ACL Surgery: Is It Still Necessary?
What scientific data should we consider before deciding whether to treat ACL tears surgically or non-surgically?
Through systematic reviews and meta-analyses, where the highest standard of empirical evidence of interventions’ effects is evaluated, physician readers can best respond to a specific topic like this (Travers et al 2019). Recent literature reviews (Smith et al. 2014, Delincé and Ghafil 2012, Monk et al. 2016) found similar outcomes in both non-surgical and surgical groups with regard to pain, symptoms, function, return to sport levels, quality of life, subsequent meniscal tear and surgery rates, and radiographic knee osteoarthritis (OA) prevalence.
When comparing the efficacy of exercise therapy to non-necessary-for-life surgical procedures, randomised control trials (RCTs) are the best study design for musculoskeletal pain and injury presentations. Since typical elective procedures for the knee, shoulder, and elbow have recently been proven to be no better than a placebo, it is ideal for therapies to be tested alongside a placebo surgery arm (Sihvonen et al 2013, Beard et al. 2018, Kroslak and Murrell 2018). Since this has not yet been done for ACL injuries, clinicians are being urged to be sceptical, exercise critical thinking, and consider if any optional surgeries have a need before being evaluated in a placebo-controlled trial (Zadro et al 2019).
It is nearly incomprehensible that, according to a recent review by Kay et al. (2017), only one of 412 ACL randomised controlled trials actually compared ACL reconstruction (ACLR) to structured rehabilitation for acute ACL injury, with the majority of studies contrasting different ACL surgeries and graft types to one another (Culvenor and Barton 2018). The results of this one RCT, known as the KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell and colleagues (2013), were cited in a statement that said “clinicians and young active adult patients should be encouraged to consider rehabilitation as a primary treatment option after an acute ACL tear.” This is liberating and encouraging, especially in light of cultural trends in Western civilization up until this point in time. and cutting-edge ideas!
Why do you think so many physiotherapists and athletes assume an ACL rupture requires surgery?
This is a fantastic question with a lot to cover, and it almost merits its own PhD research study! The mainstream media, our existing healthcare structures, and views about the ligament itself are, in my opinion, three major forces behind this notion.
Our understanding of ACL tears has changed from one of “let’s try to replicate the ACL’s job anatomically by doing X, Y, and Z” to “what do the best-designed studies show that compare the 2 groups of trying to reconstruct the ligament and receiving rehabilitation versus doing physiotherapy and exercise alone?” Thus, a multi-billion dollar business has sprung up around our attempts to “re-create” a ligament, and the best methodologically rigorous studies are questioning what we formerly thought.
When compared to individualised, graded functional strengthening alone, we previously hypothesised that ACLR prevented OA and further meniscal damage. However, recent evidence suggests that ACLR may actually increase the risk of OA.
(Filbay 2019, Nordenvall et al. 2014, Culvenor et al. 2019) Studies have also demonstrated that the ACL can heal if left untreated (Ihara et al., 1994; Fujimoto et al., 2002; Costa-Paz et al., 2012), contrary to earlier beliefs that this was impossible due to the absence of blood clot formation.
All of our public and commercial healthcare structures are set up to speed-up and fund early MRI, early surgical opinion, and early surgery—at least in Australia, where we have the highest rates of reconstruction in the world (Zbrojkiewicz, Vertullo, and Grayson 2018). Both physicians and patients are simply uninformed of the calibre of the research for the intervention they may receive because physiotherapy and exercise are not currently routinely advertised, financed, or recommended through government systems or private insurance firms.
When a player hurts their knee on the field, there is a pervasive image in the media of alarmism and destruction, with pundits frequently “dreading” the worse. The assumption that the athlete has injured their ACL, will need surgery, and will need to take nine to twelve months off from their sport causes the next wave of emotion. This assumption is false, and we need to encourage players (and the general public) that many can perform at the highest level without invasive surgery.
What is the best management strategy following an ACL rupture, according to the research?
The authors are now underlining the “growing reality that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation” because to the dearth of high-quality research demonstrating the added benefits of reconstruction to physiotherapy and exercises (Grindem, Arundale and Ardern 2018) Consequently, there has to be a cultural shift away from early surgery and toward non-surgical treatment with surgery only when absolutely necessary (Zadro and Pappas 2018).
Further investigation of the KANON trial by Filbay et al. (2017) revealed that patients who underwent early ACLR had worse prognoses in several areas compared to the non-surgical and delayed surgical arms. These patients also experienced a “second trauma” as a result of the surgery’s drilling through intra-articular structures, a period of protracted joint inflammation, and altered weight bearing (Bowes et al 2019, Larsson et al 2017).
After an ACL injury, we need to take our time educating any patients about the relevant evidence through a process of shared decision-making, emphasising to them the importance of commitment and adherence to graded, thorough, long-term rehabilitation with prevention exercises continued after return to sport. We must dispel any notion that an ACLR is a “short fix” and emphasise the many advantages of beginning immediate rehabilitation on one’s own, ideally for at least 3 to 6 months, which is referred to as “World’s Best Practice” (Rooney 2018). The ultimate message is that non-surgical care continues to be a durable, long-term option for many active people.
What should the rehabilitation procedure entail for someone receiving non-surgical care? comparable to rehabilitation following ACL surgery?
Even though the rehabilitation method is quite similar, there is no need to recuperate after surgery or keep an eye on a graft, therefore recovery times are anticipated to be much quicker. Static stability tests that do not include weight bearing, such as the pivot-shift or Lachman’s test, are less important because it is now widely acknowledged that there is a poor association between them and functional stability (Snyder-Mackler et al 1997, Hurd et al 2009).
For a baseline evaluation of patients’ knee function, I like to use questionnaires like the IKDC and KOOS (Collins et al. 2011, van Meer 2013), and to assess psychological risk, I like to use the short version of the Rebro Musculoskeletal Pain Screening Questionnaire (Linton et al. 2011, or the Tampa Scale of Kinesiophobia (Miller et al. 1991).
It is crucial to explain to the patient the anticipated programme phases and the requirements for advancement, ideally in a verbal and written Treatment Plan. Initial treatment focuses on minimising discomfort and effusion while enhancing range of motion (ROM), muscular strength, function, and movement patterns.
End-stage physical therapy for athletes returning to sport includes evaluation of psychological preparation as well as sports performance (such as acceleration, agility, coordination, balance, and other sport-specific skills) (Filbay and Grindem 2019). After a successful return to play, booster follow-up sessions can be scheduled occasionally to make sure that preventative exercises are still being performed (Skou et al 2018, Fleig et al 2013, Nessler et al 2017). The broader public can gain from these uplifting messages if patients share their success stories with friends, family, coworkers, and social media connections, I also advise!
Can you pivot in sports without having surgery? Exist any solid case studies of top athletes?
Absolutely. It’s crucial for readers to understand that the myth that returning to pivoting or cutting sports with an ACL-deficient knee is impossible is false and is based on biologically implausible theory. Instead, numerous peer-reviewed papers demonstrate that returning to these sports is feasible and safe for many patients (Meuffels et al 2009, Grindem et al 2012, Kovalak et al 2018). In actuality, there isn’t a single study that demonstrates that playing twisting sports is impossible without an ACL. Your musculoskeletal system may be more than competent to compensate for ligament laxity through rigorous strengthening, neuromuscular control, balance, and sports-specific training, rendering the ligament basically redundant.
Studies on professional athletes comparing treatment alone to physiotherapy plus surgery haven’t truly demonstrated any benefit to the surgery group. A group-comparison research by Myklebust in 2003 among professional European handball players revealed no significant differences in return to sports rates and OA from a prospective study from Sweden conducted in the 1990s (Roos et al. 1995). Van Yperen et al. (2018) examined the meniscectomy rates, radiographic OA, and functional outcomes during a 20-year follow-up in 50 high-level athletes and discovered no between-group differences.
The most well-known non-operative case study involved an English Premier League player who, after suffering a complete thickness rupture, was able to resume playing without surgery in 8 weeks and went on to experience no further issues (Weiler et al 2015, Weiler 2016). There are many other athletes who have achieved greatness at the highest levels of competition, including in the NBA, NFL, and Major League Baseball, but DeJuan Blair is one of my personal favourites because he played for the San Antonio Spurs in the NBA for several seasons while avoiding having an ACL in either of his knees.
What are some significant factors that might enable us to identify potential “copers” or “non-copers” from non-surgical management?
The jury is still out on how to determine whether a person “needs” an elective reconstruction; we are unsure if it is due to cultural tendencies, typical healthcare pathways, beliefsfearspreferences of the clinician or patientparentssporting clubs, a lack of commitment to the rehab, or true pathophysiological reasons for their knee giving way with the resulting persistent pain and effusion despite high-quality, intense, structured, and graded rehabilitation.
With factors like progressive, rigorous rehabilitation beyond a tight time frame, movement patterns, and psychological fear-avoidance never before taken into account, traditional algorithms have been highly skewed towards early ACLR ( (Fitzgerald, Axe, Snyder-Mackler 2000, Hartigan et al 2013). Many patients who have been labelled “copers” nonetheless choose to have surgery (Hurd et al. 2008), while many “non-copers” who are given enough time eventually turn into “copers”! (Moksnes et al. 2008, Thoma et al. 2019, etc.)
According to the KANON trial, patients primarily chose to have a reconstruction due to psychological reasons such as pre-existing preferences, beliefs, and a lack of motivation for rehabilitation and exercises (Thorstensson et al 2009), with physical performance on the quadriceps strength and hop tests being crucial success factors (Ericcson et al 2013) in all groups. At the 5-year follow-up, choosing not to have an ACLR and to only get exercise therapy is another predictive predictor for fewer knee problems (Filbay et al 2017).
How should patients who choose a non-surgical treatment plan handle any potential psychological problems that may arise after an ACL rupture?
Once more, this is such a great question with so many interesting possibilities! We must at least briefly probe the patient’s perceptions of the available injury management alternatives, expectations, short- and long-term objectives, social concerns, anxieties, and motivations during our subjective examination (Burland et al 2019, Sommerfeldt et al 2018, Scott, Perry and Sole 2017). I’ve written articles elsewhere that discuss particular screening questions centred on these factors (Richardson 2018).
I look for signs of fear-avoidant movement patterns through the affected limb during the physical examination, such as guarding, bracing, excessive co-contraction of the hamstrings and quadriceps, and disproportionate off-loading of the knee (Hartigan et al 2013). I then make an effort to fix this by providing verbal or tactile clues, as well as encouragement, to replace these dysfunctional motor-control methods, which should improve quality and range of motion (ROM) during functional task assessment and lessen pain.
Reference
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