Mowbray MAS, Ireland J. Personal and narrative review of the current management of the injured anterior cruciate ligament of the knee in the UK with reference to surgical treatment versus rehabilitation. 



What is the story behind your study?
My late friend and colleague John Ireland was a distinguished Knee Surgeon who, like myself, was interested in the management of knee ligament injuries. He took the view, however, that the outcome following ACLR perhaps did not fully justify the volume of surgery currently being undertaken for ACL injuries. On full retirement from active surgical practice in 2009, I, therefore, decided, together with John, to produce a review of the work on ACL Surgery which I and my Knee Fellows and John’s team at Holly House had undertaken over the years. We broadly concluded that perhaps too many injured ACLs were being treated surgically when conservative measures would have sufficed. I passed the review on to my fellows, many of whom are now practising knee surgeons. I asked for their comments and was surprised to receive an eerie silence except those who had retired and broadly agreed with our conclusions. Like myself, whilst in practice, I think many of my old trainees who were undertaking ACL surgery were generally satisfied with their results.
In your own words, what did you find?
On reviewing many of the reported studies on ACL surgery, John and I found that the huge volume of published material on the subject, which was sometimes contradictory, allowed “cherry picking” or confirmation bias to operate in subsequent publications. A range of other biases was also extant in many other ACL studies. In recent times, however, we found our views were in step with several key publications from Scandinavia questioning the efficacy of surgery as opposed to rehabilitation in managing the injured ACL. We largely agree that a relatively small group of elite sporting individuals and other vulnerable groups may benefit from ACLR. Still, there are an unknown number of individuals in the recreational sporting community who have undergone an ACLR where Rehabilitation would have sufficed. Therefore we concluded that a more rigorous and focused preoperative assessment programme is required before offering surgery to recreational sporting individuals with greater involvement of sports physiotherapists. Ideally, patients with knee injuries should be managed in specialised clinics.
What was the main challenge you faced in your study?
Clearly, the greatest challenge we faced was getting the review published in the first place. As you can see from the above comments, the Review was conceived in 2009, some 13 years ago. The fundamental problem, like many scientific papers expressing negative results, is that they are not popular with the Editors of many scientific journals. On the face of it, the demonstration of anterolateral rotatory instability in the presence of a ruptured ACL is a powerful incentive to correct the instability by surgery. I certainly thought so. Also, surgeons and major surgical instrument companies have developed an extensive and sophisticated range of instrumentation and fixation devices to support surgery rather than encourage a more conservative approach. I know; I played a part in their development.
If there is one take-home message from your study, what would that be?
Our take-home messages are; Firstly, if you believe you have an important point to make, be patient and persistent if you don’t seem to be getting the message across. I think our time came with the recent papers published mainly by Scandinavian researchers questioning the efficacy of ACLR in the broader sporting population. Secondly, the vast literature published on the management of the injured ACL, in many instances, is contributing to what has been called the “Replication Crisis” to quote an article published in the New Scientist, it can lead to a Cycle of Dysfunction; “The problems are driven by three sectors that seem locked in a self-perpetuating cycle of dysfunction. Journals want flashy results to boost their impact factors and gain prestige. Funders award grants to people who have published in the most prestigious journals. And universities hire those who bring in the grant money.” The orthopaedic surgical community must retain a healthy cynicism toward the efficacy of even their most cherished surgical procedures. I certainly needed to.
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