Tuesday, July 21, 2009

ACL Tear – To Operate or Not To Operate

ACL Tear – To Operate or Not To Operate

PREVIEW
ACL reconstruction is one of the most commonly done surgeries in field of sports medicine. In past several authors have reported that non-operative treatment of a rupture of the anterior cruciate ligament, with coordinated rehabilitation and modification of activity, resulted in satisfactory function [1,2]. Others have been convinced that an operation is necessary to avoid progressively worse function of the knee [3,4]. We here will analyze the evidence for recommendation of this surgery.

INTRODUCTION
ACL disruption is been associated with increased incidence of arthrosis of the knee is a fact that is backed up by enough evidence [5,6], however controversy still exists whether ACL reconstruction reduces this arthrosis incidence and a great clinical divide seems to exist among the surgeons. A recent survey of American academy of orthopedic surgeons [2003] suggests that this disagreement may be multifactorial [7]. A lack of adequate peer-reviewed literature, controversy among the available scientific publications, inadequate information dissemination, the preference to rely on clinical experience, or a combination of these factors may lead to such clinical disagreement.

LITERATURE REVIEW
Kessler et al [2008]retrospectively analysed 109 patients with mean of 11.4 years follow up comparing the conservative and surgical management of ACL tear [8]. Comparison of the groups based on the IKDC criteria showed a clear advantage in favor of ACL reconstruction. Nevertheless, it must be remembered that the overall IKDC score is determined by the worst individual parameter. Therefore, it is not a surprise to find that patients without ACL have greater anteroposterior translation and achieve lower IKDC scores. Even though surgical procedures might be preferred on the basis of these results, a large proportion of the patients with distinct, objective anteroposterior instability were subjectively almost symptom-free and have high level of activity. A very unique finding of this study is significantly lower rate of osteoarthritis in patient group after conservative treatment as compared to surgically reconstructed group (42% vs. 25%). Thus conservatively treated patients had better results with respect to long term osteoarthritis.
Casteleyn and Handelberg [1996]were of the opinion that if physical activity is kept to minimum and pivotal sports activities are avoided, then the situation may remain stable for many years [9].
Kostogiannis et al [2007] prospectively observed 100 patients with an acute total ACL injury without reconstruction for 15 years and concluded that early modification of activity and neuromuscular rehabilitation resulted in good knee function and an acceptable activity level in the majority of patients [10].
On the other hand, Strehl and Eggli [2007], in their investigation of conservative treatment for ACL rupture found that almost two-thirds of those patients selected for primary conservative treatment required surgical reconstruction in the long-term [11]. However most of the patients included wished to continue with high demand activity and demanded surgery in their series.
Daniel et al [1994] showed that ACL reconstruction does not always yield improved outcomes compared to the natural history and pointed out that patients who were able to “cope” with ACL deficiency may actually have better outcomes in some respects than do patients who have reconstruction [12].
The Cochrane database analysis of 2005 scrutinized two randomized studies [13], one by Sandberg et al [14] and another by Anderson et al [15]. Sandberg et al concluded that surgery of the anterior cruciate ligament produces a somewhat more stable knee joint, at least for the first few years, whereas non-operative treatment has the advantage that muscle power, range of motion, and function are regained more rapidly. The recovery of function is similar for the two regimens and for most purposes is satisfactory, but patients who have a lesion of the anterior cruciate ligament. Anderson et al concluded that repair and augmentation of the anterior Cruciate ligament resulted in better function of the knee at a higher level of activity than did simple repair or repair of only the peripheral lesions. The patients who had augmented repair had better stability in the sagittal plane, even though the restored stability was not equivalent to that of the uninjured knee. The database analyst however concluded that there was insufficient evidence to determine the relative effects of the surgical versus non-surgical treatment interventions performed in the early 1980s. However, there was some evidence that conservative treatment of acute ACL injuries can result in a satisfactory outcome.

RECENT STUDIES
Meuffels et al [2009] presented their results of 10 years follow-up of ACL tear in highly active individuals treated operatively versus non-operatively [16]. They concluded that the instability repair using a bone-patella-tendon-bone anterior cruciate ligament reconstruction is a good knee stabilizing operation. Both treatment options however show similar patient outcome at 10 year follow up.
Meunier et al [2007] investigated the long-term outcome of 100 patients 15 years after having been randomly allocated to primary repair (augmented or non-augmented) or non-surgical treatment of an anterior cruciate ligament (ACL) rupture [17]. The subjective outcome was similar between the groups, with no difference regarding activity level and knee-injury and osteoarthritis outcome score but with a slightly lower Lysholm score for the non-surgically treated group. This difference was attributed to more instability symptoms. The radiological osteoarthritis (OA) frequency did not differ between surgically or non-surgically treated patients, but if a meniscectomy was performed, two-thirds of the patients showed OA changes regardless of initial treatment of the ACL. There were significantly more meniscus injuries in patients initially treated non-surgically. Early ACL repair and also ACL reconstruction can reduce the risk of secondary meniscus tears which indirectly will decrease the incidence of osteoarthrosis
Fithian et al [2005] performed a prospective nonrandomized controlled trial to study the surgical risk factors that can be used to indicate whether reconstruction or conservative management is best for an individual patient [18]. Patients were classified as high, moderate, or low risk using preinjury sports participation and knee laxity measurements. Early phase conservative management resulted in more late phase meniscus surgery than did early phase reconstruction at all risk levels. Early- and late-reconstruction patients' Tegner scores increased from presurgery to follow-up but did not return to preinjury levels. Early-reconstruction patients had higher rates of degenerative change on radiographs than did nonreconstruction patients. They concluded that early phase reconstruction reduces the late phase knee laxity, risk of symptomatic instability, and the risk of late meniscus tear and surgery. Moderate- and high-risk patients had similar rates of late phase injury and surgery. Reconstruction did not prevent the appearance of late degenerative changes on radiographs.

CONCLUSION
Present literature suggest following guidelines
* Conservative treatment for isolated ACL tear gives good long term results although with slightly higher risk of secondary meniscal injury.
* Primary ACL reconstruction is absolutely indicated in following scenarios
- associated meniscal injury
- High preinjury activity level
* delayed ACL reconstruction is recommended for patients with symptomatic instability
* ACL reconstruction has no effect on appearance of degenerative changes on radiographs

FUTURE PROSPECTS
We agree with Cochrane database study that there is a need for good quality, and well reported, randomized trials evaluating the effectiveness and cost-effectiveness of current methods of surgical treatment versus non-surgical treatment. The follow up of such trials should be at least 10 years so that the long term effects including degenerative changes can be established.


REFERENCES

1. Giove, T. P.; Miller, S. J., HI; Kent, B. E.; Sanford, T. L.; and Garrick, J. G.: Non-operative treatment of the torn anterior Cruciate ligament.J. Bone and Joint Surg., 65-A: 184-192, Feb. 1983.

2. JokI, P.; Kaplan, N.; Stovell, P.; and Keggi, K.: Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. ]. Bone and Joint Surg... 66-A: 741-744, June 1984.

3. Hawkins, R. J.; Misamore, G. W.; and Merritt, T. R.: Follow-up of the acute non-operative isolated anterior cruciate ligament tear. Am. J. Sports Med., 14: 205-210, 1986.

4. Clancy, W. G.,Jr.: Intra-articular reconstruction of the anterior cruciate ligament. Orthop. Clin. North America, 16: 181-189, 1985.


5. Caborn DN, Johnson BM. The natural history of the anterior cruciate ligament-deficient knee: A review. Clin Sports Med 1993;12:625-636.

6. Roos H, Adalberth T, Dahlberg L, Lohmander LS. Osteoarthritis of the knee after injury to the anterior cruciate ligament or meniscus: The influence of time and age. Osteoarthritis Cartilage 1995;3:261-267.

7. Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF. Beliefs and Attitudes of Members of the American Academy of Orthopaedic Surgeons Regarding the Treatment of Anterior Cruciate Ligament Injury. Arthroscopy. 2003 Sep;19(7):762-70.

8.Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS.Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment. Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):442-8.

9. Casteleyn PP, Handelberg F . Non-operative management of anterior cruciate ligament injuries in the general population. J Bone Joint Surg Br. 1996, 78:446–451

10. Kostogiannis I, Ageberg E, Neuman P, Dahlberg L, Friden T, Roos H Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients. Am J Sports Med. 2007, 35:1135–1143

11. Strehl A, Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma. 2007, 62:1159–1162

12. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med. 1994;22:632-644.

13. Linko E, Harilainen A, Malmivaara A, Seitsalo S. Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev. 2005 Apr 18;(2):

14. Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. Journal of Bone and Joint Surgery - American Volume 1987;69(8):1120–6.

15. Andersson C, Odensten M, Good L, Gillquist J. Surgical or nonsurgicalbtreatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up. Journal of Bone and Joint Surgery - American Volume 1989;71(7):965–74.

16. D E Meuffels, M M Favejee, M M Vissers, M P Heijboer, M Reijman, and J A N VerhaarTen year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletesBr. J. Sports Med., May 2009; 43: 347 - 351.

17. Meunier A, Odensten M, Good L. Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: a randomized study with a 15-year follow-up. Scand J Med Sci Sports. 2007 Jun;17(3):230-7

18. Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM.Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med. 2005 Mar;33(3):335-46.