Br J Sports Med: first published as 10.1136/bjsports-2020-102816 on 21 August 2020. Downloaded from http://bjsm.bmj.

com/ on August 23, 2020 at Univ Of West Ontario GSTR101749364

PhD Academy Award

Paediatric anterior cruciate ligament injuries:

management, treatment rationale and long-­term
outcomes (PhD Academy Award)
Guri Ranum Ekås  ‍ ‍1,2,3

1
Division of Orthopaedic
Surgery, Akershus University
Hospital, Lorenskog, Norway
2
Oslo Sports Trauma Research
Centre, Norwegian School of
Sport Science, Oslo, Norway
3
Institute of Clinical medicine,
University of Oslo, Oslo, Norway
Correspondence to
Guri Ranum Ekås, Division of
Orthopaedic Surgery, Akershus
University Hospital, Lorenskog
1478, Norway;
WHAT DID I DO?
I am an orthopaedic surgeon focusing on knee inju-
ries especially in the paediatric population. My PhD
involved investigating paediatric anterior cruciate
ligament (ACL) injury management, treatment
rationale and long-­term outcomes.
My research questions included:
1. How should clinicians manage paediatric ACL
injuries? Is it possible to reach a consensus?
2. What are the long-­term clinical and radiological
outcomes following a primary non-­ operative
treatment approach?
3. My final PhD contribution was a systematic
review of new meniscal tears after ACL inju-
ry.5 6 Two independent reviewers screened all
articles, assessed eligibility and risk of bias and
extracted data. We evaluated the certainty of ev-
idence using the Grading of Recommendations
Assessment Development and Evaluation
methodology.
WHAT DID I FIND?
This PhD thesis demonstrated that children with
ACL injuries require a multidisciplinary approach

Serials Acquisitions Unit. Protected by copyright.

​gurire@​gmail.​com
3. What is the risk of new meniscal tears after ACL to guide their recovery and prevent further knee
Accepted 31 July 2020 injury? injuries. High-­
quality rehabilitation and injury
prevention are essential for all children affected,
WHY DID I DO IT?
The incidence of paediatric ACL injuries is
increasing.1 This trend is alarming due to the high
risk of reinjury to the affected knee and the poten-
tial for early-­onset knee osteoarthritis. Management
is controversial—largely guided by local traditions
and surgeon preferences (ie, dogma, eminence-­
based). The prevailing clinical dogma, in many
centres, has been to undertake early ACL recon-
struction to protect the other knee structures such
as menisci and cartilage. Current evidence is sparse.

HOW DID I DO IT?

1. I contributed to the 2018 International Olympic
2. I followed a cohort of 47 young adults who had
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Ekås GR.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2020-102816
Committee Consensus Statement on prevention,
diagnosis and management of paediatric ACL
injuries.2 Twenty-­one field experts reviewed the
literature, discussed key topics and formed a
clinically relevant consensus statement based on
a modified Delphi process.
sustained an ACL injury during childhood (be-
fore age 13 years while being skeletally imma-
ture). These patients were prospectively includ-
ed in the Oslo Paediatric ACL Cohort between
2006 and 2010. Clinical follow-­up at mean 8
years included surgical and reinjury history,
clinical examination, patient-­reported outcome
measures, strength testing and hop testing and
evaluation of activity level.3 Knee pathology
was evaluated at mean 9.5 years based on long-­
leg radiographs and a series of bilateral knee
MRIs.4 Outcomes included: (1) incidence of
new meniscal injuries during the study period,
(2) prevalence of meniscal and cartilage injuries Figure 1  Illustration showing full knee extension
in both knees and (3) whether any growth dis- during one leg stance—an important exercise for
turbances occurred. quadriceps control.

Ekås GR. Br J Sports Med 2020;0:1–2. doi:10.1136/bjsports-2020-102816    1


PhD Academy Award
Figure 2  This graph illustrates the KOOS mean subscale scores in our
study at final follow-­up (black line) and at 2 years follow-­up (blue line).
The orange, red and chestnut coloured lines show mean scores for all
ACL reconstructed patients included in the NKLR with an isolated ACL
tear or combined ACL and additional injury at different follow-­ups. The
green line illustrates normative values in uninjured adult controls. ACL,
anterior cruciate ligament; KOOS, Knee Outcome and Osteoarthritis;
NKLR, Norwegian Knee Ligament Registry.
but there is no consensus as to whether ACL reconstruction
should be mandatory for all patients (figure 1).
Most young adults who sustained an ACL injury during child-
hood had overall good long-­term outcomes following primary
non-­operative treatment with optional delayed ACL reconstruc-
tion (figure 2).
A proportion of children who are ACL deficient and not
operated on can cope well—undertake high levels of sporting
activity—without damaging their menisci. However, reconstruc-
tive ACL surgery may be warranted for approximately 50% of
the patients within 9.5 years post-­injury. One in three children
who rupture their ACL may sustain a new meniscal injury.
The systematic review showed very low certainty of evidence
regarding the risk of new meniscal tears after ACL injury, and this
evidence was insufficient to support clinical decision-­making.
WHAT IS THE MOST IMPORTANT FINDING/CLINICAL
IMPACT?
This PhD thesis supports an individualised treatment approach
and suggests that non-­ operative treatment has a role in
2 Ekås GR. Br J Sports Med 2020;0:1–2. doi:10.1136/bjsports-2020-102816
Br J Sports Med: first published as 10.1136/bjsports-2020-102816 on 21 August 2020. Downloaded from http://bjsm.bmj.com/ on August 23, 2020 at Univ Of West Ontario GSTR101749364
management of paediatric ACL injuries. However, reconstructive
ACL surgery is advocated for children with additional meniscal
injuries that require repair, and/or those who suffer from knee
joint instability over time.
Acknowledgements  The author would like to gratefully acknowledge the entire
team of supervisors and coauthors. A special thanks to Professor Lars Engebretsen
(main supervisor), Hege Grindem, Clare Ardern, Håvard Moksnes and Professor May-­
Arna Risberg for their contributions. A sincere thanks to all the patients involved in
the clinical outcome studies, who in some cases have been followed for more than
10 years.
Collaborators  All supervisors and coauthors are collaborators. Professor Lars
Engebretsen, Professor May-­Arna Risberg, Hege Grindem, Håvard Moksnes, Clare
Ardern, Marit Mjelde Laane and Arne Larmo.
Contributors  I wrote the PhD award and my main supervisor professor Lars
Engebretsen read it and confirm that it reflects the work we have done.
Funding  This study was funded by Sophies Minde Ortopedi.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; internally peer reviewed.
ORCID iD
Guri Ranum Ekås http://​orcid.​org/​0000-​0002-​3677-​1101
Serials Acquisitions Unit. Protected by copyright.
REFERENCES
1 Weitz FK, Sillanpää PJ, Mattila VM. The incidence of paediatric ACL injury is increasing
in Finland. Knee Surg Sports Traumatol Arthrosc 2020;28:363–8.
2 Ardern CL, Ekås GR, Grindem H, et al. 2018 international Olympic Committee
consensus statement on prevention, diagnosis and management of paediatric anterior
cruciate ligament (ACL) injuries. Br J Sports Med 2018;52:422–38.
3 Ekås GR, Moksnes H, Grindem H, et al. Coping With Anterior Cruciate Ligament Injury
From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8
Years’ Follow-­up. Am J Sports Med 2019;47:22–30.
4 Ekås GR, Laane MM, Larmo A, et al. Knee pathology in young adults after pediatric
anterior cruciate ligament injury: a prospective case series of 47 patients with a mean
9.5-­Year follow-­up. Am J Sports Med 2019;47:1557–66.
5 Ekås GR, Ardern C, Grindem H, et al. New meniscal tears after ACL injury: what is the
risk? A systematic review protocol. Br J Sports Med 2018;52:386.
6 Ekås GR, Ardern CL, Grindem H, et al. Evidence too weak to guide surgical
treatment decisions for anterior cruciate ligament injury: a systematic review of the
risk of new meniscal tears after anterior cruciate ligament injury. Br J Sports Med
2020;54:520–7.