Long Term Results of Nonoperative Treatment for ACL InjuryStudies show that athletes who tear their anterior cruciate ligament (ACL) often damage other soft tissues at the same time. Meniscus and cartilage tears are the most common injuries associated with ACL rupture. Meniscal tears and meniscectomy (removing a torn meniscus) are both risk factors for developing osteoarthritis of the knee.
The usual treatment for ACL tears is reconstructive surgery. The goals of ACL repair are to stabilize the knee and prevent further damage to the meniscus. But do patients really need this surgery? From many other studies, we know that having ACL surgery doesn't prevent arthritis from developing. What happens to patients with ACL and meniscal tears who don't have surgery? What's the risk of arthritis for these patients?
In this Swedish study, 100 patients with complete ACL tears were treated with early neuromuscular rehab and activity modification. Patients were supervised by physical therapists in hour-long sessions twice a week for five to eight months. A program of neuromuscular rehab was provided. Patients were advised to avoid contact sports (e.g., soccer, handball).
Everyone was followed at regular intervals for 15 years. Knee function, symptoms, and amount of arthritis were measured. Weight-bearing X-rays were used to measure the arthritis. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure symptoms and function. It was noted that no one had any signs of arthritis at the time of diagnosis. X-rays and arthroscopic exam were used to make the initial diagnosis.
Some of the patients (23 per cent) in this study ended up having ACL repairs. Approximately one-third of the 100 patients (35 total) had a meniscectomy. Half of the meniscectomy group developed knee arthritis. No one in the other half (no meniscectomy) had arthritis even after 15 years.
A large number of patients (68 per cent) in the nonoperative group received no further treatment after the physical therapy program. They remained pain free. The combination of intact menisci and nonreconstructed knees seemed to have the best results.
Much of today's research efforts are geared toward finding the subgroups of patients who would benefit the most by a particular treatment approach. Finding a subgroup of patients with ACL tears who need surgery could help reduce the risk of developing osteoarthritis. Likewise, finding the subgroup who don't need surgery but could do well with nonoperative rehab could increase quality of life and patient satisfaction while reducing total health care costs.
Based on the results of this study, the authors conclude that changing activity level for patients with ACL injury is an acceptable treatment approach. The initial treatment does not have to be with ACL repair to prevent arthritis. It is possible to follow a program of sports activity modification including avoiding contact sports.
Monitoring patients for signs of meniscal problems and treating them when necessary is an acceptable treatment approach. Saving the meniscus seems to be an important way to prevent knee osteoarthritis after ACL injury.
Paul Neuman, MD, et al. Prevalence of Tibiofemoral Osteoarthritis 15 Years After Nonoperative Treatment of Anterior Cruciate Ligament Injury. In The American Journal of Sports Medicine. September 2008. Vol. 36. No. 9. Pp. 1717-1725.
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