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Early ACL reconstruction in children leads to less meniscal and articular cartilage damage when compared with conservative or delayed treatment
  1. Peter D Fabricant1,
  2. Nikita Lakomkin2,
  3. Aristides I Cruz Jr3,
  4. Elad Spitzer1,
  5. J Todd R Lawrence4,
  6. Robert G Marx1
  1. 1Hospital for Special Surgery, New York, New York, USA
  2. 2Vanderbilt University, Nashville, Tennessee, USA
  3. 3The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
  4. 4Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Peter D Fabricant, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; FabricantP{at}HSS.EDU

Abstract

Background Anterior cruciate ligament (ACL) tears are being seen and treated with increasing frequency in children and adolescent athletes. The superiority of treating ACL tears in children and adolescents with acute reconstruction, delayed reconstruction or non-operative treatment remains controversial.

Objectives To perform a systematic literature review to investigate for any associations between progressive intra-articular joint damage (increasing rates of meniscal and cartilage injury) with delayed or non-operative treatment of ACL tears in children and adolescents under age 18 when compared with acute ACL reconstruction (ACLR).

Data sources PubMed, EMBASE and Cochrane computerised databases.

Study eligibility criteria Inclusion criteria: (1) paediatric patient population (defined as <18 years of age), (2) investigated association between operative or non-operative treatment and consequent meniscal/chondral injury rates, (3) original research article, rather than a review, case report or meta-analysis. Exclusion criteria: (1) revision ACL cohort, (2) full-text article in a language other than English and (3) not a human clinical study.

Participants Youth aged <18 years with ACL tears.

Interventions Acute ACLR, delayed ACLR, non-operative management.

Synthesis methods Qualitative synthesis.

Results 17 studies were included in the final analysis, all of which reported on medial meniscal injuries, of which 8 (47%) favoured acute reconstruction. 10 of 17 reported on cartilage injuries, of which 4 (40%) favoured acute ACLR. No study concluded that delayed reconstruction or non-operative management was associated with fewer cartilage or meniscus injuries.

Limitations While the included studies provided patient age data, not all provided details about distribution of skeletal maturity. Furthermore, the majority of studies were retrospective and subject to selection bias, measurement bias and design bias (eg, surgical decision-making may have accounted for intra-articular pathology sustained at the time of injury). Constituent study heterogeneity with regard to ACLR techniques, definitions of surgical delay and variable length of follow-up precluded combining results in quantitative meta-analysis.

Conclusions and implications of key findings On the basis of the available published literature which is largely retrospective, acute reconstruction for ACL tears appears to be associated with fewer medial meniscal injuries and articular cartilage lesions when compared with delayed or non-operative management. Several studies that were equivocal showed clinically relevant effect sizes but were underpowered to detect statistical differences between groups. Future prospective research in a large uniform cohort of skeletally immature patients with ACL tears may provide more answers to this important clinical question.

Trial registration number CRD42015027614.

  • Intraarticular
  • Arthrosis
  • Anterior Cruciate Ligament
  • Non-operative
  • Acute

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