ACL rupture - Conservative vs Surgical at 10-year follow up.

Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. 
Meuffels, D., Favejee, M., Vissers, M.,  Heijboer, P.,  Reijman, M., Verhaar, J. British Journal of Sports Medicine, 2009; 43, 347–351. 
http://bjsm.bmj.com/content/43/5/347.abstract

Treatment of ruptured ACL should focus on restoring functional knee stability and thus preventing new injuries or degenerative changes within knee joint. There is no consensus existing on whether ACL should be treated conservatively or surgically. Generally held opinion is that to recommend early reconstruction in the highly active patients and to start with a non-surgical treatment for the less active patients. ACL reconstruction is suggested to prevent from later injuries to meniscus and cartilage and hence decreasing the risk of knee OA. However, there appears to be lack of research supporting that notion. Moreover, insufficient evidence is present to show that reconstructing the ACL is better than conservative treatment. The purpose of this study was to compare conservative and surgical treatment in high level athletes who had sustained an ACL rupture.

The first cohort were patients who had been treated conservatively for 10 years after being

diagnosed with an ACL rupture. These patients were pair-matched with patients who underwent a reconstruction of the ACL rupture 10 years previously. In total 50 patients were pair-matched. The patient groups were compared with regard to OA of the knee, meniscal lesions, instability, activity level during the 10 year period, and objective and subjective functional outcome.

Authors found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. Patients treated with reconstruction though, had their knee stability significantly better as measure with Pivot Shift Test and the KT-1000 arthrometer.

As authors state, this findings seems surprising and in contrast to some research published up to date. One could expect that knee OA prevalence would be higher in conservative group however there was a tendency to have more radiological OA in the reconstructed group. A possible explanation could be the operatively induced haemarthos and the intraarticular tunnel bone marrow. This study cannot be regarded as a final statement but more research is needed, especially with bigger cohort.

What are your experiences with patients treated conservatively? Do you follow them up once the rehab is done? How do they cope?

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