ACL Tears Don't Always Require Surgery for Best Results

Early surgery followed by rehabilitation for an anterior cruciate ligament (ACL) tear is no more effective than skipping surgery and concentrating on rehab exercises, according to a Scandinavian study of young active adults.

Patients who did not have surgery reported better levels of pain, ability to participate in sports and recreational activities and knee-related quality of life, compared to those who had early surgery, say researchers at Lund University in Sweden and the University of Southern Denmark in Odense. They based their findings, published in the July 22 issue of the New England Journal of Medicine, on patients' responses to the Knee Injury and Osteoarthritis Score survey 2 years after tearing an ACL.

After 2 years, 61% of 59 patients who planned to forego surgery and concentrate on rehabilitation were able to avoid surgery and reported acceptable levels of pain, activity and quality of life. "More than half of the ACL reconstructions could be avoided without adversely affecting outcomes," write the authors.

Whether a patient should have ACL reconstruction surgery sooner rather than later also may depend on type of activities the patient does, says Bruce Levy, MD, an orthopedic surgeon at the Mayo Clinic in Rochester, Minn., in an accompanying editorial.

"For example, it is highly unlikely that an 18-year-old college soccer player who performs repetitive planting, pivoting and cutting maneuvers would be able to carry out these activities without ACL reconstruction," writes Dr. Levy. "However, a 35-year old who participated in recreational sports such as cycling or jogging may function well with rehabilitation, bracing, or both."

For children, earlier ACL reconstruction may be more effective than rehabilitation and possibly surgery later, according to a different study. In mid-July, researchers from the Children's Hospital of Philadelphia reported that waiting more than 12 weeks to reconstruct resulted in a 4- to 11-fold increase in meniscal and cartilage injuries. The Philadelphia researchers presented their findings at the annual meeting of the American Orthopaedic Society for Sports Medicine in Providence, R.I.

"The timing of pediatric and adolescent ACL surgery has historically been controversial," says Theodore Ganley, MD, head of sports medicine at Children's Hospital. "Risks of growth disturbance [need to be] balanced against the risk of further knee damage related to delaying treatment until closer to skeletal maturity." i

Kent Steinriede

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