ACL Ruptures – Do all patients ‘K-need’ surgery?

 

ACL rehabilitation strategies

 

Is ACL Reconstruction Necessary?

At 2 and 5 year follow-up that there was no difference in patient reported knee outcomes, objective performance measures or return to sport rates, between patients treated with reconstruction or those treated with rehabilitation alone. There is low quality evidence of increased radiological knee damage in the reconstructed knee which may lead to a greater risk of developing OA.  Exercise therapy alone was prognostic for less knee symptoms at 5 year follow-up.

Patients who had baseline meniscal or osteochondral injuries had a better prognosis with when managed with rehab alone or delayed reconstruction.  While patients with a higher KOOS score pre-reconstruction had better outcomes up to 5 years later. This highlights the role of ‘prehab’ and exercise therapy to increase knee function and strength pre-reconstruction.

Interestingly, despite studies indicating that non-surgical management offering at least equivalent results at 5 year follow-up, up to 50% of patients managed with rehab alone opted for delayed reconstruction. These patients often cited ongoing reports on knee instability. Thus, it is important to identify those patients which would benefit from conservative treatment and those who require reconstruction. (Monk 2016., Fillbay 2018)

Copers V Non-copers

One proposed criterion for a coper is:

  • 80% LSI for 6m timed hop test
  • KOS-ADLS score over 80%
  • Global rating of function > 80
  • No more than 1 episode of knee giving way post injury

(Moksnes et. Al., 2008)

It is important to note that there is not a dichotomy of patients. Some patients may initially pass this criterion but still require surgery and vice versa with patients who initially fail having good outcomes with conservative management. (Snyder-Mackler & Risberg, 2011) (Grindem, 2018)

Elite Athletes

Little is known about the conservative management of Elite footballers who rupture their ACL, however a recent case study (Weiler et al., 2015) of an elite English premier league footballer (aged 32) who returned to full competition 8 weeks post ACL rupture, and remained problem free at 18months (and still playing at EPL level) has been published in the BJSM.

While this is a single case study of a high level athlete with access to world class rehab facilities, it proves that reconstruction is not always necessary for a return to sport, and that conservative management may actually lead to a faster return to competition.

Summary

The research on conservative management of ACL ruptures is relatively young, and longer term outcomes are yet to be established. That said, findings so far indicate that non-surgical management for many patients will yield equivalent function and have slightly better prognosis for future development of osteoarthritis, especially when there is concomitant meniscal or osteochondral lesions. All patients would benefit from a period of exercise and physical rehabilitation after injury. Some patients may have instability without a reconstruction ‘non-copers’, while others may be ‘copers’ and could return to sport faster with non-surgical management. Management of ACL ruptures should be patient specific, and decisions should be shared between an informed patient, the surgeon and treating physiotherapist or rehabilitation professional.

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