Knee injuries, including anterior cruciate ligament tears, among young athletes seem to be rising in recent years. Increased participation in sports, increased diagnosis of ligament injuries with improvements in MRI, and single-sport specialization are just a few of the factors that could be involved with this spike in ACL tears.
We have also evolved with our surgical decision-making for ACL injuries in skeletally immature athletes. In earlier decades, concern for growth arrest from drilling through the growth plates led many surgeons to advocate that kids should wait until they were finished growing to have surgery. Recently, several studies have shown higher rates of secondary damage to the knee with delayed treatment of pediatric ACL injuries. Those risks, plus the development of surgical techniques to avoid the growth plates, have led to increasingly earlier ACL surgery for many injured kids.
A study presented last week at the American Orthopaedic Society for Sports Medicine’s Specialty Day in New Orleans looked at the long-term outcomes of ACL reconstruction among young kids. ACL surgeries are done largely to provide stability to the knee and allow the athlete to return to demanding sports or exercise. The researchers in this study, though, wanted to see how these kids were doing 10 to 20 years after surgery.
Long-term outcomes for kids after ACL surgeries
The authors followed 32 children who underwent ACL reconstruction between the ages of 12 and 16. 91% of the patients were available for follow-up at an average of 175 months after surgery. They found some valuable information on the long-term outcomes of these surgeries:
• Knee scores, activity levels, and health-related quality-of-life scores were comparable among patients who had undergone ACL surgeries to those outcomes among people with no history of ACL injury.
• Knees which underwent ACL reconstruction had significantly higher rates of osteoarthritis changes compared to the patients’ opposite, nonsurgical knees (65%, compared to 14%).
“Early reconstruction of ACLs is often the trend for young, more skeletally mature athletes to restore knee stability and prevent progressive meniscal and/or articular cartilage damage. Often these procedures do allow individuals to return to the playing field and continue an active lifestyle. However, it is still important to evaluate long-term effects such as osteoarthritis when considering surgeries for these pediatric patients,” said Olle Mansson, MD, the lead author of the study.
It would be possible to conclude that ACL surgeries done in kids lead to higher rates of osteoarthritis later in life and therefore should be avoided. Unfortunately the risk of further damage to the knee by delaying or avoiding surgery could cause even higher rates of osteoarthritis. While studies in adults also show higher rates of osteoarthritis in knees after ACL surgeries, they usually show even higher rates of arthritis changes in patients who suffer ACL tears but elect to avoid surgery.
The goals of ACL surgery include providing a stable knee to allow patients to return to sports and exercise. While return to sports after surgery can be challenging and is never guaranteed for patients at any age, playing with a knee that buckles or gives way might likely prove unsuccessful. Some of the long-term results for the patients in the study – the essentially equivalent knee scores, activity levels and health-related quality-of-life scores compared to nonsurgical patients – are encouraging.
Finally, young athletes and their parents need to understand that ACL injuries and surgeries are serious ones. Not only does a young athlete usually miss the remainder of the season, but also he often misses up to 12 months after surgery in the rehab process. While it is impossible to completely prevent any traumatic sports injury, parents and coaches could encourage kids to learn and perform ACL injury prevention exercises to try to decrease the risk of these devastating injuries.