From the LA TImes…

Tearing the anterior cruciate ligament — better known as the ACL — sometimes results in early surgery, sometimes in later surgery and sometimes in no surgery. But which scenario has the best outcome? Two studies released this week seem to contradict each other. One study found that for children younger than 14 who needed ACL reconstruction, early surgery was better than delayed surgery. But for 18- to 35-year-olds, early surgery with rehabilitation was no better than rehab plus later surgery if it was needed.

 

 

This LA Times article looks at two recent studies about ACL injuries. The first deals with ACL injuries in children and the timing of surgery.  The second study referenced seeks to determine whether a reconstruction is necessary— and if so, when should the reconstruction be performed.  The author tries to drive comparisons that are not necessarily correct, or statistically valid.  They are trying to compare apples to oranges… but at least they’re putting the information out there.

 

As a lead in, this is one of the many reasons why I believe that physicians should be taking a very active role in social media.  These articles, primarily titled to draw eyeballs,  (not the LA Times article) were very actively *discussed* on Twitter and on Facebook.  I received a number of direct messages regarding the articles and 3 patients brought an article in to the office to discuss the findings and whether or not it was pertinent to their particular case.

But I digress…

The first paper mentioned focused on children and the timing of an ACL reconstruction… ACL injuries in children present themselves as a challenge because they have open growth plates.  These are areas in the bottom of the femur or thigh bone and on the top of the tibia or shin.  An ACL reconstruction will typically cross the growth plates (although some techniques don’t) and this poses a theoretical risk of injury to the growth plate, which can stunt the growth of the leg, or cause the leg to grow at an unusual angle if part of the growth plate fuses.   Children, unlike most adults with ACL injuries, simply can’t help but continue with what they believe to be their usual activities.  This may lead to instability episodes where the bones of the knee slide on one another.  These buckling, giving way or instability episodes can cause tears of the medial or lateral meniscus (the cartilage discs in the knee), or it can damage the articular cartilage on the ends of the bones themselves.  Because children will not curtail their activities, these associated injuries tend to increase with time from the initial injury which tore the ACL.   The study presented showed that a reconstruction of the ACL within 12 weeks of the injury was beneficial because it minimized the risk of developing associated injuries and there were few growth plate injuries.  There are unique considerations when performing an ACL reconstruction in children in order to minimize the risk of developing a growth plate issue, so parents should seek out a sports medicine professional with experience reconstructing ligaments in this population.

 

The second article referenced focused on adults.  The article questioned whether or not an ACL reconstruction was necessary in all cases when an MRI documented tear exists.   As I have discussed for years on my website, the indication for an ACL reconstruction is not merely the fact that a tear exists.  This study was further proof that this is true.  Many patients without instability, buckling or giving way after a course of rehabilitation can be managed non-operatively.  Patients involved in sports requiring significant cutting, pivoting, twisting, or rapid acceleration or deceleration may not be able to participate in these activities without an ACL and may want to consider an early reconstruction to minimize the risk of developing common associated injuries as outlined above.  That said, I have a few patients who are skiing or playing certain sports, with a brace, and without an ACL reconstruction and are quite pleased with their quality of life… and that’s what it boils down to.  You can change your knee to suit your lifestyle or change your lifestyle to suit your knee.  Some patients may choose not to ski twice a year in order to avoid surgery… that is their decision to make… I am simply a team member there to provide you with the information you need to make an informed decision…. the  key element of Participatory Medicine.

Just wanted to add a great Podcast from authors of a recent study out of Europe which revealed that patients treated either with early PT and early reconstruction of the ACL or  those who waited — considered their options — and then chose whether or not to have surgery essentially had the same results after following them for 2 years.

As with all posts where I discuss medical issues, my standard disclaimer applies.

 

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About the author:

Howard J. Luks, MD

A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions will be. Ultimately your treatments and his recommendations will be based on proper communications, proper understanding, and shared decision making principles --- all geared to improve your quality of life. Please read our Disclaimer

9 comments on “Anterior Cruciate Ligament (ACL) Tears: To Reconstruct or Not… and if so, When? Adults vs. Peds

  1. @boltboy I hope this helps to clarify the final question posed on your blog post. For those of you who have not read his post, his final question was simply how many patients who sustain an ACL rupture actually require a reconstruction. It’s not a straight forward answer. Patients with functional instability who do not respond to PT and who do not wish to alter their lifestyle are good candidates for an ACL reconstruction. There is a very rough rule of thirds that applies in ACL injured patients. 1/3 will barely notice any issues and should not require a reconstruction. 1/3 of patients will be symptomatic but can alter their lifestyle to adjust to their limitations and thus avoid surgery. 1/3 will have significant instability with most any activity and are good candidates for surgery to avoid instability with daily activities. That said, people who work on roofs, climb ladders, rock climb or in general work in precarious situations routinely should consider a reconstruction early on to minimize risk of serious personal injury. Again, std disclaimer applies.

  2. Great post Dr. Luks,There are two things that strike me. First, I really appreciate your comment about the need for physicians to be involved in the conversation. When articles with sensational titles such as: “Knee Surgery Looks No Better Than Therapy For Torn ACL” (NPR: http://daws.in/cuYl7L) come out, they “sound” definitive. That article in particular leaves to the penultimate paragraph this critical quote: “…a majority of the people assigned to the rehab-focused group said their injured knees were wobbly.” This week, I scheduled my 2nd ACL repair (different leg). Unlike my first tear, there was no swelling and no immediate loss of stability. In fact, I skied the rest of the season…hard…double blacks, cliffs, bumps, etc. Over the course of the last few months the instability has become noticeable although not incapacitating, despite being in the gym, focused on quad strength, 3 days a week. So in some ways I am able to keep up normal activity, and in other ways I’m acutely reminded, daily, of the absence of the ligament. When I read the headlines I was both confused and concerned that I had made the wrong choice in scheduling the repair. Having the physician perspective on these ad-selling, click-generating headlines helps level the information and put it into a trusted perspective. At this point, I am confident in my choice to have the surgery. Could you elaborate on your comments about having patients who have resumed normal activity, sans ACL? Can an unstable knee become stable or is any instability a strong indication for surgery? On a related note, it has been suggested to me (by folks other than my physician) that any instability, perhaps even when it is imperceptible to someone without an ACL, causes shear force on the cartilage and inevitably leads to pre-mature arthritis. Rather than ask you to dispense medical advice via blog comment…The articles don’t discuss the long term impacts of surgery vs therapy alone. Do you have a strong feeling that either choice has important long term ramifications?

  3. @nickdawson Nick… as you know this is general advice and not specific to you… If a patient perceives the knee is unstable and it affects the quality of their life and their chosen activities of daily living or sports then an ACL reconstruction is an attractive alternative to limiting their lifestyle, sports, activities, etc…. It is an informed choice. Evidence based medicine shows that instability can lead to meniscal tears which can in turn result in arthritic changes. The literature also shows that arthritic changes in the reconstructed knee can appear worse on X-ray, but the patients are still more satisfied because of the enhanced stability and ability to participate in sports, etc. To my knowledge, there is no concrete evidence that a “stable” ACL deficient knee will lead to more degenerative changes than a reconstructed knee. It turns out there are very important nerve fibers in a normal ACL and those nerves help minimize risk of developing arthritis (complicated process). Even in the reconstructed knee, those nerve fibers do not grow back… so having an ACL reconstructed to prevent arthritic changes, in the absence of instability, disability or meniscal pathology is not supported by the literature. std disclaimer!

  4. My 14 year old daughter was recently (mid-May) in a direct contact injury that fully tore her ACL. My husband and I are at a crossroads where we have to decide her course of treatment (surgery vs. delayed surgery if PT does not work). She is a competitive athlete and wants to do everything she did before the injury. Based on what I’ve read, there are so many pros/cons to consider, but I’ve also been told that ACL reconstructions are very common. I’m curious of there are a portion of young athletes who are able to regain knee stability without their ACL so that they can continue with activities prior to injury or if this is more uncommon.

    1. Jennifer … As a parent I know how wrenching this decision can be. I can not speak to the specifics of your daughter’s case, however most all of the recent scientific literature shows that delaying an ACL reconstruction in children raises the risks of her suffering from secondary injuries such as meniscus and cartilage. This needs to weighed against the risks of the surgery.

      I hope this helps a bit…
      Good Luck

      Howard Luks

  5. First of all, thank you for sharing your insight. I am 38y/o, highly active, and injured my knee 3 weeks ago. MRI results show a moderate to high grade ACL tear. Does this mean my ACL is fully torn for sure? Also it shows a partial bucket handle tear of lateral meniscus. Is surgery a must? I have no instability in my knee, can fully extend it, but can’t flex it completely. I have been able to use a stationary bike and elliptical with no pain. Am I in need of immediate surgery or can I delay it and continue with rehab and see how it feels in 3 months? My orthopedic surgeon simply told me I need surgery rather urgently to prevent further meniscal injury. He recommends ACL reconstruction and meniscal repair. I was left to feel very unsatisfied with his vague approach in outlining these procedures. Any feedback you have would be greatly appreciated.
    Thank you, Kim

    1. Kim …
      It depends what you mean by “highly active” ? People who rock climb, work on a roof or in precarious situations usually need to opt for surgery. People who plan on playing at a high level in cutting, pivoting and twisting sports usually need to consider a reconstruction — but, the research is fairly clear — not everyone with an ACL tear will require an ACL reconstruction.

      Can your meniscus tear become larger? yes. Could it remain the same size, yes. If your knee is stable, then many docs would consider observing you and rehabbing your knee. Many might consider actually repairing or suturing the meniscus tear.

      There is no clear cut answer… and I can not tell you which way to go. It would depend on a long discussion of your issues, your goals, expectations etc.

      Good Luck with your decision making.
      Howard Luks

  6. I am a 36 yr old single mom, I do manual labor, heavy lifting, up and down a lot and stay active with my 2 children. 20 yrs ago I had acl reconstruction on my left knee. On Feb 28, I tore my acl in my left knee. I’m not sure the extent as the Dr didn’t say, just that he didn’t think I needed surgery anytime soon, (lack of insurance is best I can tell). My knee still has swelling and gives several times a day, and I still don’t have ROM. I’m worried I will injure it worse without the surgery, something I just can’t afford to deal with. What would you recommend?

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