title: Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment.
abstract: BACKGROUND
  Debate regarding the optimal initial treatment for anterior cruciate ligament (ACL) injuries in children and adolescents has not resulted in a clear consensus for initial nonoperative treatment or operative reconstruction.
  
  
  OBJECTIVE
  The purpose of this meta-analysis was to systematically analyze aggregated data from the literature to determine if a benefit exists for either nonoperative or early operative treatment for ACL injuries in the pediatric patient. The hypothesis was that combined results would favor early operative reconstruction with respect to posttreatment episodes of instability/pathological laxity, symptomatic meniscal tears, clinical outcome scores, and return to activity.
  
  
  METHODS
  Meta-analysis.
  
  
  METHODS
  A literature selection process included the extraction of data on the following clinical variables: symptomatic meniscal tears, return to activities, clinical outcome scores, return to the operating room, and posttreatment instability/pathological laxity. A symptomatic meniscal tear was defined as occurring after the initial presentation, limiting activity, and requiring further treatment. Instability/pathological laxity was defined for the sake of this study as having an episode of giving way, a grade ≥2 Lachman/pivot-shift test result, or a side-to-side difference of >4 mm as measured by the KT-1000 arthrometer. All studies were evaluated using a formal study quality analysis. Meta-analysis was conducted for aggregated data in each category.
  
  
  RESULTS
  Six studies (217 patients) comparing operative to nonoperative treatment and 5 studies (353 patients) comparing early to delayed reconstruction were identified. Three studies reported posttreatment instability/pathological laxity; 13.6% of patients after operative treatment experienced instability/pathological laxity compared with 75% of patients after nonoperative treatment (P < .01). Two studies reported symptomatic meniscal tears; patients were over 12 times more likely to have a medial meniscal tear after nonoperative treatment than after operative treatment (35.4% vs 3.9%, respectively; P = .02). A significant difference in scores between groups was noted in 1 of 2 studies reporting International Knee Documentation Committee (IKDC) scores (P = .002) and in 1 of 2 studies reporting Tegner scores (P = .007). Two studies reported return to activity; none of the patients in the nonoperative groups returned to their previous level of play compared with 85.7% of patients in the operative groups (P < .01). Study quality analysis revealed that the majority of the studies were inconsistent in reporting outcomes.
  
  
  CONCLUSIONS
  Meta-analysis revealed multiple trends that favor early surgical stabilization over nonoperative or delayed treatment. Patients after nonoperative and delayed treatment experienced more instability/pathological laxity and inability to return to previous activity levels than did patients treated with early surgical stabilization.
authors.affiliation: St Luke's University Health Network Orthopaedic Residency Program, Bethlehem, Pennsylvania, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Ramski
authors.affiliation: Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts.
authors.forename: Wajdi W
authors.initials: WW
authors.lastname: Kanj
authors.affiliation: Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania.
authors.forename: Corinna C
authors.initials: CC
authors.lastname: Franklin
authors.affiliation: Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Baldwin
authors.affiliation: Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania ganley@email.chop.edu.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Ganley
mesh_terms: D000293:Adolescent; D016118:Anterior Cruciate Ligament / Q000601:surgery; D000070598:Anterior Cruciate Ligament Injuries; D059549:Anterior Cruciate Ligament Reconstruction; D001915:Braces; D002648:Child; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000628:therapy*; D007718:Knee Injuries / Q000150:complications / Q000628:therapy*; D019233:Retreatment; D012421:Rupture / Q000628:therapy; D013165:Splints; D000070600:Tibial Meniscus Injuries; D057832:Watchful Waiting
keywords: adolescent; anterior cruciate ligament (ACL); management; meta-analysis; pediatric ACL reconstruction