Meniscal Injury After Adolescent Anterior Cruciate Ligament Injury: How Long Are Patients at Risk?

Abstract

Background Delay of as much as 5 months between ACL injury and surgery is known to be associated with increased risk of a medial meniscal tear, but the risk of additional meniscal tear progression with a longer delay to surgery is unclear. Questions/purposes We determined the (1) times of injury, MRI, and surgery in adolescents with ACL tears, and whether (2) timing of surgery, or (3) initial integrity of the meniscus seen on MR images predicted development of meniscal tears. Methods We reviewed 112 adolescents who were 15 ± 1 years old (mean ± SD) (range, 11-16 years) with a torn ACL. These patients underwent surgical repair from 2005 to 2011 in a Canadian city. We compared dates of injury, MRI, and surgery. A pediatric and musculoskeletal fellowship-trained radiologist reread the MR images, and meniscal injuries were graded according to severity. This was compared with surgical findings described in the operative report. Results Time after injury to MRI and surgery averaged 77 days (range, 1-377 days) and 342 days (range, 42-1637 days), respectively. Patients with new or worsened medial meniscal tears had waited longer for surgery (445 versus 290 days; p = 0.002). Bucket handle medial meniscal tears were more common in patients with surgery more than 1 year after injury than others (15 of 34 versus 14 of 75; p = 0.013). A medial meniscal tear observed on MR images was a significant covariate for a torn meniscus at surgery (relative risk, 5.7; 95% CI, 2.8-11.6). Medial meniscal survival continued to decline sharply greater than 1 year after injury. Conclusions Medial meniscal tears, especially bucket handle tears, increased steadily in frequency more than 1 year after ACL injury. Timely ACL reconstruction may be warranted to reduce the risk of further medial meniscal damage even in patients whose original injury occurred more than 1 year before. Level of Evidence Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Meniscal tears associated with anterior cruciate ligament injury

“…Guenther et al [7] confirmed an increased likelihood of medial meniscal tears when surgery was performed more than 1 year after injury, but no change in lateral meniscal tears with time. Similar findings have been reported by Millett et al [11] using a cutoff time to treatment of 6 weeks after ACL tear, by Lawrence et al [10] using 12 weeks, and by Dumont et al [5] using 5 months.…”

“…In addition, the number of bucket handle tears was greater in the chronic group (lateral meniscal tear in 12 knees and medial in 69 knees, total 81 knees) than in the acute group (lateral meniscal tear in 8 knees and medial in 17 knees, total 25 knees). Guenther et al [7] investigated 112 adolescents with ACL ruptures, and reported that medial Fig. 4 The radial zone distribution of meniscal tears Arch Orthop Trauma Surg meniscal tears, especially bucket handle tears, increased steadily in frequency more than 1 year after ACL injury.…”

“…Dumont et al [5] reported that pediatric patients treated more than 150 days after injury for ACL tears had a higher rate of medial meniscal tears than those treated 150 days or less after injury, and demonstrated that increased age and weight are independently associated with a higher rate of medial meniscal tear. Guenther et al [7] proposed that timely ACL reconstruction may be warranted to reduce the risk of further medial meniscal damage even in the patients who sustained the original injury more than 1 year before.…”

Anterior cruciate ligament reconstruction in skeletally immature patients

“…These findings were particularly magnified in patients with any pivoting episodes and in patients returning to pivoting sports prior to reconstruction [6]. Guenther et al published similar results in a retrospective series where patients who were reconstructed greater than a year after their injury had a higher incidence of medial meniscus tears and were more likely to have a bucket-handle tear [14]. A recent metaanalysis by Ramski et al extracted data on clinical variables such as symptomatic meniscal tears and post-treatment instability from 11 studies [15].…”

“…The natural history of the untreated ACL deficient knee in the pediatric population is somewhat controversial, but mounting evidence suggests that delays in reconstruction result in greater meniscus tears and cartilage pathology [6,14]. Anderson et al recently showed that delays in surgical reconstruction not only resulted in a significant increase in medial meniscal tears and chondral injuries, but more severe injuries as well.…”