Delayed ACL reconstruction may be acceptable in less active, less injury-prone adults
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Key takeaways:
- ACL reconstruction delayed longer than 8 weeks from injury did not increase new meniscus tears in adults.
- Delayed surgery was associated with increased new medial meniscus tears in pediatric patients.
According to published results, a delay of 8 weeks or longer between injury and ACL reconstruction may be acceptable for adults who are less active and less injury-prone than pediatric patients.
Researchers performed a retrospective study of 173 pediatric patients (mean age of 15 years) and 369 adults (mean age of 31 years) who underwent primary ACL reconstruction from Oct. 1, 2013, to Jan. 31, 2022, and had an MRI scan within 3 weeks after injury.
The primary outcome was new meniscal tears, which were defined as tears diagnosed arthroscopically that had not been detected on initial MRI. Researchers compared outcomes between patients who received acute operative treatment (less than 8 weeks from injury) vs. delayed operative treatment (8 weeks or longer from injury).
Overall, mean time from injury to MRI was 1 week for pediatric patients and 1.1 weeks for adults. Among all patients, mean time from injury to surgery was 9.2 weeks. Researchers noted adults were significantly more likely to undergo delayed ACL reconstruction.
According to the study, new medial meniscal tears occurred in 15% of pediatric patients and 16% of adult patients, while new lateral meniscal tears occurred in 48% of pediatric patients and 34% of adult patients. In pediatric patients, researchers found delayed ACL reconstruction was associated with a higher risk for new medial tears (adjusted risk ratio [ARR] = 3.9) but not new lateral tears (ARR = 0.8). They noted new medial tears occurred in 28% of pediatric patients who underwent delayed surgery compared with 8.3% of pediatric patients who underwent acute surgery. In adults s, researchers found delayed ACL reconstruction was not associated with any significant increases in medial or lateral meniscus tears.
“Our findings suggest that delaying ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents,” the researchers wrote in the study.
Perspective
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Alexander K. Meininger, MD, FAAOS
Arjun Gupta, BS, and colleagues have done a great job reinforcing the risk of meniscus tears in treating pediatric ACL patients with delayed reconstruction showing greater than threefold increased risk of medial meniscus tears if surgery is delayed more than 8 weeks. Medial meniscus tears are known to increase joint reaction forces, and meniscus repair has been shown to restore contact pressures to the untorn state. Nonetheless, even when repaired, these carry a 10% risk of failure. Preventing new-onset medial meniscus tears by approaching pediatric patients more acutely has potential to improve outcomes and satisfaction in young patients.
However, the rate of irreparable or complex medial meniscus tears in adults is known to increase as ACL reconstruction is delayed from time of injury. As complex tears increase, the likelihood of meniscectomy over repair increases coincidentally. Meniscectomy in the adult population is known to increase cartilage forces and contribute to the onset of osteoarthritis. Thus, I think the takeaway is that adults who can avoid recurrent instability through lifestyle changes or external support are safe to delay more than 8 weeks; though the consequences of delaying upward of 6 months or greater would require further study.
References:
Freshman RD, et al. Knee Surg Sports Traumatol Arthrosc. 2023;doi:10.1007/s00167-022-07249-z.
Kimura Y, et al. Am J Sports Med. 2020;doi:10.1177/0363546520967670.
Marchetti DC, et al. Arthroscopy. 2017;doi:10.1016/j.arthro.2017.04.013.
Perspective
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Controversy persists regarding the ideal timing for ACL reconstruction, particularly in young adolescent patients. The article “Is delayed anterior cruciate ligament reconstruction associated with a risk of new meniscal rears? Reevaluating a longstanding paradigm” by Arjun Gupta, BS, and colleagues attempts to shed light on this issue. Based upon prior studies, the established dogma has been that delayed ACL reconstruction is associated with higher rates of and more complex meniscal and chondral injuries compared to early surgical intervention. To assess whether meniscal tears observed at surgery are truly new injuries, the authors compared the number of tears seen on early initial MRI with those seen at surgical arthroscopy for adult and pediatric patients undergoing either early or delayed ACL reconstruction. They found a statistically significant increased incidence of new medial meniscal tears with delayed surgery in the pediatric group, but no difference in the adult cohort. From this, they conclude that delaying ACL reconstruction may be acceptable in adults.
I commend the authors in their attempt to address this controversial topic and appreciate their diligence to obtain expedient MR imaging after injury; however, it is critical to avoid overgeneralization to this conclusion. While this study suggests that delaying ACL reconstruction greater than 8 weeks in adults may not significantly increase the incidence of new meniscal tears, it is crucial to avoid extrapolating this to mean that there is no increased risk with delayed intervention in this cohort. Previous research has shown higher rates of chondral injuries and meniscal tears requiring partial meniscectomy with delayed ACL reconstruction, both of which have long-term implications on joint health. Ultimately, the debate surrounding the optimal timing for ACL reconstruction will persist until we have high-quality prospective studies that comprehensively evaluate long-term outcomes and the risk of secondary injuries in early vs. delayed intervention.
References:
Anderson AF, et al. Am J Sports Med. 2015;doi:10.1177/0363546514559912.
Everhart JS, et al. Am J Sports Med. 2019;doi:10.1177/0363546519849695.
Gupta A, et al. Orthop J Sports Med. 2023;doi:10.1177/23259671231203239.
Krutsch W, et al. Knee Surg Sports Traumatol Arthrosc. 2017;doi:10.1007/s00167-015-3830-2.
Mok YR, et al. Knee Surg Sports Traumatol Arthrosc. 2019;doi:10.1007/s00167-018-5027-y.
Newman JT, et al. Am J Sports Med. 2015;doi:10.1177/0363546514562168.
Sorey W, et al. Am J Sports Med. 2023;doi:10.1177/03635465221142325.
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