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From the American Orthopaedic Society for Sports Medicine

Delay in ACL Surgery Increases Risk of Permanent Injury

Early reconstructive surgery recommended for athletes under age 14

Delaying surgery to repair a torn anterior cruciate ligament (ACL) in young athletes under the age of 14 significantly increases the risk of irreparable joint damage, says a new study. Early reconstructive surgery is recommended.

"Parents should understand that early reconstruction of the ACL, before any other damage to the knee, gives their child the best chance of a good outcome in the future.  Once other structures in the knee are damaged, the final outcome may not be as good, no matter what the surgeon does at the time of reconstruction." 

"Telling kids in this age group [who have torn ACLs] to be careful simply does not work, " says Dr. Darren Johnson, Chairman of the Department of Orthopedic Surgery and Director of Sports Medicine at the University of Kentucky, "because they do not appreciate the ramifications of their injury and the problems created if they re-buckle their knee."

"The bottom line, even for young kids, is that delaying ACL surgery and reconstruction puts an athletically or even a normally active teenager at significant risk for re-injury, and, most importantly, for injury to other structures in the knee," says Dr. Johnson. 

Dr. Johnson says that the only athlete who may delay surgery until his bones are mature is the "coach potato" who does nothing but play XBox, watch television and engage in other sedentary activities.  "Unfortunately, kids like that don't tear their ACL; it is the very active teenager who suffer this type of injury," he notes.

Study details

The study,  which was presented at the 2009 Annual Meeting of the American Orthopaedic Society for Sports Medicine,  linked a delay in ACL surgical reconstruction of more than 12 weeks to:

  • a 4-fold increase in irreparable tears of the medial meniscus;
  • an 11-fold increase in lateral compartment chondral injuries; and
  • a 3-fold increase in patellotrochlear injuries. 
  • Knee instability also increased significantly.

"The risk of inducing a growth disturbance with early reconstruction of a torn ACL must be balanced against the risk of further knee damage by delaying treatment until 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 the lead author, Theodore J. Ganley, MD, Director of the Sports Medicine and Performance Center for The Children's Hospital of Pennsylvania and the University of Pennsylvania School of Medicine.

"Given that both ACL injury and meniscal damage are independent risk factors for the development of osteoarthritis, these data argue strongly in favor of early ACL reconstruction in this population," the investigators concluded.

Researchers analyzed the records of 69 patients, 14 years of age and younger who had undergone ACL reconstruction between 1991 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 MRI findings and physical exam findings. Operative reports and intra-operative images were also used to classify meniscal and articular cartilage pathology.

All of the patients were counseled as to the benefits and risks of delaying ACL reconstruction and advised to avoid any at-risk activities along with participating in physical therapy prior to their reconstruction. If the decision was made to delay treatment, patients were instructed to wear a custom ACL brace. All patients who underwent the surgery utilized a soft tissue graft with anatomically placed tunnels and fixation devices that did not cross the growth plate. Patients were also followed for a minimum of one-year post-operatively with no growth disturbances being noted.

"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 Ganley.

Source: American Orthopaedic Society for Sports Medicine

Created July 18, 2009