ACL Injury
From WikiMSK
Once torn, it doesn’t heal Reconstruction does not make it normal – posttraumatic osteoarthritis can occur regardless of management
ACL Surgery
Surgical vs non-surgical management
- RCT of 121 “young active adults”
- Rehab (plus delayed surgery if needed) vs rehab plus early surgery
- 5 year follow up: no differences in ability to return to sport, knee function, or rate of meniscal injury
- 50% crossover (50% in rehab group crossed over to surgery)
- Take-away: 50% can be managed non-operatively
- In my opinion we don’t know if those other 50% eventually managed operatively would have better outcomes than sham surgery
Subsequent OA and Meniscal Tears
- Metanalysis 2019, comparing surgery vs non-surgical treatment with 10 year follow up
- Patient reported outcomes the same
- Higher rate of radiographic knee OA
- Lower rate of secondary meniscal injury and meniscal surgery
- Reduced laxity
- Significant methodological flaws in the included studies and heterogeneity
Copers vs non-copers
- Copers – use neuro-musculo-skeletal strategies to dynamically stabilise their ACL-deficient knee even with pivoting
- Non-copers – knee instability, higher rates of surgery
- Not possible to classify this early on
- in one study 70% of those initially classified as non-copers, were copers after 1 year of non-operative management. And only 60% of potential copers were true copers.
ACL Reconstruction
- Indications??
- Recurrent instability
- Associated tear when amenable to repair
- Associated ligament injury especially posterolateral corner
- Professional and elite players
- High-risk occupation (where instability could cause harm)
- ?Adolescents, risk of instability, ?protect against future meniscal and chondral damage.
- Delay surgery until normal range of motion, effusion largely resolved and able to walk comfortably (to reduce risk of athrofibrosis i.e. stiffness)
ACL Graft Selection
- Bone-Patella-Bone
- possible earlier graft fixation and stability due to included portion of bone
- anterior knee pain up to 1 year
- possible higher rate of OA.
- Hamstring
- Initial fixation may be slower and weaker (no bone), but quadruple strand is stronger than B-P-B
- Donor site pain resolves by 3 months
- hamstring strength normal by 12 months.
- Other: Allografts, quadriceps graft,
ACL Postoperative
[4] Graft re-rupture (from surgical failure or re-trauma) Outcomes worse for revision ACL repair Increased risk tear contralateral knee – 7% cumulative incidence 5770 reconstructed knees – 60% returned to pre-injury level, and 44% returned to competitive sport. Professional players – 90% return to play by 12 months, sensible?? Shorter careers.
Unknown Unknowns
[5] Cultural norms in professional sport and other areas ?Uncertainty of non-operative treatment Loss of option of early ACL repair ACL-deficient sport ?future meniscal and cartilage injury What is success, return to pivoting sport? What is in the athlete’s best interest? “Doing nothing” is hard
Rehabilitation for Athletes
- Protection and controlled mobilisation
- Controlled training
- More intensive training
- Return to play (many months)
- ↑ Frobel R et al, Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial BMJ 2013;346:f232
- ↑ Lien-Iversen, T., Morgan, D. B., Jensen, C., Risberg, M. A., Engebretsen, L., & Viberg, B. (2019). Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis. British Journal of Sports Medicine, bjsports–2019–100765.
- ↑ Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2008). Individuals With an Anterior Cruciate Ligament-Deficient Knee Classified as Noncopers May Be Candidates for Nonsurgical Rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 38(10), 586–595. doi:10.2519/jospt.2008.2750
- ↑ Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011;45:596-606.
- ↑ Weiler, R. (2015). Unknown unknowns and lessons from non-operative rehabilitation and return to play of a complete anterior cruciate ligament injury in English Premier League football. British Journal of Sports Medicine, 50(5), 261–262. doi:10.1136/bjsports-2015-095141
- ↑ Bizzini, M., Hancock, D., & Impellizzeri, F. (2012). Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction: Soccer. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 304–312. doi:10.2519/jospt.2012.4005
