Oslo Sports Trauma Research Center

Intoduction

MD Guri Ranum Ekås is defending her thesis "Pediatric Anterior Cruciate Ligament Injuries – management, treatment rationale and long-term outcomes" at Ullevål University Hospital.

Thesis Defense

• Date: March 5th 2020
• Where: Auditorium Building 11 (Kreftsenteret), Ullevål University Hospital
• Time - Trial lecture: 10.15 am, "Meniscus surgery - is there any evidence?"
• Time - Thesis Defense: 01.15 pm

Committee

• 1. Opponent: Professor Mininder Kocher (Harvard Medical School/ Boston Children’s hospital, USA)
• 2. Opponent: Professor Jon Karlsson (Gothenburg University, Sahlgrenska Hospital, Sweden)
• Committee chair: Professor Inger Holm (University of Oslo, Norway)

Pediatric anterior cruciate ligament (ACL) injuries are believed to be increasing due to the rapid surge in the number of children undergoing ACL reconstructive surgery. This trend is alarming due to the high risk of re-injuries to the affected knee, and the potential development of early-onset knee osteoarthritis.

Clinical decision making regarding ACL injuries in children is challenging because current evidence is inconsistent and has scientific limitations. Treatment is controversial, especially regarding surgical intervention. Despite weak scientific evidence, a common clinical dogma has been to advocate early ACL reconstructive surgery in order to protect the other important structures in the knee such as menisci and cartilage.

Multidisciplinary approach in order to optimize recovery and prevent further knee injuries

This thesis has demonstrated that children with ACL injuries require a multidisciplinary approach in order to optimize recovery and prevent further knee injuries. High-quality rehabilitation and injury prevention are essential for all patients, but there is no consensus regarding surgical intervention. The clinical study in this thesis showed that most young adults who sustained an ACL injury during childhood had overall good long-term outcomes following primary non-operative treatment with optional delayed surgery. In addition, there is very low certainty of evidence regarding the risk of new meniscal tears after ACL injury, and this evidence is insufficient to support decision making. Thus, our study findings challenge the current clinical dogma that all children with ACL injury require early reconstructive surgery.

Conclusion

In conclusion, this thesis supports an individualized treatment approach and suggests that non-operative treatment has a role in the management of pediatric ACL injuries. However, reconstructive ACL surgery is advocated for those children with additional meniscal injuries that require repair, and/or those who suffer from knee joint instability over time. 

Impacts

The impact of this thesis is strong. The included studies address the major issues in the management of pediatric ACL injury. They point out deficiencies in the literature, which are many. They provide prospective and robust data regarding outcomes of initial non-operative treatment in terms of outcomes and meniscal pathology. The body of works does challenge the current clinical dogma that all children with ACL injury require early reconstructive surgery. However, it is important to keep in mind that some children require ACL reconstructive surgery, including those with additional injuries such as repairable meniscal injuries.

Supervisors

Main supervisor: Professor Lars Engebretsen (University of Oslo/ Orthopedic Division, Oslo University Hospital/ Oslo Sports Trauma Research Centre),

Co-Supervisors: Professor May-Arna Risberg (Ortopedic Division, Oslo University Hospital/  Norwegian Research Centre for Active Rehabilitation) Hege Grindem (Oslo Sports Trauma Research Centre/ Karolinska Institute), Håvard Moksnes (Oslo Sports Trauma Research Centre).

The thesis is based on five articles

1. Ekas GR, Moksnes H, Grindem H,  Risberg MA, Engebretsen L. Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years' Follow-up. 

2. Ekas GR, Moksnes H, Grindem H,  Risberg MA, Engebretsen L. Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years' Follow-up. 

3. Ekas GR, Laane MM, Larmo A, Moksnes H, Grindem H, Risberg MA, Engebretsen L. 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.  

4. Ekas GR, Ardern C, Grindem H, Engebretsen L. New meniscal tears after ACL injury: what is the risk? A systematic review protocol. 

 5. Ekas GR, Ardern C, Grindem H, Engebretsen L. 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. 

Read more about Guri and her projects here.