Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years’ Follow-up

Abstract

Background: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision-making is limited. Purpose: To evaluate functional and patient-reported outcome, surgical history and complications in young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. Study design: Prospective case seriesMethods: Forty-six children younger than 13 years of age with a total, intrasubstance ACL injury were included. None of these patients had additional injuries that warranted early surgery. At final followup at mean 8 years after time of injury, 44 patients remained in the study. The same test battery was conducted at baseline, 1 and 2 years and at final follow-up at approximately 18 years of age. The test battery included functional tests (hop tests and isokinetic muscle strength tests of quadriceps and hamstrings), patient-reported outcome measures (including the Knee and Osteoarthritis Outcome Score KOOS and the International Knee Documentation Committee Subjective Knee form IKDC) and clinical examination. Medical records were reviewed to assess surgical history and complications. Results: At mean 8 years follow-up, 24 patients (55 %) had undergone ACL reconstruction, and 16 patients (36 %) had undergone meniscal surgery. Quadriceps muscle strength symmetry was above 90 % for 30 patients (68 %). Mean leg symmetry indexes for hop and strength tests were consistently above 90 %, except for the single hop and hamstrings muscle strength for ACL-reconstructed patients. Mean IKDC scores were 86.3 ± 13.7 for the ACL-reconstructed patients and 90.6 ± 11.8 for the non-reconstructed patients. Forty patients (91 %) remained active in sports, but 29 patients (66 %) reduced their activity level to non-pivoting sports.Conclusion: Active rehabilitation may have a role in treatment of ACL injured children. Approximately 50 % of children may cope well even through to adulthood without a surgical intervention. The other half may develop instability which warrants ACL reconstruction and one third may require meniscal surgery.

Uninjured Youth Athlete Performance on Single-Leg Hop Testing: How Many Can Achieve Recommended Return-to-Sport Criterion?

“…Our results may help explain why other studies have identified similar low functional hop test “passing” rates within ACLR populations 11,14,43 and why a recent systematic review and meta-analysis identified that only 23% of patients post-ACLR are able to pass return-to-play assessments at a 90% LSI threshold. 42 Future research should seek to determine whether other factors such as strength or balance may affect hop test performance within young athletes and focus on examining hop test performance across a wider age range of healthy individuals.…”

“…Unfortunately, neither study included frequency counts of individual patients able to achieve a threshold of ≥90% LSI on the entire battery of tests, which limits our ability to make further comparisons between those data and the current study. Ekas et al 11 recently published a case series evaluating the functional abilities of a cohort of young athletes who sustained an ACL injury before the age of 13 years. Among this group of patients, the mean age at the time of injury was 11 years, and the average follow-up occurred 8 years postinjury, yielding a mean age of 19.1 years at time of testing.…”

“…9,12,13,25 The battery of hop tests used within the present study have demonstrated good discriminative accuracy and predictive abilities 7,24,32 ; however, the clinical utility of these and other commonly utilized return-to-sports assessment methods have recently been questioned due to a lack of association with secondary ACL injury risk. 26,27,34,42 In addition, several reports have identified that many athletes cleared to return to sports after ACLR are unable to achieve the contemporary standard of ≥90% LSI, 11,14,27,39 further challenging the clinical utility of these measures and raising concerns about the validity of the 90% LSI criteria to which post-ACLR athletes are held.…”

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

“…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…”

Paediatric anterior cruciate ligament tears: Management and growth disturbances. A survey of EPOS and POSNA membership

“…11,12 On the other hand, rehabilitation programmes and satisfactory outcomes from nonoperative treatment were reported in Europe. 9,13 The primary objective of our study was to assess the evolution of treatment approaches to ACL tears among skeletally immature patients and to examine the variations among members of Pediatric Orthopaedic Society of North America (POSNA) and European Paediatric Orthopaedic Society (EPOS). The secondary objective was to determine the number, type and severity of growth disturbances correlated with surgical reconstruction of the ACL.…”