Abstract & Commentary
Synopsis: This report prospectively examined the functional outcome of partial ACL tears in 45 children and adolescents treated conservatively.
Source: Kocher MS, et al. Functional outcome of the conservative treatment of partial tears of the ACL in children and adolescents. Am J Sports Med. 2002;30(5):697-703.
ACL ruptures in children and adolescents are a growing problem in sports medicine. Though the true incidence and prevalence are unknown, the numbers are definitely increasing. The appropriate treatment for ACL tears, especially partial tears, is controversial. Intra-articular repair across open physes may be contraindicated due to possible growth disturbances. In addition, children have greater ligament healing potential. The results of nonsurgical treatment of complete ACL tears in the pediatric population have been poor, but the results of conservative treatment of partial tears have not been established. The purpose of this study was to report the functional outcome of partial tears of the ACL in the pediatric population and determine risk factors for the failure of conservative treatment.
This was a well-done, prospective cohort study of 45 immature and mature patients, age 17 and younger. All had a Lachman and pivot shift test of grade A or B (normal or near-normal) and arthroscopic evidence of a partial ACL tear and did not undergo ACL reconstruction (initially).
The statistical analysis was appropriate and well designed. It progressed from univariate inter-group comparisons to multivariate analyses and survivorship analyses. The results were well supported. Thirty-one percent of patients went on to ACL reconstruction an average of 13.5 months postinjury. Univariate analysis demonstrated significant associations between the need for reconstruction and 1) tears of greater than 50%; 2) predominantly posterolateral tears; 3) grade B pivot shift test; and 4) old chronological and skeletal age. Multivariate analysis identified only 1 and 2 as significant predictors of subsequent ACL reconstruction.
Comments by Timothy E. Hewett, PhD
This is a very strong study of ACL injury and conservative treatment in the young, athletic population. The prospective study design is a good one. Kocher and associates recommend nonoperative treatment for partial ACLs in patients 14 years or younger with near-normal Lachman and pivot shift tests. They recommend reconstruction in athletes who are older or have a greater than 50% tear or who have a predominantly posterolateral tear. I believe Kocher et al’s recommendations to be well founded based on the study results. They stayed well within their findings in the discussion. I highly recommend this study for those physicians who deal with ACL injury in the pediatric population.
Dr. Hewett, Director and Assistant Professor, The Sports Medicine Biodynamics Center, University of Cincinnati College of Medicine, Cincinnati, OH, is Associate Editor of Sports Medicine Reports.