Who Should Consider an ACL Reconstruction? Five Professional Opinions.

ACL tears are are occurring at an alarming rate.  With lifelong implications, an ACL tear can be a devastating injury in a teenager.  While 65-80% of athletes can expect to return to sports, that means that more than 20% will not.  More worrisome is an ACL re-injury rate of 15-20% despite a well-performed reconstruction and well-executed rehabilitation phase.

There is a common misconception in the patient community that ACL tears are a straightforward problem with a simple solution.  Nothing could be further from the truth.  Who requires an ACL reconstruction, how should the reconstruction be performed, which graft should be used to repair the ACL and when can an athlete return to sports are very important considerations that surgeons and patients wrestle with on a daily basis.

In this series of posts we are going to present the responses of five prominent Sports Medicine Surgeons (see below)  with their thoughts about many of the issues surrounding an ACL injury in an 18-year-old athlete.  Providing you with an opportunity to learn from 5 accomplished sports medicine Orthopedic Surgeons is something I am very happy to offer our readers.  ACL surgery is not a straightforward process, and only those that need it should consider it.

So, without further delay.  Here are 5 opinions on when we should consider ACL surgery in a young athlete.

When should we consider ACL surgery in an 18 year old athlete?

D.G. : As I would with any patient with an ACL injury, I would discuss both surgical and nonsurgical options. Given that the patient is an 18-year-old athlete, I think that almost certainly we would decide to proceed with surgical reconstruction. With the likely instability that would exist with an ACL-deficient knee in a young athlete trying to play a sport like soccer, I would worry about the risk of secondary injury to the menisci or articular cartilage.

D.O. : There is “no one size fits all” approach in my practice.  If MRI shows a clear meniscal tear associated with the ACL rupture, I am more likely to recommend surgery, as the meniscus can be repaired simultaneously with the ACL reconstruction, and chances of healing the meniscal tear concomitantly with ACL reconstruction is high.  If the patient does not have a meniscal tear and they were in their senior season of soccer WITH NO PLANS TO PLAY AT THE NEXT LEVEL, then I would talk to them about conservative management and possibly be bracing for recreational activities, and see if they can be active and happy with this alone.  A positive Pivot Shift Test would make it less likely that an active individual could tolerate the instability without surgery, but definitely not impossible.  Also, many times a Pivot Shift test is “falsely negative”, because the patient is subconsciously guarding and protecting their knee.

J.B. : I tell all pts who sustain an isolated ACL tear (if have other injuries can be different): only 2 smart options 1.  Give up pivoting and jumping sports and activities (team sports, Racquet sports, trail running and hiking, dancing, etc.) or 2) have an ACL reconstruction.  In 18 yo who is athletic, I don’t believe that there really is a choice.  Even if the athlete felt they didn’t wish to continue, I would think that is unlikely.  I would suggest ACL reconstruction.

S.S : I would recommend surgical treatment with ACL reconstruction for the vast majority of these patients.  I always have a discussion with the patient and family about the natural history of ACL tears.  I tell them that surgery is not mandatory, and discuss the risks and benefits of surgical and non-surgical options.  If the patient has other associated injuries such as meniscus tears or other ligament injuries, I feel that surgery is almost always the best option.  Even if it just an ACL tear, further problems are likely without reconstruction.  Patients with ACL tears and obviously unstable knees on physical exam, that are involved in more than 50 hours per year of Level I sports, like soccer, are at very high risk for further instability episodes.  These instability episodes can frequently cause further additional damage to the knee.  This is my biggest concern with non-surgical treatment.  At least 80% of patients with an untreated ACL tear, with a currently normal meniscus, will develop a meniscus tear within 10 years if they continue to be active.  In addition to possible protection against further injury, an ACL reconstruction will more reliably allow most patients with an unstable knee to return to their sport with greater confidence and improved function.

S.M : My decision to operate on an 18 yo soccer player with an ACL tear is based on the level of instability of the knee and on whether or not there are other significant tears.  I do not automatically recommend ACL reconstruction in patients with isolated ACL tears. Although it is uncommon, I have seen patients who have not had clinical instability after an ACL tear.  I think these cases are probably due to the ACL not being 100% torn or the tear healed onto the PCL in such a way that it provides support.  After an acute tear, I will send patients to physical therapy for 4 weeks to help regain motion and strength.  After the initial therapy, I see them for re-evaluation.  If there is no block to motion and the acute signs and symptoms are resolved,  I ask them to slowly increase activities.  If a patient is showing no signs of instability I continue them on physical therapy with the goal of doing a trial of soccer once all the signs of the ACL tear are resolved and the leg is back to pre-injury strength.  If a patient feels that the knee is unstable after the initial therapy trial  I will recommend ACL reconstruction.  Cases which would require a sooner surgery are those patients who have a displaced bucket handle meniscus tear.  In these cases, I will do a knee arthroscopy and meniscus repair.  These patients will undergo rehabilitation and possible staged ACL reconstruction.

Notice the common threads that are emerging in this discussion:

• Not all patients need to consider an ACL reconstruction… but most do.
• If you have also torn a meniscus or if you have torn more than one ligament then surgery to reconstruct your ACL is likely to be your best option.
• People who choose not to have an ACL reconstruction are at high risk for secondary injuries such as a meniscus tear or an injury to the cartilage or cushioning on the ends of our bones.  Both of these injuries dramatically increase your risk for developing arthritis in the knee.

The participants :

D.G.: Dr David Geier : Twitter: @DrDavidGeier  ; Website

J. B.: Dr Jeff Berg:  Twitter: @DrJeffBerg ; Website 

D.O.: Dr Derek Ochiai: Twitter: @DrDerekOchiai ; Website

S.M.: Dr. Steve Mora: Twitter: @myorthodoc ; Website 

S.S:   Dr Scott Slattery: Twitter: @sportscaduceus  ; Website