The ethical dilemma surrounding management of anterior cruciate ligament injuries

By Grayson Harwood @GraysonHarwood

I recently had a patient (female, early 20’s) with a full-thickness ACL rupture with no other associated osteochondral, ligamentous, or meniscal injury – A ‘clean’ ACL rupture if you will. The injury occurred in a typical fashion – non-contact, change of direction, valgus/internal rotation mechanism while playing social-level football. At the time of writing, 12 weeks post-surgery, there is no obvious swelling, no pain with most activities of daily living, no giving-way episodes and full active and passive range of motion. She is back running comfortably and her strength is increasing every week. Importantly, she is ambivalent about returning to play football. All apparently predictors for a likely successful non-surgical pathway with rehabilitation only. HOWEVER, this patient’s sister also tore her ACL a year earlier and subsequently underwent an ACL reconstruction (ACLR) with apparently good outcomes. Because of this, it is understandable that the patient’s family want her to undergo surgery as soon as possible. They have taken her to the same surgeon who ‘fixed’ her sister’s knee and has (unsurprisingly) reported she needs surgery when she gets back from university. The key differences with my patient and her sister, however, is that her sister reportedly had a concomitant MCL injury, as well as an injury to her meniscus. The sister is playing high-level football which she was desperate to get back to. This situation is all too common in private practice, where patients who have experienced an ACL injury, are overwhelmed by the current beliefs surrounding ACL injuries that one MUST receive reconstructive surgery and undergo the 9 – 12-month minimum post-surgical rehabilitation if they want to return to sport.

Now, allow me to provide a few quick thoughts to challenge such beliefs:

ACLR is a larger trauma to the body than the initial injury.

A quick literature search on ACL rehabilitation can leave you overwhelmed with hundreds of search results evaluating the best graft choice, surgical technique, or fixation method. All methods require drilled tunnels into the femur and tibia causing significant inflammation and bone bruising. Patella tendon grafts have been shown to alter loading through the patellofemoral joint (PFJ) leading to increased risk of PFJ pain, patella tendon pain and even patella fracture (1). Hamstring tendon grafts result in donor muscle atrophy/weakness leading to a higher risk of hamstring strain injury (1).

Surgery vs conservative rehab and hopefully sham-surgery.

The KANON trial (Frobell et al, 2013) (2) is still the only high-level study comparing conservative rehabilitation vs ACLR + rehabilitation. The results showed no differences between groups in pain, function, radiographic evidence of knee osteoarthritis or consequent need for meniscus surgery. I for one, am looking forward to reading the inevitable surgery vs sham-surgery for ACLR to follow in the footsteps of arthroscopy for knee meniscectomy (3) and osteoarthritis (4), and also shoulder labrum repairs (5) and acromion decompressions (6) which have all showed no difference in outcomes.

Evidence for conservative rehab.

Costa-Paz et al (2012) (7) reported 14 patients at follow-up two to three years post-injury had complete healing of their once full-thickness ACL rupture.  A well-known case study of return to elite sport following conservative rehab was published by Weiler et al (2015) (8): an English Premier League footballer returned to competitive play an astonishing 8-weeks post full-thickness rupture, after two separate surgical consults both recommending surgery.

Ligamentous laxity ≠ functional instability.

We’ve all put our hands on knees that have a naturally lax ACL that has made us second-guess our clinical skills. As it is well documented that muscle strength, motor control and co-ordination can compensate for loss of ligamentous support (9), surgery may not be necessary for the patient’s context.

So, where does this leave me with my patient? In our next session I plan to evaluate her as per the “coper vs non-coper” algorithm (10) to see if she fits into the “coper” category. If so, I can confidently recommend conservative care, with evidence-based practice to back me up. I’ll need to give appropriate and clear education around surgical vs conservative treatment while trying not to over-emphasise my bias of conservative care (at least for this specific patient). It is important to individualise care to each ACL injured patient and not habitually head down the path of ACLR because that’s what we’ve always done. Ultimately, it is our patient’s decision to have surgery or not, all we can do is educate and provide them with all the available options and respect their end decision.

***

Grayson @GraysonHarwood is a physiotherapist in Wellington, New Zealand. He undertook this blog as part of requirements for a Masters in Sports Physiotherapy at the University of Otago. He owns his own clinic with his wife www.exercisewell.co.nz and is the head physiotherapist for the Wellington Phoenix Football Academy. Email: graysonh88@gmail.com

References

(1) Hardy, A., Casabianca, L., Andrieu, K., Baverel, L. and Noailles, T. (2017). Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature. Orthopaedics & Traumatology: Surgery & Research, 103(8), pp.S245-S248. doi: 10.1016/j.otsr.2017.09.002

(2) Frobell, R., Roos, H., Roos, E., Roemer, F., Ranstam, J. and Lohmander, L. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 346(jan24 1), pp.f232-f232. doi: 10.1136/bmj.f232

(3) Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., Kalske, J. and Järvinen, T. (2013). Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine, 369(26), pp.2515-2524. doi: 10.1056/nejmoa1305189

(4) Moseley, J., O’Malley, K., Petersen, N., Menke, T., Brody, B., Kuykendall, D., Hollingsworth, J., Ashton, C. and Wray, N. (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine, 347(2), pp.81-88. doi: 10.1056/nejmoa013259

(5) Schrøder, C., Skare, Ø., Reikerås, O., Mowinckel, P. and Brox, J. (2017). Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. British Journal of Sports Medicine, 51(24), pp.1759-1766. doi: 10.1136/bjsports-2016-097098

(6) Paavola, M., Malmivaara, A., Taimela, S., Kanto, K., Inkinen, J., Kalske, J., Sinisaari, I., Savolainen, V., Ranstam, J. and Järvinen, T. (2018). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ, p.k2860. doi: 10.1136/bmj.k2860

(7) Costa-Paz, M., Ayerza, M., Tanoira, I., Astoul, J. and Muscolo, D. (2011). Spontaneous Healing in Complete ACL Ruptures: A Clinical and MRI Study. Clinical Orthopaedics and Related Research®, 470(4), pp.979-985. doi: 10.1007/s11999-011-1933-8

(8) Weiler, R., Monte-Colombo, M., Mitchell, A. and Haddad, F. (2015). Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence. Case Reports, 2015(apr26 1), pp.bcr2014208012-bcr2014208012. doi: 10.1136/bcr-2014-208012

(9) Smith, T., Postle, K., Penny, F., McNamara, I. and Mann, C. (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), pp.462-470. doi: 10.1016/j.knee.2013.10.009

(10) Thoma, L., Grindem, H., Logerstedt, D., Axe, M., Engebretsen, L., Risberg, M. and Snyder-Mackler, L. (2019). Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study. The American Journal of Sports Medicine, 47(4), pp.807-814.

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