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Repairing Knee Ligament Tears in Children Under 14 Reduces Risk for Severe Cartilage Damage

A recent study to assess the risk and reward of repairing anterior cruciate ligament (ACL) tears in children 14 and younger will serve to allay the struggle orthopedists confront over the decision to perform ACL reconstruction on skeletally immature patients.

Presented at the 35th Annual Meeting of the American Orthopaedic Society for Sports Medicine, the study found that delaying surgery to repair ACL tears in patients younger than 14 years of age is associated with a 4-fold increase in medial meniscus cartilage tears and an 11-fold increase in severe lateral cartilage injuries.

“The benefit of performing the ACL reconstruction in a child 14 or younger is far greater than the risk of waiting to perform the operation because of the concern that it may cause a growth disturbance,” said Craig Levitz, MD, chair of orthopedics at South Nassau Communities Hospital. “Additionally, the potential for either growth arrest or angular deformities resulting from the ACL reconstruction are minuscule.”

Spearheaded by J. Todd R. Lawrence, MD, of the Sports Medicine and Performance Center for the Children’s Hospital of Pennsylvania and the University of Pennsylvania School of Medicine, the study reviewed the records of 69 patients 14 years and younger who underwent ACL reconstruction between 1991- 2005 at the Children’s Hospital of Pennsylvania. The review accounted for demographic, MRI, and intra-operative findings, and graded each patient's meniscal and articular cartilage pathology.

Of the 69 patients identified, ACL reconstruction was delayed for more than 12 weeks in 29 patients whose average age was 12.9 years. Their outcomes were compared with those of the remaining patients who waited fewer than 12 weeks to have the surgery. Applying logistic regression analysis (the description of the nature of the relationship between two or more variables) the study found that delayed surgery significantly increased the odds for medial meniscus tears, including irreparable tears.

Irreparable cartilage tears were present in nearly 25 percent of the patients who waited to have the surgery and approximately 14 percent of those tears were defined as “massive irreparable.” Additionally, nearly 45 percent of the 29 patients had significant lateral compartmental damage.

“Based on the fact that limb length discrepancy or angular deformity can be corrected and that the end result of severe meniscus cartilage damage is a sentence to a lifelong battle with osteoarthritis, it is logical to perform ACL reconstruction without delay,” said Dr. Levitz, who trained at Children’s Hospital of Pennsylvania and earned his medical degree from the University of Pennsylvania School of Medicine.

As chief of orthopedics, Dr. Levitz serves as director of South Nassau’s Center for Advanced Orthopedics. The Center is one of the first of its kind in the northeast that is committed to using arthroscopic technology and minor incisions to repair common, and sometimes even serious, knee or shoulder injuries. The patient benefits of minimally invasive surgery include significantly less post-operative pain, scarring, blood loss and damage to the tissue; reduced recovery time after surgery; faster return to normal activities; and shorter hospital stays. Many surgeries can be performed on an outpatient basis.

The arthroscope is a pen-shaped instrument with a very small video camera attached to the end of it that transmits a three-dimensional view of the surgical field on a high definition monitor. The view can be magnified as much as 30 times, giving the surgeon a clear and unobstructed vision of damaged areas of the joint.

From this visual advantage, the surgeon completes the operation in no more than two hours with minimally invasive surgical tools, which require just 1/2-inch incisions to be inserted in the joint. This results in reduced pain caused by trauma to surrounding tissue and loss of blood. As a result, patients experience a quicker recovery and return to daily activities of their choice.

Knee and shoulder injuries repaired arthroscopically at the center include: torn cartilage and anterior cruciate, posterior cruciate and medial collateral ligaments in the knee and instability, impingement, rotator cuff or labrum tears, recurrent dislocations, and other conditions in the shoulder.

“‘No pain, no gain’ is not what we believe in,” said Dr. Levitz. “The mission of the Center is to use the advantages of modern surgical technology, such as the arthroscope, to eliminate the painful and often debilitating after effects of traditional surgery that delay patients’ recovery and hinder rehabilitation.”

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