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To Operate or not to Operate? That is the question
  1. C Niek van Dijk
  1. Correspondence to Professor C Niek van Dijk, Academic Medical Center Amsterdam, Amsterdam 1105AZ, The Netherlands; C.NiekvanDijk{at}

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Anterior cruciate ligament (ACL) injuries amongst children worry us more than other age groups.

An ACL rupture can limit a child’s present physical activity and contentment. But it can also threaten his or her adulthood, with an increased risk of further injury, leading to meniscal tears and early osteoarthritis. (Whittaker JL, 2015)1

The key question, therefore, when we are faced with a child’s ACL rupture, is ‘To Operate or Not To Operate?’. There are conflicting opinions regarding the best treatment approach. Some argue for early ACL reconstruction, and for all children. Others urge rehabilitation (non-surgical management), with an option for late ACL reconstruction when instability remains. It has been argued that children who begin with conservative management, but later resort to ACL reconstruction, have by then accumulated more meniscal and chondral injuries compared with those who immediately had ACL reconstruction.2–4 This consideration is the background for early surgery decisions.

Certainly, a well-performed ACL reconstruction can restore knee stability. However, it has been shown that a majority (62%) of adolescents develop IKDC grade B or higher osteoarthritis within 15 years of ACL reconstruction.5 This is disturbing and makes one wonder whether it is the initial damage or the surgery itself that induces the osteoarthritis? The surgery certainly doesn’t prevent it. And there are other risks, such as growth disturbance, stiffness and secondary rupture.

It is clear that non-surgical treatment can be both viable and safe for skeletally-immature patients (Moksnes H, 2013)6, and ‘high-quality rehabilitation’ can, by itself, …

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