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1st Jan

2012

Can ACL Injuries be Treated Conservatively?

A new well received dissertation by a Swedish orthopedic surgeon looked at factors which may predict whether or not surgery is needed after knee anterior cruciate ligament (ACL) injury, and it looked at long-term outcome after injury, and after having initial physical therapy and making acceptable activity modifications.

One hundred patients in their mid 20s, who sustained ACL injuries typically during sports, initially had rehabilitation and were encouraged to modify their activities and e.g. not return to pivoting contact sports. They were followed up 15 years later. Approximately 1/3 of the subjects had undergone reconstructive surgery. Another recent study showed that less than 50% needed surgery.

The type of injuries that had the greatest chance of requiring surgery were compression type injuries, such as with pivoting and contact sports, often sustained in sports such as soccer, football, and basketball. In addition to causing ACL tears, such injuries also cause the most meniscus injuries, and are associated with the highest risk of later developing arthritis in the knee. Distraction type ligament injuries may be caused by sports such as skiing, and often have better prognosis and require surgery less often.

At the 15-year-follow-up, all people on average reported little symptoms or difficulties with daily activities, and up to 60% of those not operated on had returned to their previous activity level. However, some people who initially were injured in contact sports reported lower quality of life, as compared to those injured in non-contact sports.

The average occurrence of definite knee arthritis after 15 years was only 16% in this long-term study, which is clearly less than what has been reported in other studies following ACL reconstruction, which was believed to be in part due to the activity modifications made.

It was found that differences in activity level and knee instability signs right after the ACL injury were not predictive of need for reconstructive surgery. However, those who showed good joint stability with testing three months after the injury typically would not need surgery over the next 15 years.

This research team recommended a minimum of three months of physical therapy rehabilitation, before making a decision whether or not to proceed with reconstructive surgery. A good percentage of people who are patient enough to do that, and are committed to their rehabilitation and can cope with modifying their sports activities, have a good chance of doing well and staying active long-term and possibly even having less chance of developing knee arthritis later on. However, those who injure the ACL in pivoting contact sports, who have instability signs even at three months after the injury, and who are not willing to accept a reduction in their sports participation, may be more likely to require reconstructive surgery.

These types of injuries are common in particular in sports, so it may be helpful to pass this information on to family and friends. I want to wish you a good start to the New Year!

With best wishes for continued good health,

Gunnar

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