New Posts  All Forums:Forum Nav:

Is ACL surgery necessary?

post #1 of 18
Thread Starter 

 

This has been discussed at length before, and it seems people tend to defend the route they took.  Now there is a published double-blind study.  Certainly not definative, but it shows we need more studies of this sort, as well as work on therapy programs specifically designed to avoid surgery.

 

 

Quote:
The first group began physical therapy and then underwent surgical reconstruction of the ligament, considered by many people to be the best option for injured athletes. The second group received only physical therapy, with the option to have the operation later. Twenty-three subjects of that group did eventually have the operation. (For those fortunate enough not to be personally familiar with A.C.L. surgery, reconstruction involves replacing the injured ligament with tissue from elsewhere in your own leg or from a cadaver.) Over two years, the injured knees were assessed using a comprehensive numerical score that rated pain, function during activity and other measures. At the time of the original injury, the knee also had been scored. At the end of the two years, both groups showed considerable improvement. The scores for the surgically repaired knees had risen by 39.2 points. The scores for the more conservatively treated knees also had risen, by 39.4 points. In other words, the outcomes were virtually identical.

 

The article then points out that a repaired knee is less likely to see further injury:

 

Quote:
in The New England Journal of Medicine study, only 8 percent of the patients in the first surgical group subsequently tore a meniscus, a fragile pillow of cartilage that can rip if a knee gives way. Twenty-five percent of those in the physical therapy group eventually tore their meniscuses.

 

The authors are not convinced that that is not something which can be overcome, perhaps with specifically designed braces and therapy.  I have been missing an ACL for 17 years, and can't really tell any difference in the knees, so I fall into that camp.  Someone with drastically reduced stability would probably be best off going with the surgery.  Interesting stuff.

http://well.blogs.nytimes.com/2010/08/04/phys-ed-how-much-does-knee-surgery-really-help/?src=me&ref=health


Edited by newfydog - 8/6/10 at 8:29am
post #2 of 18

It is interesting.  I had a partially torn ACL that eventually tore all the way. I had no evidence of instability.   I skied, biked, played tennis etc.   I ended up with 2 meniscus tears following a minor event.  I have always wondered if I had the ACL repaired earlier whether I would have had the meniscus tear. ACLs are much easier to replace than meniscus.  If I knew then what I know now, I would have had the ACL repair earlier. 

 

If you are going to do sports, I think it is important to have an ACL even if you don't feel instability. 

post #3 of 18

I went without an ACL for about 16 years ('85 - '01). I skied hard with a brace during those years. Skiing wasn't painful or restricted by the lack of ACL or use of the brace. I married into good insurance and had the ACL reconstructed after beginning to experience pain simply walking without the ACL. I've raced and skied hard since. I've been pain free and brace free since. I did wear the brace for the first post op season as insurance. In '02 I tore the other ACL and immediately decided for a reconstruction (I was on the same insurance, fortuantely). The second reconstruction is pain free and brace free and has supported extensive ski racing without fail.

 

I absolutely noticed the laxity when I was ACL deficient for 16 years and had to compensate by maintaining strength and actively keeping my affected leg in tension during activity.

 

Some people adjust their physical condition (get stronger) to compensate for a loss. Some restrict their activities to reduce exposure. Some endure. The best solution in my book is to get stronger and get a reconstruction if you are going to be active. I haven't been able to maintain my fitness level to the point that I'm comfortable racing much but I still do ski the whole mountain without a thought for me knee holding up. I know it will.

post #4 of 18

I been over two years without an ACL.  At this point I wish I was able to get it replaced when it first happened (arthrofibrosis found during the surgery attempt to replace the ACL prevented completion of the surgery).  25 months post op and every now and again a feel instability but it's infrequent.  The arthrofibrosis is cleared and my leg is very strong.  The knee does swell a little frequently.  Nothing to prevent my activities but enough to let me know to back off OR I haven't been on the bike for a few days and need to get back on it.  I've tried running several times and the swelling gets worse.  Kept trying a little at a time and increasing it but couldn't do it without severe swelling.

 

The OS told me that I had rehabilitated my knee enough that I shouldn't miss not having an ACL.  I'm not sure how much of that is influenced by Insurance companies but he's a good guy so I've convinced myself he hasn't been influenced.  He also told me that if anything happened that would cause my ACL to tear, I would tear the miniscus instead.

 

I was out of work for a bit in '08 because of ACL surgery.  I was out of work for a lot in '10 because of Rotator Cuff Repair surgery.  I would like to go back and have my ACL replaced but I'll need to wait a couple of years or hope the economy turns around enough that I'm not causing undue stress on the folks that have to cover for me while I'm out (we are short staffed at work).

 

The human body is most incredible and will adapt fairly quickly to compensate for deficiencies.  That doesn't negate the fact that we work better with ACL's than without.

post #5 of 18
Thread Starter 
Quote:
Originally Posted by L&AirC View Post

The OS told me that I had rehabilitated my knee enough that I shouldn't miss not having an ACL. .....  That doesn't negate the fact that we work better with ACL's than without.



It seems rare for an Orthopedic surgeon to not want to cut.  Mine was diagnosed after 12 years, and the doc, a Stedman trained, US Ski Team OS told me she wouldn't recommend operating.  All I had to hear.  Mine is very stable, and I bike a lot, so it seems to be going just fine without the operation.

post #6 of 18

My husband tore his acl in 2008 ... finished out the ski season with an off-the-shelf brace, then skied the next two with a custom brace. Doctor said he was pretty stable, didn't really need to do the operation unless he wanted to increase activity or if things started bugging him.

 

Fast forward to May 2010, when he crunched it while playing ... wiffle ball. The boys next to him could hear the thunk of bone on bone, lovely. So, time to get the surgery.

 

Not sure of timing, whether he'll wait and try to ski on it this season and then do it in April or May, or just do it sooner. He's okay now, after getting it drained and stuff, but it definitely feels looser, and the meniscus is probably damaged. (Kind of sounds like he shouldn't ski on it.) Moral of story: stick to safe sports like downhill skiing, not wiffle ball! (truth be told, he most likely would have been fine had he been wearing his brace.)

post #7 of 18

Not to nitpick, but, the study was not double blinded but was, however, randomized.  I think the most valuable result of this study is that it does not create complications to delay reconstruction.

post #8 of 18
Quote:
Originally Posted by newfydog View Post


It seems rare for an Orthopedic surgeon to not want to cut.  Mine was diagnosed after 12 years, and the doc, a Stedman trained, US Ski Team OS told me she wouldn't recommend operating.  All I had to hear.  Mine is very stable, and I bike a lot, so it seems to be going just fine without the operation.


He did cut.  It would have been a second time to go back and repair it.  He knew I wanted to ski that season and a delay would prevent that.  Told me to ski with a brace for a season and then re-assess in the Spring.  Did that and both legs were equally stable.  OS, Chiropractor and PT all said they couldn't believe how stable my knee was.  So, why risk it?  I think I'm going to give it one more year and then decide.

 

One thing to keep in mind - There's nothing surgery can't make worse.
 

post #9 of 18
Quote:
Originally Posted by segbrown View Post
Moral of story: stick to safe sports like downhill skiing, not wiffle ball! (truth be told, he most likely would have been fine had he been wearing his brace.)


I'm always wondering what is going to cause me to crunch it.

 

My wife tore her ACL in a bouncy house with a bunch of 4 year olds!
 

post #10 of 18
Thread Starter 
Quote:
Originally Posted by Pwdrhnd View Post

Not to nitpick, but, the study was not double blinded but was, however, randomized. 


Good point.  To make it blind, half the group would have to have a fake surgery where they didn't actually fix it!

post #11 of 18
Quote:
Originally Posted by L&AirC View Post



 

My wife tore her ACL in a bouncy house with a bunch of 4 year olds!
 

 

I think that qualifies as an extreme sport. (Seriously!)
 

post #12 of 18

I just had my 4th ACLR and my surgeon told me right from the beginning that an ACL is not particularly necessary. It all depends on what is necessary to you. If your knee gives out everyday and you really want to ski then you are better to have an ACL. If on the other hand, your knee is stable and you feel comfortable then hit the slopes without it. 

 

The one thing he did say was that younger people are likely to suffer more damage in an ACL-less knee (ie. arthritis and cartilage tears) but even then you don't have to fix it if you don't want to. 

 

I skied without and ACL in both knees for a season but I ended up tearing more cartilage and had some laxity so we figured I'd be better off to have knees with functioning ACL's. Unfortunately, I'm too rough and a little heavy so I've had a revision on both knees. Just recently I used my quadriceps tendon for my right knee revision. 

 

If either one of my ACL's blow out again I probably won't bother getting them reconstructed (at the ripe old age of 40 I'll probably need a knee replacement anyway). I'll just ski the best I can without them. That may mean giving up rough terrain but it's doable. 

 

No surgeon should ever tell you that an ACL is necessary because it most definitely isn't. It all depends on the person's perception of stability and whether or not they are still able to participate in the activities they want. For people who do not participate in any extreme sports an ACL-less knee would likely still serve them well. Even without ACL's I was quite able- bodied. 

 

However, I am missing most of my medial meniscus in my left knee and already have degenerative joint spaces (arthritis) in that knee. I had an osteochondral allograft in my right knee when I had my last ACLR 2 months ago.

 

Regardless, in many cases ACL's are over-hyped. 

post #13 of 18

I ruptured my left ACL in March, and my surgeon was fairly straight up about the options. My knee stability was good - I had no buckling and the absence of an ACL wasn't impeding my activities, including skiing with a brace - but there was noticeable laxity in the knee on manual testing. He said that if I maintained my muscle condition I could happily go on playing sports comfortably without an ACL, but with that laxity the risk would be that if I had another injury, I would end up with meniscus or cartilage damage. Given that I already have early stage OA in both knees and want to go back to skiing the kind of terrain I was on before my injury, that sealed the deal for me.

 

I definitely didn't feel any pressure from the OS to have the surgery, or that he was dead set on cutting. (The same surgeon convinced me to try conservative measures over surgery to correct maltracking patellars four years ago, a recommendation which proved very successful.) That said, he was realistic about future outcomes for my knee if I chose not to have surgery.

 

My understanding from the studies I've read is that there's a rule of thirds when it comes to ACL deficiency. A third of people are able to go back to doing everything they were doing before with no ACL with no ill effects ("copers") ; a third are able to get by without an ACL provided they stop participating in activities that involve cutting and pivoting; and a third are left with knees so unstable that they buckle during regular everyday activities. I'm pretty confident that I would have been in the first group, but the risk of doing permanent long-term damage to the knee was enough for me to opt for surgery.

 

It's sure not an easy route to go (I'm five weeks post-op, and going through the stress and paranoia of trying to balance rehab and leg strengthening with protecting the graft as it revasculates and heals) but I hope it will be worth it in the long run. It's very difficult choosing whether or not to have surgery when an ACL-deficient knee is basically stable, and ultimately there's no black or white answer - the shade of grey you see will depend on your personal situation, goals and concerns.

post #14 of 18

I torn my ACL in february, doctor told me not to go back skiing but I  went back. By april my knee gave up twice, so I torn my meniscus and fractured my shoulder. From my experience I would not go back on the slopes without ACL. My orthopedist strongly believed that I need the surgery because I am very active. I am glad I had the surgery.

post #15 of 18

This is an interesting and worthwhile study for skiers. 

 

Going back to the original study though, I didn't find the conclusion nearly as strong as the NY Times article stated.  Some of the secondary results (e.g. median Tegner score, return to pre-injury activity level) would be of interest to skiers, and those results favoured an earlier surgery option.

 

It would be really great to see this study repeated to see how results compared.  It would also be informative to see another followup with the original group after another couple of years, to see if the two-year results had changed at all.

 

I was curious about the sports represented in this study, and found that 16 participants (out of 121) were alpine skiers. 

post #16 of 18

I severed my ACL in 1988. At that time my orthopedic surgeon said to wait another year for improvement in replacement surgery (arthroscopy for ACL replacement was new at the time). He told me that I may not need it at all as long as I gave up basketball and kept it strong through training. He was right. I've kept it strong for the last 30+ years and my knee has remained stable. I ski 40-50 days a year using a CTI brace. However, I've been hit with some latent problems related to the lack of an ACL and wish I'd had it replaced years ago.

 

Towards the end of the 08/09 ski season my knee started to get very sore by the end of the day. When I started playing water polo again in the spring my range of movement was inhibited and the pain was causing me concern. I went to a new orthopedic surgeon and after tests, x-ray and MRI, he indicated that my problem stemmed from not having the ACL. He said that while my knee was strong and wasn't loose, the ACL lessens that extra grind that occurs each time the knee is pressured. Over the last 30+ years, I had ground out the material on the end of my bones and worn down the meniscus cartilage. So I'm now dealing with osteoarthritus. The surgery to clean up my knee went well and I'm back to the same workout program (no plyometrics anymore). I skied 50 days last season and played in several water polo tournaments this spring and summer. It's no big deal and very common problem for a guy my age (51). Nonetheless, if I had to do over again - I would've had the ACL replaced.

post #17 of 18
Quote:
Originally Posted by segbrown View Post


My husband tore his acl in 2008 ... finished out the ski season with an off-the-shelf brace, then skied the next two with a custom brace. Doctor said he was pretty stable, didn't really need to do the operation unless he wanted to increase activity or if things started bugging him.



 



Fast forward to May 2010, when he crunched it while playing ... wiffle ball. The boys next to him could hear the thunk of bone on bone, lovely. So, time to get the surgery.



 



Not sure of timing, whether he'll wait and try to ski on it this season and then do it in April or May, or just do it sooner. He's okay now, after getting it drained and stuff, but it definitely feels looser, and the meniscus is probably damaged. (Kind of sounds like he shouldn't ski on it.) Moral of story: stick to safe sports like downhill skiing, not wiffle ball! (truth be told, he most likely would have been fine had he been wearing his brace.)




Sorry to hear about the husband...depending on recovery, he could still have a good spring if he has it done now. when I had mine done in Nov '08, I got in about 15 days at the end of the season...good luck either way!
post #18 of 18
Quote:
Originally Posted by skier31 View Post
 

It is interesting.  I had a partially torn ACL that eventually tore all the way. I had no evidence of instability.   I skied, biked, played tennis etc.   I ended up with 2 meniscus tears following a minor event.  I have always wondered if I had the ACL repaired earlier whether I would have had the meniscus tear. ACLs are much easier to replace than meniscus.  If I knew then what I know now, I would have had the ACL repair earlier. 

 

If you are going to do sports, I think it is important to have an ACL even if you don't feel instability. 


Hi,

 

I agree . I have acl tear and both meniscus tear . Going for knee reco this week. I am wondering how you are going with you knee . Did you end up doing the knee reco ? Have you got any OA ? How old are you ?

New Posts  All Forums:Forum Nav: