2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

Abstract

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Why all the fuss about paediatric ACL rupture: isn’t the meniscus much more important?

“…We must adapt the culture of youth sport to emphasise injury prevention 1. A knee injury with an acute haemarthrosis is an ACL rupture until proven otherwise 1.…”

“…A knee injury with an acute haemarthrosis is an ACL rupture until proven otherwise 1. There are other causes, but in cases such as Ava’s, we must immediately suspect that the ACL is injured.…”

“…The clinicians involved in Ava’s care did not have the benefit of access to the 2018 IOC consensus statement on prevention, diagnosis and management of paediatric ACL injuries 1. Had the consensus statement been available, it might have helped them to quickly and accurately diagnose the injury.…”

“…The IOC consensus statement emphasises the need to protect the meniscus 1. With most of the lateral meniscus missing, Ava’s long-term prognosis for knee health is poor 2.…”

Applying ethical standards to guide shared decision-making with youth athletes

“…When arriving at a decision in a clinical dilemma, one or several ethical standards may help the decision-making team evaluate if a decision is ethically justifiable. The 2018 International Olympic Committee consensus on paediatric ACL injury4 outlined six ethical standards (box 1) that may apply to different situations in sports medicine clinical practice.

Six ethical standards that can apply to sports medicine clinical scenarios Best interests 5: what is in the youth athlete’s best long-term interests. Harm principle 6: a threshold below which the clinician should not acquiesce to a parent-led decision, so that the youth athlete is not harmed. Parental discretion 7 8: parent preference is accepted because the preferred course of action is not sufficiently harmful to the youth athlete for the clinician to dissent. Costs–benefits 9: involve a risk assessment, but its application to the youth athlete means that the clinician may need to compare very different kinds of futures that may or may not eventuate. Not unreasonable 10: focuses only on the appropriateness of decisions and decision-maker(s). Reasonable choice 11: a decision method that attempts to incorporate the previous five standards into a single model or intervention.

…”