 years). All patients were treated by 1 of 2 physicians utilizing similar reconstructive techniques, however one of the physicians favored delaying treatment until the patient was more skeletally mature. The timing of the surgery was ultimately determined by the attending physician and the patient’s family. Meniscal and chondral injuries were identified and graded through operative reports and intraoperative imaging review. Independent variables that were examined for each patient were time from injury to surgery, the grade of medial meniscal tear (0 to 5, where 0 = no tear and 5 = irreparable tear), and the degree of chondral damage in the affected knee (0 to 4 using the Outerbridge scale). Other risk factors that were investigated for their relationship to medial meniscal tears and chondral defects included age, sex, side, time to reconstruction, Lachman test, pivot shift test, subjective sense of instability after initial injury, and return to sports while awaiting reconstruction. The authors were able to determine that patients undergoing surgery after waiting 12 or more weeks were 4 times more likely to have medial meniscus tears. Patients experiencing instability, regardless of the surgical intervention timeframe, were 11 times more likely to have a medial meniscus tear. More irreparable medial meniscus tears were identified in patients having waited longer than 12 weeks for surgery. The authors also discovered that there was also an associated 11-fold increase in lateral femoral and 3-fold increase in patellotrochlear chondral injuries when the patients waited 12 weeks or longer for surgery. These cartilage defects were also noted to be greater in severity as well as depth.
This study is important for many reasons; but especially because it shows that adolescents who suffer an ACL injury may be at a greater risk for meniscus tears and chondral lesions when the ACL reconstruction is delayed for more than 12 weeks. While the authors note that this study does not determine causality, it is concerning that an adolescent’s knee is at greater risk for considerable damage when treatment is delayed. This study illustrated that there are some serious items to consider when deciding on which treatment to select. While there may be the potential for growth complications resulting from ACL reconstruction, are those risks outweighed by a future of knee degradation, early osteoarthritis, and potential/eventual knee arthroplasty that could result from delaying surgery? Truly, this is a topic where the future isn’t seen through the lens of return to sport. Are you surprised by the dramatic increase in medial meniscus and chondral cartilage injuries seen in younger patients when delaying surgery for greater than 12 weeks? What are you and your team physician doing currently to minimize knee degeneration when your younger athletes sustain an ACL tear?
Written by: Mark Rice
Reviewed by: Stephen Thomas
Related posts:
Lawrence JT, Argawal N, & Ganley TJ (2011). Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? The American Journal of Sports Medicine, 39 (12), 2582-7 PMID: 21917611
I figured there would be a greater chance for joint damage but not to that extent. Even with the small surgeon sample size it raises some eyebrows. Great work as always guys!
Mark, nice post. I think one of the subtle questions this raises is what is the state of the knees among the early-surgery group at a similar time point to when the delayed-surgery group was evaluated? In other words, does the early-surgery reduce the risk of having the severe meniscal and chondral lesions at the later time point or are all of the knees that bad when you assess the knees at a later time.
The other serious question to consider is the effect that early or delayed intervention may have on the epiphyseal plates of both the tibia and femur. It would be reasonable to assume that surgical intervention would damage those areas and possibly cause premature closing. This could also lead to complications due to differences in leg length. I would say that neither situation is ideal because both can cause a lifetime of complications along the whole kinetic chain.
Timothy: Regarding the concern of epiphyseal plates I recommend you check out a previous post:
https://sportsmedresearch.blogspot.com/2011/05/treating-acl-tears-in-skeletally.html
"The authors propose that while transphyseal reconstructions (adhering to a few established rules) can be safely done in skeletally immature patients there are physeal-sparing procedures that lead to comparable results with possibly less risk to the growth plate."
Jeff,as you and I talked about yesterday, I think that it'd be interesting to see a study that follows the early surgery group and attemts to quantify those meniscal and chondral issues through MRI/ 3d CT SCAN. Conducting the imaging tests at around 12 weeks might allow us to draw some type of comparison between the 2 surgical groups and whether or not joint degeneration is minimized with earlier surgery. Those are probably our only options in a human population, short of opening theknee back up and taking a peek.
Keep your eyes open for more publications from this randomized trial:
https://www.nejm.org/doi/full/10.1056/NEJMoa0907797#t=article
"We conducted a randomized, controlled trial involving 121 young, active adults with acute ACL injury in which we compared two strategies: structured rehabilitation plus early ACL reconstruction and structured rehabilitation with the option of later ACL reconstruction if needed."
I think they collected MRI data.
Big thanks to Tim and our "commento to be identified later". Please share this post on all your social media outlets, to help SMR reach even more people. We can't do this without you.
On another note… Jeff would you like me to predict tonight's powerball numbers for you, too. Ha!
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