Injuries more prevalent in children after ACL surgery

Recently published data indicated older children had a greater prevalence of concomitant knee injuries and the need for additional surgical procedures after ACL reconstruction compared with younger patients.

Nikkita Holder in 100 metre hurdles. Peter J. Thompson/National Post.

by Monica Jaramillo and Casey Tingle, Healio Orthopaedics Today Europe March 2016

The longer you wait to address the ACL [in pediatric patients], the more likely it is that something else is going to be damaged that requires surgery or further intervention. That leads to a poorer long term outcome for the knee. Justin T. Newman MD.

Older vs. younger patients

Retrospectively reviewing data for adolescent patients who underwent primary ACL reconstruction between July 2005 and December 2012, Justin T. Newman and his colleagues categorized the patients into a younger cohort, which included 66 patients (aged 14 years or younger), and an older cohort, which included 165 patients (aged 14 years to 19 years).

According to study results, 73.8% of patients in the older cohort had meniscal injuries vs. 60.6% in the younger cohort. Newman also noted, during the primary ACL reconstruction, 65.1% of patients in the older cohort vs. 48.5% of patients in the younger cohort required additional operative procedures.

Results showed a statistically significant relationship between time to surgery and patients’ development of an irreparable meniscal injury in both groups. However, the time to surgery and the severity of chondral injury were correlated only in the younger cohort, according to the researchers.

A delay in surgery greater than 3 months was a predictor for additional operative procedures needed for concomitant knee injuries in the younger cohort, with patients in this category being 4.75-times more likely to need additional surgery than those who underwent the surgery less than 3 months after injury.

Return to activity and obesity were predictors for additional operative procedures needed for concomitant knee injuries in the older cohort. Patients were 3.86-times more likely to need additional operative procedures if they returned to activities before surgery, according to the researchers.

“We show [that] when you do wait to treat the ACL [in pediatric patients] there is further damage that is done to the knee,” Newman said. “The meniscal tears are more common, have a higher severity and, breaking it down between the two age groups, the younger kids have worse chondral damage as well in addition to worse meniscal injuries.”

For more information: Justin T. Newman MD, can be reached at The Steadman Clinic, 181 W. Meadow Dr., Suite 400, Vail, CO 81657 USA
Future work

According to Newman, along with including multiple institutions, in a follow-up study they hope to more accurately pinpoint which patients are skeletally immature and skeletally mature.

“We did not have the X-rays need to determine bone age because we did not want to expose the kids to that much radiation, so we did not have the definitive bone age of the patients,” Newman said.

Newman and his colleagues used age 14 years as a surrogate cutoff to compare patients, even though they knew some patients would be skeletally mature.

“We did that to stay in line with previous studies, but that is a definite limitation and we would like to, in the future, see exactly what the bone age is,” he said.

Perspective
This study investigates the management of ACL injuries in skeletally mature and immature adolescents. It adds to the limited research in this area and further defines the factors that contribute to associated intra-articular injury in the adolescent complete ACL tear. A delay in appropriate ACL reconstruction in this population resulted in further concomitant injury at all ages, with the older adolescent further injury being driven by a return to sport prior to reconstruction and an increased body mass. Severity of further concomitant injury also was related to an increased time to surgery in both groups, with the conclusion being that more prompt identification and subsequent intervention may help to improve overall outcomes in adolescent patients.

In 2013, our group at North Sydney examined the incidence of secondary pathology in more than 5,000 patients requiring ACL reconstruction. We had 431 patients younger than 17 years of age. The effect of delaying surgery on the medial meniscus was more pronounced in this group with a two-or four-times increased odds of medial meniscal surgery with a delay of greater than 4 months or 12 months, respectively. There was also no relationship between a delay in surgery and the presence of lateral meniscal injury, and this also was found in Newmans study in the adolescent group.

There is ongoing support in the literature that continues to support the trend in clinical practice that prompt attention to diagnosis and stabilization of the adolescent ACL injury is vital to the prevention of further concomitant and severe meniscal and chondral injuries that may result from a delay in appropriate surgical intervention. There is no role for surgical intervention without associated ACL reconstruction.

Justin Roe, (UNSW), MB, BS, BSc (Med) Hons, FRACS
Associate Professor Chairman, Mater Hospital Orthopaedic Department
North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, New South Wales, Australia
Advances in reconstructive techniques that avoid physeal arrest coupled with unfavorable outcomes in patients treated nonoperatively have led to a more aggressive surgical approach to ACL tears in pediatric patients. The study by Newman and colleagues investigated those factors associated with concomitant meniscal and chondral injury in patients younger than 14 years (n=66) compared to those who were aged 14 years to 19 years (n=165) at the time of ACL reconstruction. They found the prevalence of concomitant injuries and the need for additional operative procedures was greater in the older patients. A delay in surgery beyond 3 months and return to activity prior to surgery correlated with an increased risk of concomitant injuries in both groups. Furthermore, obesity was significantly related to an increased risk of concomitant injuries in the older group.

These results are consistent with prior research that has shown a delay in ACL reconstruction beyond 3 months is associated with an increased risk of meniscal injury. This is the first study to compare concomitant knee injuries in a group of skeletally immature patients with those who are skeletally mature at the time of ACL reconstruction. The separation of the two groups based on the age of 14 years is an arbitrary cutoff; and analysis of the patients bone age and remaining growth was not performed. Nevertheless, this study suggests that prompt identification and subsequent operative intervention within 3 months of an ACL injury may be beneficial in preventing the development of significant concomitant knee injuries and improve overall outcomes in pediatric patients.

Matthew Matava, MD
Professor and Chief of Sports Medicine
Washington University Orthopedics, St. Louis, USA

Source Healio Orthopaedics Today Europe

The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction, Sri-Ram K, Salmon LJ, Pinczewski LA, Roe JP. Bone Joint J. 2013 Jan;95-B(1):59-64. doi: 10.1302/0301-620X.95B1.29636.

Factors predictive of concomitant injuries among children and adolescents undergoing anterior cruciate ligament surgery, Newman JT, Carry PM, Terhune EB, Spruiell MD, Heare A, Mayo M, Vidal AF. Am J Sports Med. 2015 Feb;43(2):282-8. doi: 10.1177/0363546514562168. Epub 2014 Dec 23.

Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction, Anderson AF, Anderson CN. Am J Sports Med. 2015 Feb;43(2):275-81. doi: 10.1177/0363546514559912. Epub 2014 Dec 12.

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