Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

Abstract

Purpose: To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger.

Methods: A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded.

Results: We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies.

Conclusions: There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently.

Clinical relevance: A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

Fig 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for pediatric anterior cruciate ligament clinical outcomes literature.

Fig 2

The number of pediatric ACL reconstruction publications has increased over the past 20 years. Pediatric-specific patient-reported outcome measures (PROMs) have been implemented in a minority of studies in recent years.

Fig 3

(A) Patient-reported outcome measures (PROMs) were used inconsistently across studies. Pediatric-designed instruments (Pediatric International Knee Documentation Committee Subjective Knee Form [Pedi-IKDC] and Pediatric Functional Activity Brief Scale [Pedi-FABS]) were employed in a small minority of studies. (B) The number of PROMs used per study was variable. One asterisk (∗) indicates a PROM that was originally designed and validated in adults and later validated in a pediatric population; 2 asterisks (∗∗) indicate a PROM that was originally designed and validated in a pediatric population. The OAK scale has not been validated in English in an American population. Included PROMs: EQ-5D, EuroQol Group-5 Dimensions; KOS-ALDS, Knee Outcome Survey-Activities of Daily Living Scale; IKDC, International Knee Documentation Committee questionnaire; KOOS, Knee injury and Osteoarthritis Outcome Score; Marx, Hospital for Special Surgery Modified Marx Activity Rating Scale; Pedi-FABS, HSS Pediatric Functional Activity Brief Scale; Pedi-IKDC, Pediatric IKDC; SF, short form. OAK, Orthopädische Arbeitsgruppe Knie.

Fig 4

Photograph of a standard KT-1000 arthrometer on a young athlete’s left leg. Even on the smallest setting, the device is unable to fit a pediatric patient properly, as illustrated by the joint line indicator (white label with black arrow meant to align with joint), which aligns above the superior pole of the patella.