Deciding Between ACL Reconstruction, Repair, and Conservative Treatment in Young Athletes: A Systematic Narrative Review

Objective: The best pediatric and adolescent athlete anterior cruciate ligament (ACL) injury management method remains unknown. This systematic narrative review examined ACL reconstruction (ACLR), ACL repair, and conservative brace, or rehabilitation-based therapeutic exercise interventions with a delayed ACLR option for pediatric and adolescent ACL injury management. The primary purpose was to compare failure rates, return to sport (RTS) rates, and perceived knee function. Methods: The PubMed, ResearchGate, Google Scholar, Sage Journals, and OVID (Medline) databases were searched. The Modified Coleman Methodology Score (MCMS) assessed study methodological quality and bias risk. Results: Fifty-six studies were included. Group 1 (ACLR) studies were published before Group 2 (ACL repair) or Group 3 (conservative brace, or rehabilitation-based therapeutic exercise intervention with a delayed ACLR option) studies (Group 1 = 2010.8 ± 9; Group 2 = 2015.9 ± 10; Group 3 = 2018.0 ± 4, p = 0.05). Group 2 displayed "good" quality (MCMS = 70.2 ± 7.9), while Group 1 (MCMS = 63.3 ± 6.8) and Group 3 (MCMS = 59.8 ± 6.4) displayed "fair" quality (p ≤ 0.03). Group 2 had more level 1 or 2 studies, and Group 1 had more level 4 studies (p = 0.007). Lysholm scores were similar (Group 1 = 94.4 ± 2.7, Group 2 = 92.1 ± 6.8, Group 3 = 95, p = 0.51). Group RTS rates were similar (Group 1 = 88.8 ± 14%, Group 2 = 94.1 ± 10%, Group 3 = 78.6 ± 21%; p = 0.22). Group 1 failure rates (7.4 ± 6.6%) were < Group 2 (17.0 ± 19%) (p = 0.02) and Group 3 (32.4 ± 18%) (p < 0.001). Conclusion: Although ACLR had lower failure rates, neurocognitive, reactive strength, and psychological readiness assessments were underreported. The stronger methodological rigor for ACL repair studies was encouraging but long-term outcomes are lacking.