Correlation of Meniscal and Chondral Injuries to Chronicity of ACL Tears in Children and Adolescents

OBJECTIVES: The increase in ACL injuries among children and adolescents has intensified debate about the timing of ACL reconstruction in this age group. Historically, the prevailing opinion was that non-operative management until skeletal maturity was the treatment of choice. There is now some evidence to suggest that early reconstruction is preferable because increased time from injury to surgery may be associated with a higher rate of meniscal and articular cartilage injury. The purpose of this observational cohort study was to assess the risk of meniscal and chondral injury with delay of ACL reconstruction. Our hypotheses were that increased time from injury to surgery, recurrent giving-way, and return to sports participation prior to reconstruction was associated with a higher rate of meniscal and articular cartilage injuries. METHODS: After obtaining IRB approval, 135 consecutive patients, ages 8-16, (mean 13.8) with ACL tears were evaluated. The time from injury to surgery was divided into three periods: acute, less than six weeks; subacute, six weeks to three months; and chronic, greater than three months. The type and grade of lateral and medial meniscus tears was documented according to the ISAKOS Meniscal Documentation Criteria and chondral injury location and grade was documented according to the ICRS Criteria. RESULTS: There were 62 patients who were treated acutely, 37 subacute, and 36 chronic. One hundred twelve meniscal tears, 70 lateral and 42 medial, were found in this cohort. Eighty percent of the patients, ages 8 - 12 had a meniscal tear and 84% of patients ages 13 - 16 had a meniscal tear. Multi-variant logistic regression revealed the risk factors for lateral meniscus tears were younger age (P = .007) and increased time to surgery (P = .008). The odds ratio of lateral meniscus tears for patients who had a single episode of instability was 3.1. For time to surgery, the odds ratio was 1 for acute reconstruction, 2.6 for subacute, and 2.59 for reconstruction of chronic injuries. The odds ratio for increased grade of tear was 3.3 for a giving-way episode and 6.5 for increased time to surgery. For medial meniscus tears, the risk factors were: older age (P = .001), increasing time to surgery (P = .007), return to sports (P = .044), and instability episodes (P = .001). Risk factors for increasing grade of medial meniscus tears were: time to surgery, return to sports, and any instability episode (P = < .001 for all). The odds ratio for increasing frequency of medial meniscus tears was 4.7 for an instability episode, 8.08 for having played sports prior to reconstruction, and 4.49 for increased time to surgery. The odds ratio for having increased severity of meniscal tears was: any instability episode 6.61; having played sports prior to reconstruction 15.25, and time to surgery 4.28. There were 17 chondral injuries in this cohort. The risk factors for chondral injury were: increased time to surgery (P = .005) and any instability episode (P = .001). For increased grade of chondral injury, the risk factors were: time to surgery (P = less than .001) and any instability episode (P = .003). CONCLUSION: These data provide evidence that initial nonoperative treatment of ACL tears in this age group carries a high risk of additional meniscal and chondral injury, which may result in long-term knee impairment.