Treatment for Acute
Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial
Frobell RB,
Roos, HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS. BMJ. 2013, 346:
f232. doi: 10.1136/bmj.f232
Anterior
cruciate ligament (ACL) tears occur frequently in athletics, and carry with it
the potential risk of osteoarthritis (OA).
ACL injury is often treated with surgical reconstruction in an effort to
reduce the risk of secondary injuries and progression to OA. Some people insist that an ACL reconstruction
is needed as quickly as possible; however, the timing of surgery or the lack of
surgery on longer-term outcomes has yet to be determined. The purpose of this extended follow-up of a randomizedclinical trial (link to original article) was to
compare the outcomes of patients that had immediate ACL surgery versus those
that had optional delayed ACL surgery.
One hundred twenty patients (ages 18 – 35 years) all underwent similar
rehabilitation, but were randomized to early (n = 61) or optional delayed (n =
59) ACL reconstruction surgery groups. Of
those that were assigned to the optional delayed group, 51% (n = 30) opted for
ACL surgery. At the 5 year follow-up,
there were no group differences in patient-reported outcomes (i.e., knee specific symptoms/function,
general health, Tegner activity scale), radiographic OA, or need for meniscal surgery. Mechanical knee stability (i.e., Lachman and
pivot shift) was significantly better in knees assigned to early ACL
surgery. Within ACL reconstructed knees,
more patellofemoral radiographic OA was found in knees that received the
patellar tendon in comparison to the hamstring tendon autograft procedures. Overall,
51% of participants underwent meniscal surgery during the 5-year follow-up and
24% of participants had radiographic knee OA.
This is the
first randomized clinical trial to explore this important question and it appears
that ACL surgery timing does not really seem to affect any major outcome at a 5
year follow-up. It is interesting to see
that early ACL surgery does not necessarily provide better outcomes. Furthermore, of those assigned to the
optional delayed surgery group, about 50% never needed surgery. There were no differences between those
surgically repaired early, late, or with rehabilitation alone. This may emphasize the importance of the
rehabilitation process, since all patients underwent similar rehabilitation
processes. The study controlled for
meniscal status, but did not report any correlations between meniscal status
and outcomes, which would be interesting to see. Based on this study it may be safe to delay
the ACL reconstruction to determine if the patient can tolerate conservative
management through rehabilitation and successfully return to play after an ACL
injury. I am extremely interested in
following these same patients out to a later time point. But ultimately, an ACL tear may not
necessitate surgery, and rehabilitation should be considered as a possible
option. Has anyone had any success with
conservative management of ACL injuries?
Written by:
Nicole Cattano
Reviewed by: Jeffrey
Driban
Related
Posts:
Original Paper with 2-year Follow-up:
Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (Clinical research ed.), 346 PMID: 23349407
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3 comments:
I am a Physical Therapist and tore my ACL almost 3 years ago. I rehabed myself and generally kept strong and active but don't participate in sports except downhill ski (beginner) so I don't have much lateral/rotational stress on my knee. I did very well until a life change caused me to stop working out and generally being as active. then I noticed my knee getting achy and loose feeling. SO, I feel that rehab is a legitimate short term alternative to surgery. What I haven't found is what the research is saying on much longer term effects. Even if my knee is ok for the next 20 years without surgery, then great, but I plan to live past 50. When I get older and my muscle tone is less, will I be more vulnerable to falls, etc? If you know of any research I would love to see it. Otherwise, just food for thought I guess.
I think I strongly agree with your statement, anonymous. Specially you have had a tore ACL as well. I have experienced almost the same problem.
I would like to share my story:
I have 28 years old and I injured myself 6 month back. MRI reports Laxity in my ACL. Orthopedic sent me for physiotherapy which I did for almost 3 month and helped a lot since I did not feel any instability or pain on my knee, being able to flex it 100%. However I did not do any sports, but could do a normal life.
After I took 1 month vacations, I didn't continue with my exercises, then I started to feel insecure with my knee and started to feel unstable. Now I started with the same exercises I was doing and again I have gained strength in my injured knee. My idea is to continue with the exercises at least for 6 month up to 1 year since I can't leave my job which I just got it and I would have to save the money for the surgery.
Therefore, If anyone that have been in similar situation or have proven track about it, can you please help me by giving your point of view about my concerns which are:
Would I be in high risk to damage my Meniscus if I Delay my surgery? I am mainly doing some exercise bicycle on daily basis and also some stretching and lifting and flexing my leg while laid down.
Any other activities that you would recommend which is beneficial?
And anonymous, you mentioned that you tore your ACL 3 years ago; so at the end, did you have the surgery nowadays or you still did not have it? And if not, are you planning to have the surgery? Have you kept on doing MRI on every 6 month or 1 year to see the evolution of your knee? Do you know if your delay have brought you any meniscus or any other parts of the knee have been damaged?
Also, you being a physical therapist, why did you choose you rehab yourself instead of having a surgery at first? Any reasons in special that you have experienced that made you choose that option?
Honestly, in my case I am afraid of surgery and also the post surgery side effects from this surgery or any surgery in a short and long term basis. So this is why I want you try out rehab to see if I can avoid the surgery, however as you (Anonymous) says, apparently it can only help as a short term alternative.
I hope I can get some points of view to make up my mind and decide what to do.
Anyone that have had successful rehab after ACL tear without surgery please share your story!!! Or if anyone have had rehab and have delayed surgery also share your story!!!
Thanks to all!!!!
I'm having the same dilemma! I'm a female in my early 20's and plan on playing sports for another 30 years. I play mostly basketball and ultimate frisbee. According to the MRI, my ACL is completely torn, LCL and MCL are sprained but everything else is okay. I have been getting mixed opinions about delaying surgery.
I am leaning towards surgery but my doctor is suggesting I try rehab first... But I mean if rehab alone can return the athlete back to competitive pivoting sports, why was this so unsuccessful back in the day before ACL reconstructions existed?
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