PREVALENCE OF CONCOMITANT PATHOLOGY IN SKELETALLY IMMATURE PATIENTS WITH ANTERIOR CRUCIATE LIGAMENT TEARS
Authors: Vogel Laura A. , Kostyun Regina O. , Pace J. Lee , Gelber Jonathan D. , Nissen Carl W. 
Published: March 2019

Background: Historically, anterior cruciate ligament (ACL) injuries in children were treated non-operatively with delayed surgical reconstruction. More recently, there has been increasing literature that suggests delaying surgical reconstruction after ACL injury results in inferior outcomes and increased secondary meniscal and chondral injury in young athletes. Multiple studies have focused on the rates of these concomitant injuries in young athletes, but many of these studies include older athletes nearing or at the point of skeletal maturity and few include skeletal bone age determination. Thus, the rates of concomitant pathology in skeletally immature patients is unknown. The purpose of this study was to describe the prevalence of concomitant pathology found in a group of skeletally immature and compare them to a similar group of skeletally mature patients undergoing ACL reconstruction. Methods: The surgical case log for four orthopaedic surgeons within the sports medicine department of a children’s hospital were reviewed over a ten-year period. Patients were grouped based on skeletal maturity; skeletally immature (SI), approaching skeletal maturity (AM), and skeletally mature (SM). Operative diagnoses were obtained from the operative reports. Patient demographics including sex, bone and chronological age as well as injury and surgical dates were collected from clinical notes. Descriptive statistics were computed for patient demographics and surgical findings. A chi square analysis was completed to understand the prevalence rate among the three groups and a logistical regression was conducted to understanding the association between timing from injury to surgery and presence of concomitant pathology. Results: Our cohort consisted of 535 patients, 66 SI patients (46 males, 20 females; avg chronological age 12.9±1.6 years; avg bone age 13.2 years), 276 AM patients (118 males, 158 females; avg chronological age 15.2±1.2 years; avg bone age 14.9 years), 193 SM patients (107 males, 86 females; avg chronological age 20.3±6.0 years). All patients in the SI group were treated with a physeal sparing technique (61 patients - hybrid sparing technique, 4 patients - femoral and tibial sparing technique, 1 patient - extra-articular reconstruction). Concomitant pathology was present in 38% of SI patients compared to 52% of AM patients and 57% of SM patients. Meniscal injury was the predominant concomitant pathology in the SI group (37.9%); only a single patient had a second ligament reconstructed in addition to their ACL. In comparison, meniscal pathology was also the predominant concomitant pathology in both the AM (48.9%) and SM (51.8%) groups along with chondral lesions (AM 2.2%, SM 3.1%) and multi-ligament injuries (AM 0.4%, SM 4.1%). Lateral meniscal injuries were seen more often than medial meniscal injuries for all groups. A statistical difference was found between groups for the prevalence of concomitant pathology, with the SI group having less than the AM group (p = 0.042) and SM group (p = 0.007). The average time from injury to surgery was shorter for SI patients, 60±43 days compared to 105±208 days (AM group) and 123±185 days (SM group). The results of the logistical regression did not show an association between days from injury to surgery and presence of concomitant pathology in the SI group, but did reveal an association for the AM (p = 0.004; OR 1.004) and SM (p = 0.013; OR 1.002) groups. Conclusion: This is the first article that compares the rates of concomitant pathology in a well-defined group of skeletally immature patients undergoing ACL reconstruction surgery to a skeletally mature cohort. We found that skeletally immature patients had less concomitant pathology than skeletally mature patients.