Deconstruction of Reconstruction

Picture this scenario. Skippy, a 41 year old male software engineer comes into your clinic after tearing his right ACL when he slipped on a floppy disk at work. He lifts weights at the gym 3 days a week and runs 2 miles on the treadmill 2 days a week.  On his first visit Skippy asks “should I get my ACL reconstructed?”

SONY DSCWhat would you recommend?

In the recent past this would not have even been a question.  Still today, most patients who tear their ACL are encouraged to have it reconstructed. Without a reconstruction patients have been expected to have reduced function, knee instability, meniscus tears, osteoarthritis etc….
More recently studies have started to call into question the practice of automatically reconstructing ACLs  on every patient. Some patients are being classified as copers and are expected to function well with an ACL deficient knee.
A recent study by Frobell et al in BMJ adds to the mounting evidence which calls into question early and blanket ACL reconstruction. The authors followed a group (121) of patients (average age of 26 and “active”) who either had early ACL reconstruction or delayed optional surgery. 49% of the patients in the delayed group decided not to have an ACL reconstruction.
At the 5 year follow-up, outcomes for the two groups were similar. Early ACL reconstruction did not lead to improved outcomes or reduced incidence of subsequent meniscus injury.

” CONCLUSION: In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.”

Do the results of this study change the recommendation you would give to Skippy?


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  • It’s a question I have wondered about myself. Sometimes we like to think that everyone is some sort of an athlete and will need the reconstruction to continue on. Skippy, however, entering his mid 40s will likely be fine without the reconstruction. As physiotherapists we are supposed to have an evidenced based practice, and if evidence starts pointing towards not attaining better results with the reconstruction then we should believe in that.

    Brandon Goulding MscPT March 23, 2013 9:15 pm Reply
  • I read last year a European study that showed if patients passed a series of functional tests including one legged hop, that surgery was not needed and therefore not recommended for ACL ruptures. What I can’t believe is that Skippy slipped on a floppy disk! How about a flash drive? 😉

    Erson Religioso March 24, 2013 1:43 pm Reply

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