Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 12, pp 3738–3753 | Cite as

Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis

  • Jeffrey Kay
  • Muzammil Memon
  • Ajay Shah
  • Yi-Meng Yen
  • Kristian Samuelsson
  • Devin Peterson
  • Nicole Simunovic
  • Helene Flageole
  • Olufemi R. AyeniEmail author



To evaluate the association between surgical timing and the incidence of secondary meniscal or chondral damage in children and adolescents with anterior cruciate ligament (ACL) ruptures.


Three electronic databases, PubMed, MEDLINE, and EMBASE, were systematically searched from database inception until October 16, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported the incidence of meniscal and articular cartilage damage in children or adolescent athletes with ACL injuries as well as the timing of their ACL reconstruction (ACLR). Risk ratios were combined in a meta-analysis using a random effects model.


A total of nine studies including 1353 children and adolescents met the inclusion criteria. The mean age of patients included was 14.2 years (range 6–19), and 45% were female. There was a significantly decreased risk of concomitant medial meniscal injury in those reconstructed early (26%) compared to those with delayed reconstruction (47%) [pooled risk ratio (RR) = 0.49, 95% CI 0.36–0.65, p < 0.00001]. There was also a significantly reduced risk of medial femoral chondral (RR = 0.48, 95% CI 0.31–0.75, p = 0.001), lateral femoral chondral (RR = 0.38, 95% CI 0.20–0.75, p = 0.005), tibial chondral (RR = 0.45, 95% CI 0.27–0.75, p = 0.002), and patellofemoral chondral (RR = 0.41, 95% CI 0.20–0.82, p = 0.01) damage in the early reconstruction group in comparison to the delayed group.


Pooled results from observational studies suggest that early ACLR results in a significantly decreased risk of secondary medial meniscal injury, as well as secondary medial, lateral, and patellofemoral compartment chondral damage in children and adolescents. This study provides clinicians with valuable information regarding the benefits of early ACL reconstruction in children and adolescents, and can be used in the decision making for athletes in this population.

Level of evidence



Pediatric ACL Timing Early Meniscal damage Chondral damage 



There are no sources of funding to be declared.

Compliance with ethical standards

Conflict of interest

None of the authors have any conflicts of interest to declare.

Ethical approval

This is a systematic review of the literature and no ethical approval is required.

Supplementary material

167_2018_5012_MOESM1_ESM.docx (23 kb)
Supplementary material 1 (DOCX 23 KB)


  1. 1.
    Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH (2011) Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability. Am J Sports Med 39:2187–2193CrossRefGoogle Scholar
  2. 2.
    Anderson AF, Anderson CN (2015) Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction. Am J Sports Med 43:275–281CrossRefGoogle Scholar
  3. 3.
    Anderson AF, Anderson CN (2015) Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction. Am J Sport Med 43:275–281CrossRefGoogle Scholar
  4. 4.
    Ardern CL, Ekås G, Grindem H, Moksnes H, Anderson A, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi N, Reider B, Roe J, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L (2018) 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Knee Surgery Sport Traumatol Arthrosc. CrossRefGoogle Scholar
  5. 5.
    Chhadia AM, Inacio MCS, Maletis GB, Csintalan RP, Davis BR, Funahashi TT (2011) Are meniscus and cartilage injuries related to time to anterior cruciate ligament reconstruction? Am J Sports Med 39:1894–1899CrossRefGoogle Scholar
  6. 6.
    Crawford EA, Young LJ, Bedi A, Wojtys EM (2017) The effects of delays in diagnosis and surgical reconstruction of ACL tears in skeletally immature individuals on subsequent meniscal and chondral injury. J Pediatr Orthop. CrossRefPubMedGoogle Scholar
  7. 7.
    Dodwell ER, LaMont LE, Green DW, Pan TJ, Marx RG, Lyman S (2014) 20 years of pediatric anterior cruciate ligament reconstruction in New York State. Am J Sports Med 42:675–680CrossRefGoogle Scholar
  8. 8.
    Dumont GD, Hogue GD, Padalecki JR, Okoro N, Wilson PL (2012) Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relationship of treatment time and patient-specific factors. Am J Sports Med 40:2128–2133CrossRefGoogle Scholar
  9. 9.
    Fabricant PD, Lakomkin N, Sugimoto D, Tepolt FA, Stracciolini A, Kocher MS (2016) Youth sports specialization and musculoskeletal injury: a systematic review of the literature. Phys Sportsmed 44:257–262CrossRefGoogle Scholar
  10. 10.
    Fehnel DJ, Johnson R (2000) Anterior cruciate injuries in the skeletally immature athlete: a review of treatment outcomes. Sport Med 29:51–63CrossRefGoogle Scholar
  11. 11.
    Frosch K-H, Stengel D, Brodhun T, Stietencron I, Holsten D, Jung C, Reister D, Voigt C, Niemeyer P, Maier M, Hertel P, Jagodzinski M, Lill H (2010) Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy 26:1539–1550CrossRefGoogle Scholar
  12. 12.
    Guenther ZD, Swami V, Dhillon SS, Jaremko JL (2014) Meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? Clin Orthop Relat Res 472:990–997CrossRefGoogle Scholar
  13. 13.
    Guess TM, Razu S (2017) Loading of the medial meniscus in the ACL deficient knee: a multibody computational study. Med Eng Phys 41:26–34CrossRefGoogle Scholar
  14. 14.
    Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, Alonso-Coello P, Djulbegovic B, Atkins D, Falck-Ytter Y, Williams JW, Meerpohl J, Norris SL, Akl EA, Schünemann HJ (2011) GRADE guidelines: 5. Rating the quality of evidence—Publication bias. J Clin Epidemiol 64:1277–1282CrossRefGoogle Scholar
  15. 15.
    Henry J, Chotel F, Chouteau J, Fessy MH, Bérard J, Moyen B (2009) Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity? Knee Surgery Sport Traumatol Arthrosc 17:748–755CrossRefGoogle Scholar
  16. 16.
    Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR (2018) Over 90% of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surgery Sport Traumatol Arthrosc. CrossRefGoogle Scholar
  17. 17.
    Krych AJ, Pitts RT, Dajani KA, Stuart MJ, Levy BA, Dahm DL (2010) Surgical repair of meniscal tears with concomitant anterior cruciate ligament reconstruction in patients 18 years and younger. Am J Sports Med 38:976–982CrossRefGoogle Scholar
  18. 18.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159CrossRefGoogle Scholar
  19. 19.
    Lawrence JT, Argawal N, Ganley TJ (2011) Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Am J Sport Med 39:2582–2587CrossRefGoogle Scholar
  20. 20.
    Lawrence JTR, Argawal N, Ganley TJ (2011) Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear. Am J Sports Med 39:2582–2587CrossRefGoogle Scholar
  21. 21.
    Mantel N, Haenszel W (1959) Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 22:719–748PubMedGoogle Scholar
  22. 22.
    Millett PJ, Willis AA, Warren RF (2002) Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Arthroscopy 18:955–959CrossRefGoogle Scholar
  23. 23.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097CrossRefGoogle Scholar
  24. 24.
    Moksnes H, Engebretsen L, Eitzen I, Risberg MA (2013) Functional outcomes following a non-operative treatment algorithm for anterior cruciate ligament injuries in skeletally immature children 12 years and younger. A prospective cohort with 2 years follow-up. Br J Sport Med 47:488–494CrossRefGoogle Scholar
  25. 25.
    Moksnes H, Engebretsen L, Risberg MA (2013) Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: a prospective MRI study. Am J Sports Med 41:1771–1779CrossRefGoogle Scholar
  26. 26.
    Newman JT, Carry PM, Terhune EB, Spruiell MD, Heare A, Mayo M, Vidal AF (2015) Factors predictive of concomitant injuries among children and adolescents undergoing anterior cruciate ligament surgery. Am J Sports Med 43:282–288CrossRefGoogle Scholar
  27. 27.
    Noyes FR, Barber-Westin SD (2002) Arthroscopic repair of meniscal tears extending into the avascular zone in patients younger than twenty years of age. Am J Sport Med 30:589–600CrossRefGoogle Scholar
  28. 28.
    Placella G, Bartoli M, Peruzzi M, Speziali A, Pace V, Cerulli G (2016) Return to sport activity after anterior cruciate ligament reconstruction in skeletally immature athletes with manual drilling original all inside reconstruction at 8 years follow-up. Acta Orthop Traumatol Turc 50:635–638CrossRefGoogle Scholar
  29. 29.
    Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ (2014) Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sport Med 42:2769–2776CrossRefGoogle Scholar
  30. 30.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (Minors): development and validation of a new instrument. ANZ J Surg 73:712–716CrossRefGoogle Scholar
  31. 31.
    Vavken P, Tepolt FA, Kocher MS (2016) Concurrent meniscal and chondral injuries in pediatric and adolescent patients undergoing ACL reconstruction. J Pediatr Orthop 00:1–5Google Scholar
  32. 32.
    Webster KE, Feller JA (2016) Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 44:2827–2832CrossRefGoogle Scholar
  33. 33.
    Wright JG (2005) Levels of evidence and grades of recommendations. AAOS Bull 53.

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Jeffrey Kay
    • 1
  • Muzammil Memon
    • 1
  • Ajay Shah
    • 2
  • Yi-Meng Yen
    • 3
  • Kristian Samuelsson
    • 4
  • Devin Peterson
    • 1
  • Nicole Simunovic
    • 5
  • Helene Flageole
    • 6
  • Olufemi R. Ayeni
    • 1
    Email author
  1. 1.Division of Orthopaedic Surgery, Department of SurgeryMcMaster University Medical CentreHamiltonCanada
  2. 2.Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonCanada
  3. 3.Department of Orthopaedic SurgeryBoston Children’s Hospital, Harvard Medical SchoolBostonUSA
  4. 4.Department of OrthopaedicsThe Sahlgrenska Academy, University of GothenburgGothenburgSweden
  5. 5.Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
  6. 6.Department of Pediatric SurgeryMcMaster Children’s HospitalHamiltonCanada

Personalised recommendations