Purpose: Anterior cruciate ligament injuries in children have increased by as much as 400% in the past decade. Debate over the optimal treatment for these injuries in the skeletally immature patient persists, with some clinicians advocating for initial non-operative treatment and others for reconstruction of the torn ligament. Determining factors that are used in this decision process include symptoms of knee instability, additional incurred injuries, and the patient's ability to return to previous activity level. The purpose of this study was to review the literature and analyze aggregated data to determine if a benefit exists for early operative treatment of ACL injury in the skeletally immature patient.
Methods: PubMed, Google Scholar, and recent orthopaedic conference submissions were queried for studies comparing non-operative treatment to operative treatment or immediate ACL reconstruction to delayed reconstruction. Data extracted included symptomatic meniscal tears, return to sports, outcome scores (International Knee Documentation Committee (IKDC), Lysholm, and Tegner), return to operating room, and post-treatment instability. A symptomatic meniscal tear was defined as occurring after the initial presentation, limiting activity, and requiring further treatment. “Instability”, the primary outcome, was defined as having an episode of giving way, a Grade 2 or higher Lachman/pivot shift test, or a KT-1000 side-side difference >4mm. All studies were evaluated using a formal study quality analysis.
Results: Six studies (219 patients) comparing operative to non-operative treatment and five studies (354 patients) comparing early to delayed reconstruction were identified. Three of eleven studies reported post-treatment instability in operative and non-operative patients. 13.6% of operative patients experienced instability compared to 75% of non-operative patients (p<0.01; Figure 1). Two studies reported symptomatic meniscal tears, revealing that non-operative patients were over 9 times more likely to have a medial meniscus tear after treatment (35.4% vs. 3.9%, p=0.02; Figure 1). Two studies reported return to sports; no patients in the non-operative groups returned to their previous level of sports compared to 85.7% of operative patients (p<0.01; Figure 1). A significant difference in scores between groups was noted in one of two studies reporting IKDC (p=0.002) and in one of the two reporting Tegner scores (p=0.007). There were no significant differences between groups in terms of lateral meniscus tears, rate of return to operating room, or Lysholm scores. Study quality analysis revealed that the majority of the studies were inconsistent in reporting outcomes for both patient groups.
Conclusion: Though the pediatric ACL literature is marked by numerous inconsistencies in reporting outcomes across studies, meta-analysis revealed multiple trends that favor operative or immediate reconstruction over non-operative or delayed treatment. Non-operative and delayed patients experienced more instability and inability to return to previous activity levels than operative and immediate reconstruction patients.