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Not Every ACL Tear Needs Early Surgery, Study Suggests
Date:7/21/2010

By Steven Reinberg
HealthDay Reporter

WEDNESDAY, July 21 (HealthDay News) -- Tears to the anterior cruciate ligament (ACL) of the knee are a relatively common and debilitating sports injury, typically leading to surgical repair.

But a new study in the July 22 issue of the New England Journal of Medicine suggests that some patients may have options beyond immediate reconstructive surgery.

"ACL reconstruction, in addition to supervised rehabilitation, is not necessary for all non-professional athletes to achieve similar self-reported function and quality of life," concluded study co-author Ewa Roos, professor and head of the Research Unit for Musculoskeletal Function and Physiotherapy at the University of Southern Denmark, Odense.

"However, at least five-year follow-up is necessary to know if any of the [alternative treatment] strategies is associated with less structural damage," Roos added.

The ACL is a ligament vital to the stability of the knee. An injury or tear to this ligament can cause pain and cause the knee to give way under even normal activity. These injuries most often occur in sports that place the ACL under high stress, the researchers explained.

For the study, the Danish team randomly assigned 121 active, young adults with ACL injuries to rehabilitation plus early ACL reconstructive surgery, or rehabilitation with surgery conducted later on -- if needed.

Among the 59 patients assigned to rehabilitation, 23 ended up having the surgery later on, while the other 36 did not, the study authors said.

In terms of pain, function and "knee-related quality of life," the researchers found no differences at two years post-injury between those who underwent early knee reconstruction, those who had rehabilitation plus delayed reconstruction, or those who underwent rehabilitation only, Roos said.

"A strategy of initial supervised rehabilitation-only was associated with a reduction of the surgery rate by 60 percent," Roos said. "This has monetary implications since the direct costs for ACL reconstructions are estimated to [be] $3 billion [annually] in the U.S. alone," she said.

The results suggest the treatment for active, young adults with an acute ACL injury should start with structured rehabilitation rather than early ACL reconstruction, said coauthor Richard B. Frobell, from the department of orthopedics at Lund University in Sweden.

"By doing so, the number of patients in need of reconstructive surgery could be reduced to less than 50 percent without compromising the results," he said.

But Dr. Bruce A. Levy, from the department of orthopedic surgery at the Mayo Clinic in Rochester, Minn., said decisions on whether one should undergo surgery or not should be based on an individual patient evaluation.

"No two knees, no two ACL injuries, no two patients are the same," said Levy, who is also the author of a journal commentary accompanying the article. "The decision whether to recommend surgery or not depends on many factors and is individually tailored to meet the specific needs of each patient. So it's really hard to recommend one treatment strategy for all ACL injuries."

He noted that for high-performing athletes, the odds of being able to return to the pre-injury level activity without ACL reconstruction is very small. But, for others, opting not to have the surgery can be a successful plan.

However, if the ACL injury is associated with another knee injury, such as a repairable rip in knee cartilage, called the meniscus, surgery to repair both would be needed, Levy said. "When the surgeon goes in to repair the meniscus, but doesn't repair the ACL, there is a very good likelihood that that meniscus repair will fail," he said.

Levy agreed with the authors that surgery for ACL injuries can always be delayed. "We often do surgery years after someone sustains an ACL injury," he said.

For those who opt not to have the surgery, ACL injuries are treated with a program of rehabilitation and bracing, Levy explained. If after a time the brace doesn't work or one has persistent "giving way" of the knee, then surgery is still an option, he stated.

"Not everybody succeeds when you try non-operative management," Levy said. "But there are definitely patients that can manage without ACL reconstruction."

More information

For more information on an ACL injury, visit the U.S. National Library of Medicine.

SOURCES: Richard B. Frobell, Ph.D., department of orthopedics, clinical sciences, Lund University, Sweden; Ewa Roos, Ph.D., professor and head of the Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Bruce A. Levy, M.D., department of orthopedic surgery, Mayo Clinic, Rochester, Minn.; July 22, 2010, New England Journal of Medicine


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