The study cohort consisted of 250 patients with a mean chronological age of 12.7 years (range, 6-14). There were 136 females (54%) and 114 males (46%) (Table). Mean BMI was 21.7 kg/m2, with a range between 14.5 and 35.8. Non–sport-related trauma was the cause of ACL injury in 24% of patients, whereas 28% of patients sustained their injuries playing soccer, 16% in basketball, 13% in football or rugby, and 5% skiing or snowboarding. Autologous hamstring graft was used in 54%, iliotibial band in 29%, patellar tendon in 12% and tibialis anterior allograft in 5%. A total of 239 (96%) patients eventually returned to sports participation with a Kaplan–Meier estimated median time of 9 months (95% CI, 8-10 months) after ACL reconstruction (Figure 3). At 12-month follow-up, 85% of patients had returned to sports (95% CI, 80%-90%).
The Cox regression model did not identify any significant predictors of time to return to sports, including age (P = 0.41), sex (P = 0.15), BMI (P = 0.98), trauma (P = 0.63), and type of graft (P = 0.81). Thus, the data suggest that independent of these other variables; the median time to return was 9 months.
Logistic regression analysis indicated comparable rates among the 5 most common sports (Figure 3). No significant differences were detected between the specific sports except that a lower percentage of football and rugby players returned to sports participation at 6 and 9-month follow-up compared with those in basketball, soccer, and skiing (all P < 0.05). Thus, although participation in football or rugby had slightly lower rates of patients returning at 6 and 9-month follow-up, these athletes had essentially equivalent return rates at 12 months and later.
Of the 250 patients who had completed the initial survey, with institutional review board approval, we attempted to contact them by mail to obtain additional information on (1) whether they returned to the same perceived preinjury level of play and (2) whether this level was maintained (Figure 1B). A total of 142 patients were reached by mail and answered our 2 questions (57%). Of the 142 patients, 43 (30%) said that they returned to a higher level of play compared with their preinjury level, 64 (45%) indicated that they returned to the same level of play, 31 (22%) said that they returned to a lower level of play, and 4 patients (1%) said they never returned to sports participation. Therefore, 107 of the 142 (75%) patients stated that they returned to at least the same level of play. A total of 42 of the 43 (98%) of those who returned to a higher level and 54 of 64 (84%) of those who returned to the same level were able to maintain that same level of play. However, only 19 of the 31 (62%) who had returned to a lower level of play were able to maintain that level. The follow-up mailings revealed that 3 in 4 patients who underwent ACL reconstruction were able to return to the same level or a higher level of sports, and 90% of these athletes (96 of 107) maintained that level of participation. We performed a multivariate logistic regression analysis to assess factors that might be predictive of return to play at the same or higher level versus a lower level and found that those who returned to the same or higher level were younger in age (P = 0.04), whereas sex (P = 0.87), BMI (P = 0.09), and cause (trauma vs sports related) of ACL injury (P = 0.65) were not significant predictive factors.
Our data provide the greatest number of return to sports in young athletes in an outcome-based study to date. Our primary goal is to safely restore athletes to their preinjury level of activity while minimizing growth plate damage by strict adherence to our protocol during ACL reconstruction. The challenge in reconstructing ACL tears in this age group is the risk that surgery poses to the tibia and femur physeal plates and resultant growth disturbance(s). Studies have shown that such risk does exist but failure to reconstruct portends poorer prognosis to the longevity and health of the injured knee.5,18,19 Many young athletes undergo ACL reconstruction surgery to protect the articular cartilage and meniscus and decrease the risk of developing premature knee osteoarthritis.20 A second goal of ACL surgery in the skeletally immature athlete is to allow an earlier return to sports than those patients who forego surgery until skeletally mature. Historically, the skeletally immature athlete with an ACL injury has been restricted from sports until skeletally mature and then be given the option to undergo ACL reconstruction surgery. Unfortunately, a high percentage of these sustain meniscal injury before attaining skeletal maturity. Wearing a brace to allow activity after an ACL tear does not prevent subsequent injury, as meniscal tears and instability have been documented after return to sports.18,20
Delaying or not reconstructing ACL tears may also have long-term consequences. Janarv reported that 68% of those who tried nonoperative intervention eventually opted for reconstruction, and those remaining who were not reconstructed had significantly decreased activity levels.24 Children who participate in physical activities at a young age are more likely to continue to be active as adults, which may reduce the risk of early morbidity and mortality. Consequently, delaying reconstruction may affect both a person's quality of life and limit their future participation in sports.25 Organized athletic participation as youth has been shown to promote athletic activity as adults. Tammelin et al26 followed almost 8000 young athletes and found that participation in sports was associated with high level of physical activity in later life. He also concluded that adolescent participation in the intensive endurance sports, and some sports that require and encourage diversified sports skills, seemed to be most beneficial with respect to the enhancement of adult physical activity. Telama et al27 reported that youth playing at a high level of physical activity was a significant prognostic indicator of adult activity. Studies have also shown that higher self-esteem may be associated with sports participation during the formative years of 9 to 14 years of age.28,29
Although more ACLs are being diagnosed and reconstructed in skeletally immature athletes, there are few data documenting return to organized sports and at what level. Studies in adults returning to sports after ACL reconstruction show that 53%-62% return to their previous level of play.19,21,25,30
Past studies have looked at return to sports for skeletally immature athletes after ACL reconstruction surgery. Shelbourne et al's review of ACL reconstruction in skeletally immature patients reported 55 of 60 (92%) returned to preinjury sports participation.20,23 Fuchs et al reported 9 of 10 patients treated with patellar tendon allograft in children aged 9 to 15 year old returned to their preinjury level of athletics.1 This study is the largest review to date in the medical literature which addresses this issue.
Based on this cohort, young athletes who participate in cutting and pivoting sports such as soccer, basketball, and football may be at increased risk for ACL injury. After undergoing ACL reconstruction, 239 of the 250 (96%) athletes who responded to the questionnaire were able to return to sports at the same or higher skill level. Median time to return to sports was 9 months postoperative, with most athletes returning to sports (85%) by 12 months. Rugby and football players had lower percentages of athletes returning to sports at 6 and 9 months but by 12 months had similar return to sports as compared with other cutting and pivoting athletes. This may be explained, in part, by the fact that at this age level, their sports are seasonal, as opposed to year-round sports.
In our study, patients cited physical limitations (n = 4), loss of interest in sport (n = 3), and fear of reinjury (n = 2) as reasons for not returning to previous level of sports. Psychological profiles of adult athletes have shown that those patients who did not return to their previous level of activity were more afraid of reinjury because of movement and had a worse knee-related quality of life than those who had returned to their previous level of activity.25 Children are often reliant on their families for access to physical therapy and often need very specific guidelines to remain focused and adherent to rehabilitation. A persisting problem in child and youth sports is inadequate treatment and rehabilitation for injuries.8,29
The relative injury rate in boys and girls was similar in this age group. Because this cohort was clinic based, no conclusions can be drawn as to the sex-specific risk of ACL injury in prepubescents. However, given the documented differential risk of male/female for ACL injury in older athletes, this merits further epidemiologic study.4,31
This study has some limitations. We did not have comprehensive data available from patients' initial visits to determine whether bone age or Tanner staging was used by the treating physicians to select extraphyseal or transphyseal technique. Recall bias is inherent in our retrospective study design as well. In addition, time of return to sport may be affected by seasonal sports participation because a relatively small percentage of this age group in this period was participating in year-round training in 1 sport. Finally, recall bias is inherent in any post activity questionnaire. However, both the parents and the young athletes themselves are usually quite precise about the timing and level of return to sport.
After undergoing ACL reconstruction, most athletes are able to return to sports and 50% of these athletes return within 9 months after surgery. However, the reason some athletes do not return may be resolved with sports-specific training and rehabilitation for this age group.
No outside funding was received for this work and to the best of our knowledge, no conflict of interest, financial, or other exists. The results of this study do not constitute endorsement by CJSM.
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
pediatric; ACL; surgery; return to sports