| The gold standard of ACL management for many years has been surgery. There is some variety in the options available for surgery – hamstring graft, patella tendon graft, LARS, allo or auto but was it all necessary? It is often assumed that the ACL cannot heal. The torn ends of the ligament retract, there is significant bleeding due to concurrent damage to blood vessels during the injury and surgery is opted for as a means to provide the knee with the stability that was previously given by the ACL. We have long been aware that patients can be managed conservatively and cope with no ACL but what if that ACL could heal? The KANON trial indicated a number of occasions where the ACL healed when patients were managed with rehabilitation alone (Filbay et al., 2022). So do we really need to be immediately opting for surgical management? There has long been evidence that an individual with an ACL deficient knee could be a “coper” who can manage perfectly well without it (Kaplan, 2011). In addition, there is significant evidence for the benefit of a prolonged preoperative rehabilitation prior to ACL reconstruction leading to greater patient outcomes after surgery with more patients having a successful return to sport and greater functional outcome measures (Failla et al., 2016). If this is the case, should we not try a conservative management first? With appropriate rehabilitation during this time, it’s a win-win. The ACL may heal, in which case, no surgery required. If the ACL doesn’t heal, you’re putting the patient in a better position to recover following the surgery anyway. Now there are questions around secondary arthritis and meniscal injury without completing reconstructive surgery. However, we can’t forget that as soon as you complete a surgical procedure, you’re likely going to increase the chances of arthritis anyway (Heidari, 2011). As for meniscal injury, there is no increased risk to the meniscus in ACL deficient knees compared with those who have undergone reconstruction, with no difference in meniscal surgeries completed between the two groups (van der Graaff et al., 2022). Do we op or not? Seek medical advice from a consultant and therapist and if you’re able to hold off, take the opportunity to rehabilitate! Failla, M.J. et al. (2016) “Does extended preoperative rehabilitation influence outcomes 2 years after ACL reconstruction?,” The American Journal of Sports Medicine, 44(10), pp. 2608–2614. Available at: https://doi.org/10.1177/0363546516652594. Filbay, S., Roemer, F., Lohmander, S., Turkiewicz, A., Roos, E. M., Frobell, R., & Englund, M. (2022). 32 spontaneous healing of the ruptured anterior cruciate ligament: Observations from the Kanon trial. Abstracts. doi:10.1136/bmjsem-2022-sportskongres.8 Heidari, B. (2011) Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I, 2(2), pp. 205–211. Kaplan, Y. (2011) “Identifying individuals with an anterior cruciate ligament-deficient knee as copers and noncopers: A narrative literature review,” Journal of Orthopaedic & Sports Physical Therapy, 41(10), pp. 758–766. Available at: https://doi.org/10.2519/jospt.2011.3384. Van der Graaff, S.J. et al. (2022) “Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: Results from a randomised controlled trial,” British Journal of Sports Medicine [Preprint]. Available at: https://doi.org/10.1136/bjsports-2021-105235. SerifSend |