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Knee News

Surgery Not Always Needed Following ACL Tear

Many people injure their knees and undergo anterior cruciate ligament (ACL) reconstruction,often because of sports activities. More than 100,000 ACL reconstructions are done in the United States every year. However, despite this number of surgeries, there still isn't clear data on its long-range benefits. There is also a question as to whether athletes should return to sports that require high-level pivoting following an ACL repair.

In this study, researchers wanted to see if early activity modification and neuromuscular rehabilitation would help bring the injured knee up to an acceptable activity level, without any need for surgery. To do this, the researchers followed 100 patients who had had complete ACL ruptures to assess their activity level and knee function over time. The patients ranged in age from 15 to 43 years, with the average being 25.5 years. They were followed for between 13 and 20 years, average 15 years.

The majority of the patients were male (58 patients) and the right and left knees were equally represented (51 and 49, respectively). Fifty-nine patients injured their knee playing a ball sport, 30 down-hill skiing, and 11 doing other activities. Only 15 patients had only an ACL tear, the others had other tears in the knee as well.

After examining all the patients' knees by arthroscopy, a small instrument with a camera is inserted into the knee through a small incision, the researchers assigned the patients to one of two groups: neuromuscular training with a physiotherapist, or training alone. The patients used crutches if needed and were not to force movement to the injured knee. Ten patients wore knee braces but the braces still allowed for bending the knee. All patients were advised to avoid contact sports. After 6 weeks into the program, the researchers transfered 49 percent of the patients in the self-monitoring group to the physiotherapy group because their knees were not improving and in some cases, they were worsening.

Follow-up for the patients was done at 1, 3 and 15 years after the initial knee injury. Only 6 patients were not part of the study at the end. As part of the evaluation, the patients filled out questionnaires about their knee and their status: The Tegner activity scale measured activity level, Lysholm knee score measured subjective knee function, Visual Analog Scale (VAS) measured pain levels, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the Knee injury and Osteoarthritis Outcome Score (KOOS).

The findings showed that the average Tegner activity level when patients were first injured was between 3 and 9, with the average at 7. One year later, the range was from 2 to 9, average was 6. After 3 years, the range was from 3 to 9, with an average of 6 again, and finally, at 15 years, the range was from 1 to 7, with the average activity level dropping to 4.

Regarding knee function, using the Lysholm score, the patients scored an average of 96 at 1 year and 95 at 3 years. After 15 years, 49 patients scored good/excellent results, while 14 had fair or poor results.

When looking at earlier studies, one study identified patients with ACL injuries equally divided into three groups: "copers, compensators, and non-copers." However, in the study being reviewed here, the researchers found that there were more copers (42 percent) who were able to return to their previous level of activity, even though they had not had surgery. The authors suggest that the surgery may be needed for people who participate in competitive sports or in sports that require pivoting on the leg within 6 to 12 months of sustaining the injury. That being said, another study did show that in their particular study group, 92 percent of the patients who did not have reconstructive surgery were able to return to playing handball, while only 58 percent who did have the surgery returned to handball.

Returning to this study, the researchers found a slight increase in activity among their patients at year 1, a return to previous level of activity by year 3, and then a significant decrease in activity by year 15. This decrease could, however, be due to life changes and people getting older, not necessarily because of the knee injury.

The authors conclude that the majority of patients with an ACL rupture can be treated without reconstructive surgery if they are followed with an appropriate follow-up, including physiotherapy and education.


Ioannis Kostogiannis et al. Activity Level and Subjective Knee Function 15 Years After Anterior Cruciate Ligament Injury: A Prospective, Longitudinal Study of Nonreconstructed Patients. In American Journal of Sports Medicine. July 2007. Vol. 35. Pp. 1135-1143.

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