Meniscal, chondral injuries are more severe when surgery is delayed

More children are participating in sports and getting hurt while they play each year. A new study presented at the 2009 American Orthopaedic Society for Sports Medicine Annual Meeting details the benefits and risks of reconstructing a torn anterior cruciate ligament (ACL) in athletes younger than age 14 (Fig. 1).

“The risk of inducing a growth disturbance with early reconstruction of a torn ACL must be balanced against the risk of incurring further knee damage by delaying treatment until the child is closer to skeletal maturity. Our study measured the independent risk factors for and relative risk of meniscal and chondral injuries in pediatric ACL patients,” said author Theodore J. Ganley, MD.

Researchers analyzed the records of 70 patients (14 years of age and younger; average age 12.9 years) who had undergone ACL reconstruction between 1995 and 2005. Data collected included demographics, relevant history (mechanism and side of injury, time from injury to surgery, one or more episodes of instability with activity, use of brace, and return to sports), earliest magnetic resonance imaging findings, and physical exam findings. Operative reports and intraoperative images were also used to classify meniscal and articular cartilage pathology.

All of the patients and their parents were counseled on the benefits and risks of delaying ACL reconstruction; 29 patients delayed surgery more than 12 weeks (range: 12 weeks to 248 weeks). Patients were advised to avoid any at-risk activities and to participate in physical therapy prior to their reconstruction. If the decision was made to delay treatment, patients were instructed to wear a custom ACL brace.

Patients who underwent the surgery were treated with a soft-tissue graft with anatomically placed tunnels and fixation devices that did not cross the growth plate. Patients were followed for a minimum of 1 year postoperatively, and researchers noted no growth disturbances.

“The patients were given a choice of autograft or allograft,” says coauthor J. Todd Lawrence, MD, PhD. “We currently use hamstring autograft primarily.”

“In our study—the largest of skeletally immature patients to evaluate independent risk factors for intra-articular pathology—a delay in treatment of more than 12 weeks had about a 4-fold increase in irreparable medial meniscus tears, an 11-fold increase in lateral compartment chondral injuries, and a 3-fold increase in patellotrochlear injuries as compared to those who had earlier reconstruction. Issues with instability in the knee also increased significantly,” reported Dr. Ganley.

The damage occurred despite activity modification, bracing, and continued rehabilitation. In addition, a single reported episode of instability was associated with an 11-fold increase in irreparable medial meniscus pathology.

“Our results highlight and help quantify the risk associated with delaying ACL reconstruction in young athletes and the need for continued injury prevention efforts,” said Dr. Ganley.

“Based on the results of this study, we believe that early reconstruction with a physeal sparing technique is warranted,” concluded Dr. Ganley. “As a result, Dr. Lawrence and I have developed and use an anatomic all-epiphyseal technique.”

Dr. Ganley’s coauthors for “Anterior cruciate ligament rupture in patients with significant growth remaining: What is the risk to the meniscus and cartilage when treatment is delayed?” included Dr. Lawrence, and Nina Agrawal, BA. The authors report no conflicts of interest.