ACL Tears in Children: Conservative Management

Chantal Janelle M.D., FRCSC
Assistant Professor, Department of Surgery
Montreal Children Hospital & Shriners Hospital for Children
McGill University
Montreal, QC

Anterior cruciate ligament (ACL) tears in children are increasingly recognized. Shea et al reported an analysis of 8215 insurance claims filed on behalf of six million soccer players (5-18 y.o.). There was a significant increase in ACL injury at the age of 11-12 years1.

The most common mechanism of injury to the ACL is the non-contact pivot mechanism2. The typical history is a twisting injury to the knee, sensation of a pop, immediate swelling and pain and inability to return to play. The most important diagnostic tool remains the physical exam3. Detection of an effusion, assessment of range of motion (ROM), palpation to localize tenderness are important aspects of the clinical exam. Laxity is assessed in all planes, bilaterally. X-rays including AP, Lat, Skyline and Tunnel views are obtained. MRI may be ordered to confirm ACL tear and to assess meniscal and articular cartilage damage.

The natural history of untreated ACL injury in children mirrors that seen in adults. Aichroth et al reported the natural history of ACL injury in children and adolescents. Sixty children and adolescents with ACL tear were reviewed prospectively, over 10 years. The untreated group (23 patients, aged 11 to 15) showed poor function and severe knee instability. Ten patients developed osteoarthritic changes on X-rays4.

Treatment of ACL mid-substance tear in skeletally immature patients is controversial. The potential for growth disturbance is a major factor affecting decision-making regarding the management of ACL injury. On the other hand, conservative treatment places the non-compliant patient at risk of recurrent knee instability during practice of high-risk sports, leading to further meniscal and cartilagineous knee damage4,5. The goal of any treatment should be to prevent recurrent injury in order to avoid intra-articular damage and degenerative arthritis, while preserving growth.

Mohtadi performed a systematic literature review to answer whether early ACL reconstruction results in an improved outcome compared with nonsurgical treatment or delaying surgery until skeletal maturity in the paediatric athlete. Among the analyzed articles, only seven provided comparisons between surgical and nonsurgical treatment. Several of these studies6,7,8 combined patients with growth remaining and patients near skeletal maturity. The authors concluded that the evidence for managing this population is weak. They proposed a practical management algorithm9.

Woods and O'Connor compared 13 patients who underwent delayed surgical treatment at skeletal maturity to a group of skeletally mature adolescents who received the same type of ACL reconstruction as the first group. The patients and their families in the delayed surgical group were advised about the risk of re-injury. These patients were given specific rehabilitation exercises, were excused from participating in vigorous team sports and were prescribed an inexpensive off-the-shelf ACL brace with hyperextension stops to be worn during the daytime. The results were comparable in all groups. The authors concluded that intentionally delaying ACL reconstruction does not increase the rate of additional knee injuries10.

Conservative treatment features three important aspects: 1) rehabilitation, 2) activity modification and 4) functional knee bracing.

In a review article on diagnosis and treatment of ACL injury in the skeletally immature patient, the reported nonoperative management consisted of a three-phase programme11. PHASE 1 (7-10 days): crutched protected weight bearing, daily active ROM, active assisted and passive ROM. PHASE 2 (6 weeks): Formal rehabilitation with the goal of re-establishing the muscle balance especially normalization of quadriceps-hamstrings strength ratio and full ROM. PHASE 3: Return to low and moderate demand sports when the lower extremity strength is that of the uninjured side.

Activity modification is the key to conservative management10.The high demand sports: football, soccer, hockey, basketball, volleyball, gymnastics, wrestling are avoided. Moderate demand sports such as baseball, softball, track and tennis12 as well as low demand sports can be considered after assessment of the ability to perform sport-specific tasks12. Patients must be followed closely6,11.

Graf et al identified 12 skeletally immature patients with ACL rupture. Eight patients received quadriceps and hamstrings rehabilitation and returned to sports (football, basketball and physical education classes) with bracing. All patients developed severe knee instability. The authors comment on the fact that these athletic patients did not make significant attempts at activity modification13.

Functional knee braces are widely used to protect the injured or reconstructed ACL. Beynnon et al showed that several commercially available braces were capable of reducing antero-posterior laxity to within normal limits during weight bearing and non weight bearing activities14. The patient and his or her family should understand that wearing the brace does not permit participation in high-risk sports.

There are a few exceptions to conservative management. Surgical treatment may be considered for non-compliance or persistence of symptoms despite appropriate conservative treatment15,16. Patients presenting with a meniscal injury associated with the ACL tear could be considered candidates for surgical ACL reconstruction16. Arthroscopic treatment of the meniscal tear with a delayed ACL reconstruction at skeletal maturity is an option for the compliant patient6,9.

In conclusion, conservative treatment should be used for most patients as a temporizing measure until cessation of growth when an anatomical ACL reconstruction could be safely performed. The main risk of the non-surgical approach is that the young athlete may continue to practice high-risk sports and sustain further intra-articular injuries to his knee. Careful monitoring of the patient is mandatory. Further studies with improved design are necessary to provide concrete guidelines for the treatment of ACL injuries in children.

References

  1. Shea K.G., Pfeiffer R., Wang J.H., Curtin M., Apel P.J.: Anterior Cruciate Ligament Injury in Pediatric and Adolescent Soccer Players: An Analysis of Insurance Data. JPO 24(6)623-628, 2004.
  2. Johnson D. Conference Report - ACL Injury and Open Physes in the Young Athlete. AOSSM 29th Annual Meeting;July 20-23, 2003 San Diego California.
  3. Stanitski C.L.: Correlation of Arthroscopic and Clinical Examinations with Magnetic Resonance Imaging finding of Injured Knees in Children and Adolescents. Amer J. Sports Med 26:(1)2-6, 1998
  4. Aichroth P.M., Patel D.V., Zorrilla P.: The Natural History and Treatment of Rupture of the Anterior Cruciate Ligament in Children and Adolescents - A Prospective Review. J Bone Joint Surg [B] 84B:38-41, 2001
  5. Millett P.J., Willis A.A., Warren R.F. Associated Injuries in Pediatric and Adolescent Anterior Cruciate Ligament Tears: Does a delay in Tratment Increase the risk of Meniscal Tears? J Arthroscopy & Related Surg. 18(9)955-959, 2002.
  6. McCarroll J.R., Shelbourne D., Porter D.A., Retting A.C., Murray S.: Patellar Tendon Graft Reconstruction for Midsubstance Anterior Cruciate Ligament Rupture in Junior High School Athletes - An Algorith for Management. Amer J. Sports Med 22:(4)478-484, 1994
  7. Janarv P-M., Nystrm A., Werner S., Hirsch G. Anterior Cruciate Ligament Injuries in Skeletally Immature Patients. JPO 16(5)673-677, 1996
  8. Pressman A.E., Letts R.M., James J. Antarior Cruciate Ligament Tears in Children: An Analysis of Operative versus Nonoperative Treatment. JPO 17(4)505-511, 1997
  9. Mohtadi N., Grant J.: Managing Anterior Cruciate Ligament Deficiency in the Skeletally Immature Individual: A Systematic Review of the Literature. Clin J Sport Med 16:(6)457-464, 2006
  10. Woods G.W., O'Connor D.P. Delayed Anterior Cruciate Ligament Reconstruction in Adolescent with Open Physes. Amer J. Sports Med. 32(1)201-210, 2004.
  11. Stanitski C.L. Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosis and Treatment. JAAOS (3)146-158, 1995
  12. Dorizas J.A., Stanitski C.L. Anterior Cruciate Ligament Injury in the Skeletally Immature. Orthop Clin N Am (34)355-363, 2003.
  13. Graf B.K., Lange R.H., Fujisaki K., Landry G.L., Saluja R.K. Anterior Cruciate Ligament Tears in Skelatelly Immature Patients: Meniscal Pathology at Presentation and after Attempted Conservative Treatment. J Arthroscopy & Related Surg. 8(2)229-233, 1992.
  14. Beynnon B.D., Fleming B.C., Churchill D.L., Brown D. The Effect of Anterior Cruciate Ligament Deficiency and Functional Bracing on Translation of the Tibia Relative to the Femur during Nonwerghtbearing and Weightbearing. Amer J. Sports Med 31:(1)99-105, 2003.
  15. Larsen M.W., Garrett Jr. W.E., DeLee J.C., Moorman C.T. Surgical Management of Anterior Cruciate Ligament Injuries in Patients with Open Physes. JAAOS 14:736-744, 2006.
  16. Utukuri M.M., Somayaji H.S., Khanduja V., Dowd G.S.E., Hunt D.M. Update on Paediatric ACL Injuries. The Knee 13:345-352, 2006.

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