Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury.

OBJECTIVE: To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction. DESIGN: Prognosis systematic review (PROSPERO registration number CRD42016036788). METHODS: We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology. RESULTS: Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%-21% when follow-up was <2 years, 0%-29% when follow-up was 2 to 5 years, 5%-52% when follow-up was 5 to 10 years and 4%-31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low. CONCLUSION: New meniscal tears occurred in 0%-52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

Knee Pathology in Young Adults After Pediatric Anterior Cruciate Ligament Injury: A Prospective Case Series of 47 Patients With a Mean 9.5-Year Follow-up.

BACKGROUND: The rate of secondary knee injuries after pediatric anterior cruciate ligament (ACL) injury is uncertain, and previous studies are limited because of poor methodology. PURPOSE: To evaluate the incidence of new meniscal injuries since the initial diagnostic magnetic resonance imaging (MRI) of young adults who sustained a pediatric ACL injury. In addition, to evaluate meniscal and cartilage injuries in the index knee and contralateral knee injuries on MRI at final follow-up (9.5 years). Furthermore, to assess leg length and alignment based on long-leg radiographs. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Study population at final follow-up included 47 young adults who sustained a pediatric ACL injury before age 13 years. They were followed prospectively since the time of injury for a mean 9.5 years at final follow-up. Imaging included diagnostic MRI of the index knee and 3.0-T MRI of both knees at 1-, 2-, and 9.5-year follow-up, in addition to long-leg radiographs at final follow-up. Forty-three patients underwent active rehabilitation without ACL reconstruction initially; 4 were treated with initial ACL reconstruction. At final follow-up, 27 (57%) had undergone ACL reconstruction. RESULTS: Fourteen patients had meniscal tears in the index knee at final follow-up (prevalence, 30%). The majority of these were in the same location as previously repaired tears (n = 9). Between diagnostic MRI and final follow-up, 16 patients had sustained new meniscal tears to a healthy meniscus (incidence, 34%). At final follow-up, meniscal injuries recorded at baseline or during follow-up were no longer visible and appeared healed in 17 patients (20 tears). MRI at final follow-up showed cartilage injuries in the index knee of 13 patients (28%) and contralateral injuries in 8 patients (meniscus, n = 2; cartilage, n = 5; subchondral fracture, n = 1). Two patients had a leg-length difference >15 mm, and 3 had side-to-side difference in knee alignment >5°. CONCLUSION: The incidence of new meniscal tears after pediatric ACL injury was 34% during a mean follow-up period of 9.5 years. At final follow-up, 27 patients (57%) had normal menisci, and none had developed knee osteoarthritis. Primary active rehabilitation, close follow-up, and delayed surgery if needed may be a viable and safe treatment option for some pediatric ACL injuries.

Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years' Follow-up.

BACKGROUND: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. PURPOSE: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-six children aged <13 years with a total intrasubstance ACL injury were included. None of these patients had additional injuries that warranted early surgery. At final follow-up at a mean 8 years after the time of injury, 44 patients remained in the study. The same test battery was conducted at baseline, 1 and 2 years, and final follow-up at approximately 18 years of age. The test battery included functional tests (hop tests and isokinetic muscle strength tests of quadriceps and hamstrings), patient-reported outcome measures (including the Knee injury and Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form), and clinical examination. Medical records were reviewed to assess surgical history and complications. RESULTS: At a mean 8 years of follow-up, 24 patients (55%) had undergone ACL reconstruction, and 16 (36%) had undergone meniscal surgery. Quadriceps muscle strength symmetry was >90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. CONCLUSION: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

New meniscal tears after ACL injury: what is the risk? A systematic review protocol.

BACKGROUND: Secondary meniscal tears after ACL injuries increase the risk of knee osteoarthritis. The current literature on secondary meniscal injuries after ACL injury is not consistent and may have methodological shortcomings. This protocol describes the methods of a systematic review investigating the rate of secondary meniscal injuries in children and adults after treatment (operative or non-operative) for ACL injury. METHODS: We will search electronic databases (Embase, Ovid Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, PEDro and Google Scholar) from database inception. Extracted data will include demographic data, methodology, intervention details and patient outcomes. Risk of bias will be assessed using the Newcastle Ottawa checklist for cohort studies. Article screening, eligibility assessment, risk of bias assessment and data extraction will be performed in duplicate by independent reviewers. A proportion meta-analysis will be performed if studies are homogeneous (I2<75%). If meta-analysis is precluded, data will be synthesised descriptively using best-evidence synthesis. The strength of recommendations and quality of evidence will be assessed using the Grading of Recommendations Assessment Development and Evaluation working group methodology. ETHICS AND DISSEMINATION: This protocol is written according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses, and was registered in the International Prospective Register of Systematic Reviews on 22 March 2016. TRIAL REGISTRATION NUMBER: CRD42016036788.