ACL reconstruction in youth athletes results in an improved rate of return to athletic activity when compared with non-operative treatment: a systematic review of the literature

Abstract

Background Anterior cruciate ligament (ACL) tears are being seen and treated with increasing frequency in youth athletes, with the goal of returning patients to sports activity. This is particularly important for youth athletes, for whom sports provide physical, social and psychological development. Objectives To perform a systematic review of the orthopaedic surgery literature to investigate for any associations between treatment strategy and return to athletic activity after ACL tear in youth athletes under age 18 years. Data sources PubMed, EMBASE and Cochrane computerised databases. Study eligibility criteria Inclusion criteria: (1) <18 years of age, (2) investigation of a relationship between time to treatment and consequent rates of returning to preinjury levels of athletic activity, (3) original research article (eg, not a review, case report or meta-analysis). Exclusion criteria: (1) revision ACL surgery, (2) language other than English, and (3) not a clinically based study. Participants Youth <18 years old with ACL tears. Interventions Acute ACL reconstruction, delayed ACL reconstruction, non-operative management. Synthesis methods Qualitative synthesis. Results Twenty studies met inclusion and exclusion criteria, of which four evaluated return to play after acute ACL reconstruction (ACLR), five studies evaluated return to play after delayed ACLR, and nine evaluated return to play after ACLR with an unspecified injury-tosurgery time interval. Two studies investigated return to play in a non-operative cohort. Of the 18 surgical studies, 14 employed a soft tissue transphyseal reconstruction. Rates of return to play were 78-100% after acute ACLR, 84-100% after delayed ACLR, 41-100% after ACLR with an indeterminate injury-tosurgery time interval and 6-52% after non-operative treatment of ACL tear. Limitations Several studies did not provide details about the timing of injury-to-surgery, and study heterogeneity precluded combining results in quantitative meta-analysis. Furthermore, the amount of time to full postinjury recovery remains largely unstudied. Conclusions and implications of key findingsBased on available literature, there appears to be an improved rate of return to athletic activity after ACLR when compared with non-operative treatment. Future research should directly focus on time to return to sports activity, while taking into account the unique aspects of ACL reconstruction and non-operative management in youth athletes. This is of particular importance in children and adolescents given the physical, social and psychological development that occurs with sports participation. Trial registration number CRD42015027536.

Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury

“…Several narrative reviews17 19 85–87 have focused on timing of surgery and additional knee injuries in children and adults. Because a higher proportion of patients with meniscal and cartilage injuries had delayed ACL surgery, authors of narrative reviews have urged early surgery to prevent new meniscal injuries 17 86.…”

“…But there is fierce debate about whether ACL reconstruction should be a mandatory part of treatment algorithms that focus on protecting the meniscus 13–16. Some clinicians advocate early ACL surgery to prevent knee instability, and subsequently, new injuries to the menisci and cartilage 17–21. Others advocate early active rehabilitation to improve muscle function and stabilise the knee, only recommending ACL surgery if knee instability persists despite high-quality rehabilitation, or in the presence of repairable meniscal injuries 14 22–24…”

Management of ACL Injuries in Children and Adolescents

“…However, during the 4 years after injury, 33% of the 41 knees required ACL reconstruction for persistent symptoms of instability and 20% sustained new meniscal pathology requiring treatment. Meta-analyses have shown that early stabilization decreases pathological laxity and improves rates of return to activity 4,84 .…”

“…Historically, nonoperative management until skeletal maturity followed by traditional ACL reconstruction was a popular treatment strategy. However, the recent understanding of the perils of nonoperative and delayed surgical treatment have supported a trend toward early surgery [4][5][6][7][8][9] . In light of this, surgical techniques and instrumentation have evolved in order to accommodate the unique anatomy of skeletally immature patients.…”

Magnetic resonance imaging after anterior cruciate ligament reconstruction: A practical guide

“…It is considered the standard of care for young active patients who wish to return to sport practice after ACL injury[ 1 ]. Despite the lack of clear evidence of its ability to reduce the onset and progression of knee osteoarthritis (OA), ACL reconstruction is expected to prevent further meniscal and cartilage lesions that could occur in the ACL-deficient knee[ 2 , 3 ]. Usually, ACL reconstruction is performed arthroscopically (occasionally combined with extra-articular plasty/augmentation) using autologous graft such as Gracilis and Semitendinosus tendons (HS), bone-patellar tendon bone (BPTB), and Quadriceps Tendon (QT), or allogenic grafts such as BPTB, Achilles Tendon, and Posterior or Anterior Tibialis tendons.…”