The Role of Crutches and Bracing in Preventing Secondary Meniscal Tears After Anterior Cruciate Ligament Injury in Pediatric Patients.

Abstract

Background: Secondary meniscal tears are a well-described sequela of delay in anterior cruciate ligament (ACL) reconstruction (ACLR) after ACL injury. This study aimed to evaluate whether preoperative conservative interventions (ie, crutches, bracing, and physical therapy) are associated with a reduced risk of secondary meniscal pathology in pediatric patients.

Hypothesis: Preoperative conservative interventions of the ACL-deficient knee would be associated with fewer secondary meniscal tears in pediatric patients undergoing delayed (≥8 weeks postinjury) ACLR.

Study design: Cohort study; Level of evidence, 3.

Methods: All pediatric patients (age, <18 years) undergoing primary ACLR with a single surgeon between October 1, 2013, and January 31, 2022, were retrospectively identified. The exclusion criteria were as follows: previous ipsilateral knee injury; multiligamentous knee injuries; or time frommagnetic resonance imaging to surgery ≥52 weeks. Adherence to conservative management recommendations (ie, crutches, bracing, and physical therapy) was assessed through medical record review. Secondary meniscal injuries were defined as major tears that were discovered intraoperatively and required repair or substantial meniscectomy. Meniscal tears that occurred concomitantly with ACL rupture and were detectable on the initial (<3 weeks after injury) magnetic resonance imaging scans were not considered secondary. In total, 71 pediatric patients (35 girls; 36 boys) were included.

Results: A total of 70 patients (99%) underwent ≥1 conservative interventions before ACLR-including 37 (52%) who used crutches, 47 (66%) who used bracing, and 69 (97%) who received physical therapy. There were no differences in use of conservative interventions between those who underwent early ACLR and those who had delayed ACLR (P > .05). Delayed ACLR was associated with a greater risk of medial, but not lateral, meniscal tears compared with early ACLR (P = .04). Overall, 15 secondary meniscal tears were observed intraoperatively in 14 patients-including 4 medial and 11 lateral tears. Knee bracing was associated with fewer lateral meniscal tears in patients undergoing early ACLR (6% vs 35%; P = .008), with multivariate regression analysis yielding an adjusted odds ratio of 0.06 (95% CI, 0.006-0.57; P = .015). The use of crutches was associated with fewer medial meniscal tears in patients undergoing delayed ACLR (0% vs 37%; P = .017). Since no new medial meniscal tears were observed in patients who used crutches, the adjusted odds ratio could not be calculated.

Conclusion: Bracing and crutches were associated with the preservation of the menisci in the ACL-deficient knee in pediatric patients undergoing early and delayed ACLR, respectively. Surgeons should strongly encourage adherence to these conservative modalities in patients awaiting operative reconstruction to reduce the risk of secondary meniscal pathology.