"To reconstruct.....or not?". We enter the debate on Best Practice Management of ACL injur
When I graduated as a physiotherapist, back in 1993, it became immediately apparent during the first few weeks in my first job, that I knew very little about being a physio, despite a rigorous and prestigious four year Degree from University.
In those early days there were a few things on which I was very certain...these were my absolute truths:
both legs feeling numb is never a good sign
getting surgical patients out of bed too quickly can make them faint
hospital gowns are only partially effective at maintaining modesty at best
and finally, (and this is the reason for this blog)
ACL ruptures absolutely need to be repaired, especially if someone wants to return to sport!
This "truth" is well known among health professionals and the general public alike. Even football commentators with dubious sports medicine credentials are absolutely certain that this is the case - an undeniable and inescapable inevitability - watch an AFL footballer go down clutching their knee after a hyperextension-with-rotation injury and you will hear "...well it looks like they've done their ACL so they'll be off for surgery this week".
So imagine my surprise when 2016 saw the emergence of a MAJOR randomized trial (the KANON trial) that was looking at this from a whole new perspective. This was a challenge; an International debate questioning why this was considered an absolute - and what does the evidence say?
At the end of this trial, the authors' conclusions were:
"There is insufficient evidence from randomized trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice. Good quality randomized trials are required to remedy this situation".
I am not going to lie - the thought of advising one of my ACL-deficient patients that they could return to a high-velocity multi-directional sport like AFL without surgery is a mighty daunting prospect. It flies in the face of everything I have ever believed was an ultimate truth.
But perhaps that is the point.
It's been 25 years since this wide-eyed physio walked the corridors of her first hospital. I already know that bilateral pins and needles is not ALWAYS disastrous (although assume it is until proven otherwise). I am not really bothered by old men in gapingly-open hospital gowns any more, and I am adept at reading the early warning signs of hypotension (the look a person gets when they are very close to fainting, giving you a couple of split seconds to grab a chair or lay them back onto a bed). So perhaps all truths are up for debate, and the reconstruction versus conservative management is one of these.
Over our last in-house tutorial, plus via an informative webcast debate hosted by the South Australian Sports Medicine Association, we delved into ACL injury management, because so many of the physios and medical specialists we respect are also looking at this very topic.
And this is a bit of a summary on what we know now:
World's Best practice management of ACL injury does not automatically or always have to involve reconstruction
There is currently no evidence to show that a reconstruction early (within the first ten weeks after injury) is better than late or even no reconstruction
The Anterior Cruciate Ligament (ACL) has the capacity to repair itself.
There is currently no evidence to show that ACL reconstruction prevents Osteoarthritis later on
There are some people for whom a reconstruction is actually probably going to make their long-term outcome worse.
Successful and very intensive rehab may allow certain individuals to return to high level sport without surgery (has already happened with a professional soccer player and an NBA basketballer)
Reconstruction does NOT guarantee return to pivot/twist sports like AFL, soccer, netball, Basketball - but neither does conservative management
It is probably best to avoid having additional knee surgeries where possible (ie letting a surgeon 'tidy up' the cartilages) after you've had a reconstruction
So that is the science we have found, and a lot of smart people are suggesting that it is very good science. Not that research is everything. As clinicians we try to look at each individual but must use science plus a bit of clinical experience and the person's needs/wants to help establish a plan for them.
If you suspect you or someone you know has injured and perhaps ruptured your ACL, the overriding message is:
NO MATTER what you do to manage your ACL injury, high quality, intensive rehabilitation and exercise therapy is vital to success FOR EVERYONE.
This little video sums it up nicely.
And what if you, or someone you know has had an ACL injury?
The evidence all suggests that you don't rush straight into surgery. Even if you do need it, all the evidence we have read suggests delaying it is possibly the best option long term.
Take the time to let the knee settle (if it is very sore it is definitely best to wait). Use this time to work out with your health care team what might be best for you.
Ask lots of questions of your doctor or physio. If they say that immediate reconstruction is the only way to guarantee your return to sport, ask them why they are recommending that.
Do some prehab. It is possible that even 12 weeks of really good quality exercise under physio instruction can eliminate the need for reconstruction. And if you do still need the surgery, you will almost definitely do better from your surgery with all the work done beforehand.
If you would like to read a bit more for yourself, the resources we accessed and discussed are listed below.
Stay tuned for our next blog on "What best-quality rehab after injury looks like."
Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):442-8. doi: 10.1007/s00167-008-0498-x. Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment.
Am J Sports Med. 2008 Sep;36(9):1717-25. doi: 10.1177/0363546508316770. Epub 2008 May 15. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study
Caspian J Intern Med. 2011 Spring; 2(2): 205–212. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I
Øiestad, B. E., Engebretsen, L., Storheim, K., & Risberg, M. A. (2009). Winner of the 2008 Systematic Review Competition: Knee Osteoarthritis after Anterior Cruciate Ligament Injury. The American Journal of Sports Medicine, 37(7), 1434–1443. https://doi.org/10.1177/0363546509338827
Best Practice & Research Clinical Rheumatology: A pragmatic approach to prevent post-traumatic osteoarthritis after sport or exercise-related joint injury. Jackie L.Whittaker,Ewa M.Roos
Best Practice & Research Clinical Rheumatology: Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture Stephanie R.Filbay, Hege Grindem
BMJ 2013;346:f232; Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial.