By Adam Culvenor, PT, PhD, @agculvenor; and Christian Barton, PT, PhD, @DrChrisBarton

Last month, Professor Lars Engebretsen expressed concern on this blog regarding the potential return to popularity of synthetic grafts for cruciate ligament deficient knees in an attempt to optimise outcomes. There has been a great deal of research attempting to identify the optimal surgical technique and ligament substitute since the first report of surgical repair for a ruptured cruciate ligament in 1895. Today, the two mainstay choices are hamstring-tendon and bone-patellar tendon-bone autografts, with preferences differing around the globe (1).

Systematic reviews of randomised controlled trials have identified few differences in outcomes more than 2-years postoperatively between these two popular graft choices (2, 3). Similarly, variations of surgical technique, such as double-bundle reconstruction or different drilling techniques, while potentially providing greater passive stability, offer no more superior clinical or functional outcomes (4, 5).

Professor Engebretsen cites the quest for the Holy Grail – a quick return to sport without re-injury or increased osteoarthritis risk – has led to an alarming resurgence of synthetic ligaments. But do we really need to pursue unconventional surgical interventions that have failed to stand the test of time?

Perhaps the secret lies not in chasing the next sexy surgical trend but in completing an outstanding rehabilitation program. Dare we say it; many individuals suffering an ACL rupture may not need surgery. Optimal non-operative management may even fast track a return to competitive sport. A recent BMJ Case Report detailed an elite English Premier League player’s return to full-competition within 8-weeks of a complete ACL rupture with a problem-free follow-up at 18-months (6). And importantly, you cannot re-rupture a graft that doesn’t exist.

Evidence for considering a progressive non-operative approach to ACL injury management is not isolated to case studies of patients with access to elite medical teams. The prominent KANON trial – the only high-quality randomised controlled trial comparing early reconstruction to rehabilitation alone (with the option of delayed reconstruction if indicated) for acute ACL injury – clearly demonstrated that functional, symptomatic, radiographic and activity level outcomes do not differ up to 5-years post-injury in non-elite athletes (7). If surgery is to continue in practice, perhaps research endeavours to identify those who might benefit should be the focus, rather than what seems to be futile efforts to identify better graft and surgical approaches.

If surgery didn’t make a difference in outcomes, what did?

The difference in achieving outstanding functional outcomes, irrespective of surgical or non-surgical management was physical performance (8). Preventing a delayed ACL reconstruction in those starting with rehabilitation alone, was also related to higher physical performance (8). An even more important finding of this study is possible long-term detrimental effects of early surgical management, with conservative management shifting prognostic factors for 5-year outcomes in a positive direction (9).

With evidence clearly showing the benefits of (at least) trialling a non-operative approach for ACL injury management in most scenarios, and in cases of ACL reconstruction, completing a well-designed progressive postoperative rehabilitation program, do we need to make rehabilitation and exercise-therapy more sexy? Is it any wonder that patients often wish to avoid the arduous, dull and boring sounding ‘conservative management’ when they can get a ‘quick fix’ from the surgeon? But with re-rupture rates so high and no apparent benefit based on current high quality research, this surgical ‘fix’ is not necessarily a fix.

Targeting patient buy-in through quality patient education, goal-setting and repeated functional testing to provide feedback and enhance motivation to complete adequate exercise and ‘sport-specific rehabilitation’ based on accepted resistance training principles should be a priority for all clinicians. The world leaders in this field use these approaches successfully to achieve outstanding outcomes (10).

Additionally, it is time we translated evidence-based rehabilitation programs into clinical practice. Our current pilot research indicates few patients continue rehabilitation guided by physiotherapists beyond 3-months, with minimal shared decision-making in the return-to-sport transition occurring (11). This means achievement of physical resilience before return-to-sport is unlikely, and may be a key contributor to failed return-to-sport with or without surgery.

Based on current research, we propose the first line treatment for people following ACL injury should be ensuring adequate exercise rehabilitation involving addressing range of movement deficits, lower-limb strength (with a focus on quadriceps) and a progressive return to pain-free function and sport. Surgery may remain relevant in some, but may not be the key determinant of return-to-sport or prevention of osteoarthritis. In light of these points, it is time to shift focus and funding from ‘sexy’ new synthetic graft research to understanding who needs any form of surgery and ensuring all patients receive adequate (and wherever possible, intense and progressive) exercise rehabilitation.

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Adam Culvenor PT, PhD, is a physiotherapist and National Health and Medical Research Council (NHMRC) of Australia Early Career Fellow at La Trobe University’s Sport and Exercise Medicine Research Centre, and a BJSM Associate Editor.

Christian Barton PT, PhD, is a physiotherapist and post-doctoral researcher at La Trobe University’s Sport and Exercise Medicine Research Centre, and a BJSM Associate Editor.

References

1. Chechik O, Amar E, Khashan M, Lador R, Eyal G, Gold A. An international survery on anterior cruciate ligament reconstruction practices. Int Orthop. 2013;37:201-6.
2. Li S, Chen Y, Lin Z, Cui W, Zhao J, Su W. A systematic review of randomized controlled clinical trials comparing hamstring autografts versus bone-patellar tendon-bone autografts for reconstruction of the anterior cruciate ligament. Arch Orthop Trauma Surg. 2012;132:1287-97.
3. Li S, Su W, Zhao J, Xu Y, Bo Z, Ding X, et al. A meta-analysis of hamstring autografts versus bone-patellar tendon-bone autografts for reconstruction of the anterior cruciate ligament. Knee. 2011;18:287-93.
4. Li YL, Ning GZ, Wu Q, Wu QL, Li Y, Hao Y, et al. Single-bundle or double bundle for anterior cruciate ligament reconstruction: a meta-analysis. Knee. 2014;21:28-37.
5. Riboh JC, Hasselblad V, Godin JA, Mather RC. Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:2693-702.
6. Weiler R, Monte-Colombo M, Mitchell A, Haddad F. Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less han 8 weeks: applying common sense in the absence of evidence. BMJ Case Reports. 2015:bcr2014208012.
7. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:f232.
8. Ericcson YB, Roos EM, Frobell RB. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. Br J Sports Med. 2013;47:980-5.
9. Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. Br J Sports Med. 2017;Epub ahead of print.
10. Grindem H, Risberg MA, Eitzen I. Two factors that may underpin outstanding outcomes after ACL rehabilitation. Br J Sports Med. 2015;49:1425.
11. Patterson BE, Culvenor AG, Barton CJ, Crossley KM. Shared decision making rarely occurs during return to sport following ACL reconstruction. The Future of Football Medicine Conference, Camp Nou Barcelona. 2017;Presented abstract.