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Bob's ACL WWWBoard
Re: ACL surgery-versus-conservative-treatment study -- AAOS conference paper....
Posted By: Michael Frind
Date: Friday, 7 March 2008, at 9:00 p.m.
In Response To: ACL surgery v "conservative" treatment study (Sondra)
Dear Sondra,
For ACL tears, "conservative" treatment consists of any non-surgical treatment regimen. This includes physiotherapy, use of functional bracing, and activity modification (e.g. avoidance of plant-and-twist-type sports).
Keep in mind that this Meuffels et al. paper is not quite a formal peer-reviewed study (as would be found in a medical journal). It is simply a paper that was presented AAOS Annual Meeting in San Francisco (still in progress for another couple of days).
I plan to dig up the full paper, but I would want to see comments and responses to it (i.e. not just the full paper that was presented...although I am not sure if comments will be included in the published proceedings). The finding of 48% incidence of osteoarthritis symptoms in the operative group versus 28% in the conservative group is intriguing, but I would want to read the entire paper before commenting on this in detail. My hunch is that the operated-on patients returned to knee-demanding activities (i.e. high-kinetic-energy sports, given that kinetic energy, hence injury/reinjury risk, increases with speed squared) whereas the conservative patients simply discontinued their knee-demanding sports (largely because they did not have the stability of the reconstructed knees).
Because catastrophic ACL tearing almost always results in bone-bruising, and because bone-bruising never really heals problem (instead, the smashed-up hyaline articular cartilage is simply replaced with biomechanically suboptimal fibrocartilage), tearing an ACL instantly and permanently increases the knee's predilection towards premature osteoarthritis. Pursuing running-and-jumping-type activities is especially hard on any knee that has ever had any bone bruising. (The concept of permanent injury is especially relevant to the knee, thanks to the unique biomechanics of this joint: the enormously long lever arms of the tibia and femur, the high dynamic loadings generated especially during high-speed activities, and the near-complete absence of native bony stability.)
Remember, too, that ACL reconstruction techniques have improved significantly over the past decade. More is known today about the importance of correct graft placement than was known a decade ago. The very latest methods employ double-bundle reconstruction techniques. (Articles on this can be found in the Knee Library. The only problem with double-bundle ACL reconstruction is that it increases the opportunity for surgeon error. More bone tunnels to drill means more worry about wrongly placed tunnels.)
I also think that the improved stability in the reconstructed knees is an important detail not to be overlooked. As I noted above, if the ACL-reconstructed people were able to return to knee-demanding activities and the conservatively-treated patients permanently discontinued all knee-demanding activities, then of course we don't have an apples-to-apples comparison. (I note that the patients were pair-matched based on age, gender and Tegner activity score prior to injury...but no accounting was made on post-injury activity.)
Yours truly,
Michael Frind.
P.S.: I sometimes wish I were in San Francisco right now! I am here at a Northern Ontario bush camp, where I am stationed until sometime in April. I am just south of Polar Bear Provincial Park, and about 500 km (or about 300 miles) north of the northernmost section of the Lake Superior shoreline. The temperature was -38 Celsius this morning, and we had -41 Celsius just a few days ago. (These are equivalent to about -40 Fahrenheit, since this the range at which the two scales coincide. Thankfully, the camp has all the amenities: heating, electricity, running water, satellite internet, and excellent food.) Both of my knees are still doing well, and have handled snowshoeing and hiking nicely. (My two knee braces are receiving extensive use.) And, no injuries embarking/disembarking the helicopter (as I travel in daily to travel to field sites) either.
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