#surgeryornot

       It is known that the Anterior Cruciate Ligament (ACL) provides stability to the knee. If the ACL is intact, then it can protect other structures such as the meniscus, from the shear forces of twisting. Years ago it seemed as if an ACL tear was more likely to be found in adults who participated in twisting/cutting sports. However, recently more and more children are participating in competitive sports, especially females since the implementation of Title IX.  ACL risks of tear increases in females aged 12-14 and in males aged 14-15.  By the age of 14 years old, girls have five times higher rates compared to boys. [1] The exact incidence of ACL tears in adolescents is unknown due to the lack of large-scale studies; however many studies have found that incidence is between .5-3%. [2]

       Because children are not skeletally mature, there are differing risks associated with ACL treatment compared to adults. Surgical options often have good results, but because the surgery involves drilling through the growth plates many physicians still recommend against it due to the possibility of growth plate arrest and limb length dysfunctions. [1] When conservative treatment is decided upon, questions generally arise: is return to sport possible, and is it safe to return to sport?

       A study by Mizuta et al, looked at 18 patients treated conservatively and followed for a minimum of 3 years. The study found that only 1 patient returned to their previous level of activity. Using the modified Lysholm knee score, it was found that only 1 patient reported excellent, 8 reported fair, and 8 reported poor. Additionally, six of the 18 patients suffered secondary meniscal injuries and degenerative changes were present in 11 of the 18. [3]

       Another study looked at conservative treatment and found similar results. The study found that eight of 12 skeletally immature patients with ACL tear returned to sport following conservative treatment. However, all 8 of them wore a brace and developed instability by 7 months and reported multiple accounts of the knee “giving out”.  Seven of the eight also developed a meniscal tear around 15 months post-original ACL injury. [4]

       A meta-analysis by Ramski et al, looked at non-operative versus operative treatment and compared return to sport, as well as adverse events.  Three studies in the analysis looked at return to sport. One study found that all patients returned to their previous level of sport. However, two other studies found that no patients returned to their previous level of play when treated conservatively. When combining the data it was found that 43.5% of patients treated conservatively returned to sport compared to 92% treated surgically. Adverse events included laxity and meniscal tears following the original ACL tear. Pathological laxity was found in 75% of patients when treated non-operatively compared to 13.6% of patients treated operatively. It was also found that non-operative treatment results in patients 12 times more likely to have a secondary meniscal tear compared to surgical treatment. [5]

       Internal validity of the studies is complicated due to the small sample size of the studies. It is difficult to get a large pool of adolescent subjects with an ACL tear and even more difficult to find a pool of patients who decide to be treated conservatively.  Additionally, many of the subjects ended up having secondary meniscus tears, but the studies do not consider the activity the patient returned to. For instance, high impact sports may have resulted in a meniscal tear regardless of previous injury. External validity in regards to generalizability and replication was good in the sense that drop out rates are low and the same results would most likely be found if studies were replicated. However, to avoid error it would be of benefit to look at the specific sports since different sports demand different forces and level of agility. Again, though, with the small sample size of this population specific sport studies would be near impossible to complete.   

       When consulting with a practicing physical therapist of 14 years in an outpatient sports performance setting, he said his experience is very near the evidence. Like the research, he explained that he has not see a whole bunch of these patients to compare. Additionally, he said very few of adolescents treated conservatively with an ACL tear were able to successfully return to sport. Clinically, he has seen better outcomes when adolescents are treated surgically.

       According to the literature and clinical practice, it appears to be unsafe for an adolescent to return to sport following an ACL tear if treated conservatively. The risks are high for an adverse event especially around 6-15 months post injury, which is dangerous since this is around the time patients may feel they are ready to return to sport. Clinically, we should educate our patients on the risks associated with return to sport following ACL tear in the skeletally immature patient who decides to be treated conservatively.  

References

 [1]Carl, R. L.,(2009). Anterior cruciate ligament injuries in young athletes. Retrieved from http://www2.luriechildrens.org/ce/online/article.aspx?articleID=220#credit-statement

[2] Alharby, S. W. (2010). Anterior cruciate ligament injuries in growing skeleton. International journal of health sciences, 4(1), 71–9. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3068805&tool=pmcentrez&rendertype=abstract

 [3] Mizuta, H., Kubota, K., Shiraishi, M., Otsuka, Y., Nagamoto, N., & Takagi, K. (1995). The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. The Journal of Bone and Joint Surgery, 77(6), 890–894. Retrieved from http://www.bjj.boneandjoint.org.uk.proxy.kumc.edu:2048/content/77-B/6/890.long

[4] Graf, B.K., Lange R.H., Fujisaki, C.K., Landry, G.L., & Saluja, R.K. (1992). Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attemped conservative treatment. Arthroscopy, 8(2), 229-233. Retrieved from http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/1637437