A friend of mine injured her knee when she fell on a New York City street. X-rays taken at the emergency room did not show any fractures but her knee just didn’t feel right and continued to hurt.
She went back to the ER a couple of days later and an MRI showed she had a total tear of her ACL (anterior cruciate ligament).
The orthopedic resident who looked at the MRI results told her she probably didn’t need surgery with this type of injury.
I did some research and found that there were some circumstances that an ACL tear was not surgically repaired. It seemed to mostly be a practice in those who were not very active or had good stability in their knees despite a tear.
I urged her to question the orthopedic doctor she went to see for follow up to explain to her how the decision is made to do a surgical repair or not.
She said her doctor told her that while ACL tears are frequently repaired here in the United States, that in some Scandinavian countries they weren’t in such a hurry to perform surgery.
Many people did well with just physical therapy and may not need surgery.
He explained that the ACL is an important stabilizing ligament for athletes who do twisting motions such a basketball players but for many of us, stability and support from the other ligaments surrounding the knee would be enough.
What she was told surprised me, so I had to do more research to find out why.
Science Daily reported that a Swedish study published in 2010, with a followup study in 2012, supported the practice of trying rehab alone instead of surgery, and rehab for patients with ACL tears.
The study published in 2010 actually involved patients recruited from February 2002 through June 2006, and the two-year follow-up was concluded in June 2008. The research group was called the KANON study (knee ACL non-operative versus operative) from Lund University in Sweden.
A total of 121 patients between the age of 18 and 35 were randomly divided into two groups. One group had rehabilitation plus early ACL reconstruction and the other had rehabilitation alone with the possibility of surgery later if needed.
After two years, just 40 percent of the rehab only group needed to have ACL surgery.
"There are almost 10,000 scientific publications addressing the ACL and 50 per cent of these are about surgical treatment. However, none of these studies have shown that surgical reconstruction produces better results than rehabilitation alone,” said Stefan Lohmander, professor and consultant at Lund University and Skåne University Hospital.
Based on the results of their own research, the Swedish researchers believe that there is no evidence to support that an ACL reconstruction should be performed before trying rehab alone as treatment.
A five-year follow up report on their patients published in January, 2013 continued to support the practice of giving patients with ACL tears rehab first. These findings are published in the British Medical Journal.
“Half of the patients who were randomly assigned not to undergo reconstructive surgery have had an operation in the five years since, after experiencing symptoms of instability,” according to Science Daily.
This means over the following three years, only an additional 10 percent of the people in the rehab only group needed ACL surgery.
Researchers reported that there was no increased risk of osteoarthritis or meniscal surgery needed in the rehab-only group, compared to the ACL surgery repair group.
The researchers plan to continue monitoring the patients and will report their findings again after 10 years of followup have passed.
More Than Half of All ACL Reconstructions Could Be Avoided, Five-Year Follow-Up Study Shows. ScienceDaily, 30 Jan. 2013. Web Mar. 17 2013.
Frobell, R. B. et al. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 2013; 346 (jan24 1): f232 DOI: 10.1136/bmj.f232
More Than Half of All ACL Reconstructions Could Be Avoided, Swedish Study Finds.ScienceDaily, 23 Jul. 2010. Web Mar. 17 2013
Frobell et al. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears. New England Journal of Medicine, 2010; 363 (4): 331 DOI: 10.1056/NEJMoa0907797
Michele is an R.N. freelance writer with a special interest in woman’s healthcare and quality of care issues. Other articles by Michele are at www.helium.com/users/487540/show_articles
Edited by Jody Smith