CONSERVATIVE MANAGEMENT OF ACL RUPTURES: A TIME FOR CHANGE

Everyone knows this injury, the anterior cruciate ligament (ACL) rupture. Everyone recognises the name and almost everyone would tell you that it is a sentence to surgery. A few others might try to explain that things have changed, and that surgical treatment no longer represents the only way to deal with this injury. This has been known for some time and it has been discussed before, still the vast majority of patients that show up in the clinics come straight from the hospital, after a ligament reconstruction. This article aims to present a short review of the literature about this theme, hoping to contribute to an improved perspective on the topic.

Eligibility problems

Meniscal lesions, osteoarthritis, poor outcomes on return to sporting activities, among others were some of the arguments that were used to prevent patients or surgeons from trying conservative treatment after an ACL rupture in the past (Church & Keating, 2005; Kennedy, Jackson, O’Kelly, & Moran, 2010). A review of the literature has found that not only is this not supported by research, it might even be detrimental when compared with conservative approaches (Delincé & Ghafil, 2012).

Several methods were used to select patients on the type of treatment they should receive, ranging from anterior and side-to-side laxity to pre-injury activity levels and pivot-shift tests. Neither of these has been shown to have a positive correlation with dynamic knee stability (Delincé & Ghafil, 2012; Hurd, Axe & Snyder-Mackler, 2008), though they are still used every day in clinical examinations and take a major role in determining surgical management.

Assessment of eligibility using functional screening tests was one of the few methods that proved to be reliable in determining dynamic knee stability. Hop tests and quadriceps strength index are some examples of neuromuscular adaptations that can guide patient management. Even validated knee outcome surveys seem to be more reliable for identifying potential success of conservative approaches. Almost 50% of the assessed patients are defined as potential copers of conservative treatment (Delincé & Ghafil, 2012; Hurd et al., 2008). Yet, physios and S&C coaches do not usually report participating in these types of assessments, presumably because they are not done or requested. Health and sports exercise professionals are much more commonly seen working with individuals who had surgery at some point. However, this might be about to change. Motion analysis and performance assessments have seen remarkable progress in research during the last years and specialists are now ready to be part of the process to make it easier for those who decide to choose the conservative treatment.

Follow-up operative vs conservative

So, is it clear that eligibility for surgery should be improved and that many patients could have avoided the procedure, if the assessment was done appropriately in the first place. But are there any benefits of undergoing surgery in the long term and how does it compare to a conservative management?

Several follow-up type studies have compared both methodologies regarding function, knee stability, osteoarthritis and further injuries. These studies have covered time intervals ranging from one month to more than ten years after the rupture (Kessler et al., 2008; Meuffels et al., 2009; Smith, Postle, Penny, McNamara, & Mann, 2014; Tsoukas, Fotopoulos, Basdekis, & Makridis, 2016).

It is well-known that ACL ruptures are a predictable cause of the development of knee osteoarthritis and higher incidence of cartilage degeneration (Lohmander, Östenberg, Englund, & Roos, 2004). Furthermore, it was alleged in the past that surgeries could not only increase knee stability but also, consequently, prevent these findings in operated individuals. Recently, studies have shown that this was not the case as the 10-year follow-up did not find any significant differences between both groups. In fact, even if not significant, conservative management was shown to have a slight advantage over surgery, presenting lower incidence of the pathology (Meuffels et al., 2009; Tsoukas et al., 2016).

Knee function is commonly assessed through the Knee Documentation Committee subjective form as a functional outcome measure, however the Lysholm Knee Scoring Scale and hop testing have also been used in the literature to assess knee function. Once again, as with osteoarthritis, no significant difference was found between both groups after a 10 year follow-up (Meuffels et al., 2009; Smith et al., 2014).

However, there is a clear winner in favour of reconstructed ACL groups which is passive knee stability. Pivot-shift positive tests are considerably more prevalent in non-operative groups and this can represent high rotational instability for those who decide to approach the treatment conservatively (Meuffels et al., 2009; Pinczewski et al., 2007). Still, as observed, these findings do not correlate positively with functional performance outcomes of the knee nor with higher prevalence of osteoarthritis or other lesions for those who try conservative management. So, should this factor be taken into consideration? Additional studies are needed to understand if and how passive knee stability could correlate with actual functional problems of the knee joint.

Despite all these findings, what is truly important is the ability to resume pre-injury activity levels and functional performance. This is the main goal of athletes and the reason why so many are told that surgery is their best option, as it might represent the only chance they have to maintain such performance. But what does research tell us about it? Unexpectedly, or not, there was also no significant difference, after a one and two-year follow-up between surgical reconstruction groups and training/rehab-only groups regarding activity levels, muscle strength and functional performance (Ageberg, Thomeé, Neeter, Silbernagel, & Roos, 2008; Moksnes & Risberg, 2009).

Conclusion

The main goal of this article was to show how similar the outcomes of both approaches can be. As such, it is important to fight for a change in the paradigm, especially as comorbidities of ACL surgery and the risk of secondary injury after reconstruction are not commonly taken into account. Furthermore, conservative management can also help patients avoid more expensive and time-consuming treatments which might be precisely the reason why the surgical approach is still the most prevalent one, given the obvious conflict of interest. But that’s a topic for another article …

References

· Ageberg, E., Thomeé, R., Neeter, C., Silbernagel, K. G., & Roos, E. M. (2008). Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: A two to five-year followup. Arthritis Care and Research, 59(12), 1773–1779.

· Church, S., & Keating, J. F. (2005). Reconstruction of the anterior cruciate ligament. Timing of surgery and the incidence of meniscal tears and degenerative change. Journal of Bone and Joint Surgery, 87(12), 1639–1642.

· Delincé, P., & Ghafil, D. (2012). Anterior cruciate ligament tears: Conservative or surgical treatment? A critical review of the literature. Knee Surgery Sports Traumatology Arthroscopy, 20(1), 48–61.

· Hurd, W. J., Axe, M. J., & Snyder-Mackler, L. (2008). A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 2, determinants of dynamic knee stability. American Journal of Sports Medicine, 36(1), 48–56.

· Kennedy, J., Jackson, M. P., O’Kelly, P., & Moran, R. (2010). Timing of reconstruction of the anterior cruciate ligament in athletes and the incidence of secondary pathology within the knee. Journal of Bone and Joint Surgery, 92(3), 362–366.

· Kessler, M. A., Behrend, H., Henz, S., Stutz, G., Rukavina, A., & Kuster, M. S. (2008). Function, osteoarthritis and activity after ACL-rupture: 11 Years follow-up results of conservative versus reconstructive treatment. Knee Surgery Sports Traumatology Arthroscopy, 16(5), 442–448.

· Lohmander, L. S., Östenberg, A., Englund, M., & Roos, H. (2004). High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis and Rheumatism, 50(10), 3145–3152.

· Meuffels, D. E., Favejee, M. M., Vissers, M. M., Heijboer, M. P., Reijman, M., & Verhaar, J. A. N. (2009). Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. British Journal of Sports Medicine, 43(5), 347–351.

· Moksnes, H., & Risberg, M. A. (2009). Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury. Scandinavian Journal of Medicine and Science in Sports, 19(3), 345–355.

· Pinczewski, L. A., Lyman, J., Salmon, L. J., Russell, V. J., Roe, J., & Linklater, J. (2007). A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: A controlled, prospective trial. American Journal of Sports Medicine, 35(4), 564–574.

· Smith, T. O., Postle, K., Penny, F., McNamara, I., & Mann, C. J. V. (2014). Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. The Knee, 21(2), 462–470.

· Tsoukas, D., Fotopoulos, V., Basdekis, G., & Makridis, K. G. (2016). No difference in osteoarthritis after surgical and non-surgical treatment of ACL-injured knees after 10 years. Knee Surgery Sports Traumatology Arthroscopy, 24(9), 2953–2959.