ACL injuries have been increasing in frequency among young athletes in recent years. These are serious injuries in older athletes that usually require surgery in order to return to sports. They can present a particularly challenging dilemma in skeletally immature athletes in terms of treatment options and the timing of surgery. A study presented at the American Orthopaedic Society for Sports Medicine’s Annual Meeting highlights the risks of delaying ACL surgery for young athletes with ACL tears.

Arguments for and against delaying ACL surgery

For decades many orthopaedic surgeons have treated skeletally immature athletes with ACL injuries nonoperatively. Usually delayed treatment required the young athlete to refrain from playing sports and wear a brace. The theoretical advantages of delaying surgery included avoiding growth arrest from drilling tunnels in surgery, which could lead to leg length differences or angular deformities. The athlete would also mature, potentially helping them push through the many long months of physical therapy.

On the other hand, some studies in recent years have suggested that delaying ACL surgery might increase a young patient’s risk for secondary articular cartilage and meniscus tears.

Does a young athlete risk further damage by delaying ACL surgery?

Recent study identifies risk of delaying ACL surgery

Lead author Allen F. Anderson, MD, and others from the Tennessee Orthopaedic Alliance in Nashville, Tennessee reviewed the records of patients under the age of 17 who underwent ACL reconstruction between 2000 to 2012. They reviewed the charts and arthroscopic images from surgery to obtain information such as the number of episodes of knee instability, resumption of sports prior to surgery, and the number and type of meniscal tears.

The authors then grouped each of the 130 patients who underwent 135 ACL reconstructions (5 had injuries to the opposite knee) into three groups depending on the time from injury to surgery: acute (less than 6 weeks), subacute (6 weeks – 3 months), and chronic (greater than 3 months).

Increased risk of meniscus tears

The study clearly showed the risks of developing meniscal tears by delaying ACL reconstruction. A young patient who waits 6-12 weeks after injury to undergo surgery has 1.45 times greater risk of lateral meniscus injury. Waiting 12 weeks or more increased the odds 2.82 times. Likewise, delaying surgery by even 6 weeks increased the risk of medial meniscus tear 4.3 times.

“The present study provides more evidence of the sequelae associated with delaying ACL surgery in pediatric patients. Increased time from injury to surgery, recurrent injury, giving way, and resumption of sport activities prior to reconstruction were associated with a higher rate of meniscal and articular cartilage injuries,” the authors concluded in the study.

Also read:
Ask Dr. Geier – ACL injuries in young athletes
Higher rates of arthritis in later years for kids undergoing ACL surgery

Parents should at least consider surgery for their kids

It is certainly understandable why parents would be concerned to have a young child undergo reconstructive knee surgery before he or she has finished growing. As this and other recent studies have suggested, nonoperative treatment – even for a short period of time – might be problematic. Even with restriction of sports and an ACL brace, episodes of knee instability can develop and lead to further damage to the menisci and articular cartilage. Those secondary injuries, if they occur, can lead to long-term degeneration of the knee at a fairly early age.

“While parents and other caregivers have obvious reasons for concern over ACL surgery in young patients, it’s important to recognize when it may be beneficial,” commented Anderson. “If surgery now helps eliminate long-term knee problems, it’s certainly a good choice.”

Also listen to the discussion from The Dr. David Geier Show:
Episode 48: Why are ACL injuries increasing among kids? (starts at 4:13)