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Current concepts in surgical versus conservative management of ACL injuries

There is significant discussion currently regarding the advantages and disadvantages of operative or non-operative treatment in ACL injuries. Frobell et al, (2010) performed a randomized control trial comparing two treatments for ACL tears. Subjects were randomised into conservative management with rehabilitation alone or early ACL repair with rehabilitation, at two years post treatment there were no significant differences between the two groups.


The benefits of conservative management are; no surgical risks or complications and reduced cost to the health service. Evidence shows there is no added benefit to early surgical intervention in delaying the onset of arthritis, therefore the current best practice is a trial of conservative management, but if symptoms of instability remain then late operative repair is possible (Maly, Duncan and Chopp-Hurley, 2016 and Monk et al, 2016).


Conservative rehabilitation can be split into 3 phases: Acute phase, recovery phase and return to sport phase. Initially conservative treatment is aimed at reducing swelling, restoring range of movement, restoring muscle power, normalising gait mechanics and improving flexibility. It is vital to keep initial rehabilitation to closed chain exercises, which are more functional and reduce the amount of anterior tibial translation by promoting quadriceps and hamstrings co-contraction. The knee must be put through significant neuromuscular and proprioception training, working on muscle strength and firing patterns as well as perturbation training and plyometrics for return to sport (Micheo, Hernandez and Seda, 2010).


The ideal graft site for ACL reconstruction certainly seems to be individualised preference of the patient and surgeon, bone-patella tendon grafts have been shown on objective testing to be more stable, whereas hamstring tendon grafts have been shown to be more superior in terms of patient satisfaction. Several studies have also shown that hamstring tendon autograft has a greater risk of requiring revision surgery (Mehran, Moutzouros and Bedi, 2015).


References:

Frobell, R.B, Roos, E.M, Ranstam, J, and Lohmander, L.S. (2010) 'A randomized trial of treatment for acute anterior cruciate ligament tears'; The New England Journal of Medicine, 363(9), pp. 331-342.


Maly, M., Duncan, K. and Chopp-Hurley, J. (2016) ‘A systematic review to evaluate exercise for anterior cruciate ligament injuries: Does this approach reduce the incidence of knee osteoarthritis?’, Open Access Rheumatology: Research and Reviews, 8, pp. 1-16.



Monk, A.P., Davies, L.J., Hopewell, S., Harris, K., Beard, D.J., and Price A.J. (2016) ‘Surgical versus conservative interventions for treating anterior cruciate ligament injuries’, Cochrane Database Systematic Review, 4, Art. No. CD011166.


Mehran, N., Moutzouros, V.(b. and Bedi, A. (2015) ‘A review of current graft options for anterior Cruciate ligament reconstruction’, JBJS Reviews, 3(11), pp.1.


Micheo, W, Hernandez, L. and Seda, C. (2010) ‘Evaluation, management, rehabilitation, and prevention of anterior Cruciate ligament injury: Current concepts’, PM&R, 2(10), pp. 935-944


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