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. 2018 Apr;52(7):422-438.
doi: 10.1136/bjsports-2018-099060. Epub 2018 Feb 24.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

Clare L Ardern  1   2 , Guri Ranum Ekås  3   4   5 , Hege Grindem  6 , Håvard Moksnes  4 , Allen F Anderson  7 , Franck Chotel  8 , Moises Cohen  9 , Magnus Forssblad  10 , Theodore J Ganley  11 , Julian A Feller  12   13 , Jón Karlsson  14 , Minider S Kocher  15   16 , Robert F LaPrade  17   18 , Michael McNamee  19 , Bert Mandelbaum  20 , Lyle Micheli  15   16   21 , Nicholas Mohtadi  22 , Bruce Reider  23 , Justin Roe  24 , Romain Seil  25   26 , Rainer Siebold  27   28 , Holly J Silvers-Granelli  29 , Torbjørn Soligard  30   31 , Erik Witvrouw  32 , Lars Engebretsen  3   4   5   30
Affiliations

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

Clare L Ardern et al. Br J Sports Med. 2018 Apr.

Abstract

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Keywords: consensus statement; knee Acl; orthopaedics; paediatrics; physiotherapy.

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Conflict of interest statement

Competing interests: MC is a paid consultant for Arthrex. LE is the Head of Scientific Activities in the Medical and Scientific Department of the International Olympic Committee, has received fees for speaking from Smith & Nephew, has received research funding from Biomet and Smith & Nephew, has received funds for an employee from Arthrex and Smith & Nephew, has received royalties or fees for consulting from Arthrex and is an Editor of BJSM. MSK is a paid consultant for Best Doctors, OrthoPediatrics, Össur and Smith & Nephew, receives royalties, financial or material support from OrthoPediatrics, Össur, Saunders/Mosby-Elsevier and Wolters Kluwer Health–Lippincott Williams & Wilkins, is a paid member of the Steadman Philippon Research Institute, Scientific Advisory Committee, and is an unpaid board or committee member of the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Harvard Medical School, Harvard School of Public Health, Herodicus Society, Pediatric Orthopaedic Society of North America and Pediatric Research in Sports Medicine. RLaP receives royalties from Össur, Arthrex and Smith & Nephew. BR receives royalties from Elsevier, salary from American Journal of Sports Medicine and Orthopaedic Journal of Sports Medicine, and holds stock in Merck and Johnson and Johnson. RSe is an unpaid board member and President of the European Society of Sports Traumatology Knee Surgery and Arthroscopy (ESSKA). TS works as Scientific Manager in the Medical and Scientific Department of the International Olympic Committee.

Figures

Figure 1
Figure 1
Injury prevention exercises incorporated into team training.
Figure 2
Figure 2
Child demonstrating how to hold terminal knee extension during single limb stance. This is an important marker of quadriceps control in ACL rehabilitation and prehabilitation.
Figure 3
Figure 3
One example of an exercise that could be incorporated into a home-based ACL rehabilitation program.
Figure 4
Figure 4
Transphyseal ACL reconstruction. (A) Anterior view and (B) lateral view.
Figure 5
Figure 5
Physeal-sparing ACL reconstruction using an over-the-top technique with iliotibial band. (A) Anterior  view  and  (B)  lateral view.
Figure 6
Figure 6
Physeal-sparing ACL reconstruction using an all-epiphyseal technique. (A) Anterior view and (B) lateral view.
Figure 7
Figure 7
Partial transphyseal ACL reconstruction. (A) Anterior view, (B) lateral view and (C) posterior view.
Figure 8
Figure 8
Three different options for femoral tunnel trajectories.
Figure 9
Figure 9
Three growth disturbances that may occur following ACL reconstruction. ‘p’ represents the physiological growth process; dashed lines represent the physiological growth arrest lines; continuous lines represent the observed pathological growth arrest line. Type A (arrest): growth arrest process (a) occurs after a localised injury to the physis and results in a bone bridge across the physis. The extent of deformity is proportional to the location and size of the initial physeal injury. Type B (boost): overgrowth process (indicated by p+) is probably caused by local hypervascularisation, stimulating the open physis (b). This growth disturbance is temporary and usually becomes apparent in a limited period of 2 years following ACL reconstruction. It primarily leads to leg length discrepancy. Type C (decelerate): undergrowth process (indicated by p–) due to a tenoepiphysiodesis effect (c). The graft tension across the open physis causes the deformity. Adapted from Chotel et al.
Figure 10
Figure 10
Appearance of the highly vascular paediatric meniscus  of a boy aged 10 years on 3.0 T  MRI (Signa HDxt 3.0 T; GE Medical Systems).
See this image and copyright information in PMC

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