The Quandary of Treating Anterior Cruciate Ligament Tears in Children and Adolescents: Commentary on an article by Travis J. Dekker, MD, et al.

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In this therapeutic Level-IV study of a continuous cohort of 112 patients (85 participated, representing a follow-up of 76%) who were <18 years of age undergoing an anterior cruciate ligament (ACL) reconstruction surgical procedure and a mean follow-up of 48 months, Dekker et al. report an overall prevalence of a second ACL injury of 32% (19% for ipsilateral injuries and 13% for contralateral injuries). The authors report that a slower return to sport was protective against further ACL tears. The limitations of the study included the low number of patients, which constrained the ability to fully assess further prognostic factors such as graft choice; the unknown impact of the 76% follow-up rate on the results; the self-reporting of duration of physical therapy as well as return to sport possibly introducing error; and the unreported rate of a subsequent surgical procedure for meniscal or cartilage injury leading to a risk of a subsequent surgical procedure that is likely even higher than the risks reported for subsequent ACL tears in this age group.
The findings of this study, taken in context with the similar findings in several other recent publications of a similar age cohort, necessitate that the treating clinician alter preoperative counseling of patients and families when treating an ACL tear in children and adolescents compared with adults. In a meta-analysis by Ramski et al., nonoperative management of pediatric ACL injuries resulted in persistent instability in 75% of patients, and these patients were 12 times more likely to have a medial meniscal tear compared with those who underwent operative management1. As a result, there is almost an obligation to reconstruct a torn ACL in a pediatric patient because of a desire to minimize the risk of further injury to the knee and to allow a return to sport with the accompanying benefits of athletic participation (e.g., self-esteem, character development, work ethic). The good news is that, in the current article, Dekker et al. report a high rate of return to sport (91%). This is essentially the primary reason for choosing a surgical procedure. However, the bad news is the reported overall rate of 32% for subsequent ACL tears. This result is comparable with the findings of Webster and Feller showing a 35% subsequent ACL injury rate in a cohort of 354 patients who were <20 years at the time of primary hamstring ACL reconstruction2. In a separate study of 561 patients by Webster et al., patients who were <20 years of age at the time of the index ACL reconstruction surgical procedure were 6 times more likely to sustain a graft rupture than patients ≥20 years of age3. Similarly, in a study of 288 patients who were <19 years of age, Morgan et al. reported that further ACL injury occurred in 1 in 3 patients over a 15-year time period4.
The treatment of ACL injuries in children and adolescents remains a complex clinical scenario. Because nonoperative management leads to generally poor outcomes, a reconstruction surgical procedure is likely the best choice for maximizing treatment goals. However, the high rates of reported subsequent ACL injury (approximately 33%) are unique to this population. The increased prevalence of ACL injury with an earlier return to sport in this study is likely a surrogate marker representing inadequate neuromuscular rehabilitation. With these findings taken into consideration, the emphasis on secondary injury prevention should be the focus of further study, as it is likely that standard postoperative rehabilitation is insufficient in this population with a predisposition to subsequent injury.
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