What Are the Indications for Surgical or Nonsurgical Treatment?
Multiple factors impact recommendations for surgery. One consideration is patient age. At one end of the spectrum is the adolescent anterior cruciate ligament (ACL)-deficient patient, and at the other extreme are patients over the age of 40. It has been previously demonstrated that satisfactory outcomes can be achieved in over 80% of patients treated nonoperatively in this older cohort provided that activity modification occurs.1 In this group rehabilitation is critical. Nevertheless, there are patients who may require surgical treatment. An absolute age is not used as a criterion for determining whether a patient is or is not a candidate for surgical treatment. Approximately 15% of the ACL patients in our practice are over age 40. We take into consideration the activity level, hours of sports per week, and patient expectations.
At the other end of the spectrum are the skeletally immature patients. The ACL-deficient knee in the skeletally immature patient behaves similarly to an adult and is at risk for reinjury, meniscal tears, and chondral injury.2 In the growing child, there are concerns of future growth, particularly premature growth arrest or angular deformity, that must be considered when determining which, if any, surgical procedure is best. Skeletal age, onset of menarche, Tanner stage, and even the parents’ heights are all factors that may be considered. In patients with open growth plates with more than a year and a half of skeletal growth remaining, we recommend a soft-tissue graft (hamstring), using a small vertical tibial tunnel. We place the femoral component of the graft in an over-the-top femoral position without violating the femoral growth plate. In prepubescent athletes, we consider an extra physeal tibial trough.
Activity level plays an extremely important role in consideration of surgery. Sports activity levels can be defined as category I: jumping, pivoting, hard cutting (basketball, football, and soccer); category II: lateral motion but less jumping or hard cutting (baseball, racquet sports, and skiing); and category III: sports with more linear activities (jogging, running, and low-impact sports such as swimming).3 Occupational levels may play a role as well and are similar to sports levels. Patients who perform heavy manual work and are working at height, or on uneven surfaces, are considered candidates for surgical treatment.3 Individuals performing light manual work do not, in our opinion, require surgical reconstruction. In individuals such as police officers, firemen, and construction workers, we typically recommend surgical reconstruction.
The athlete’s skill level is another consideration. Athletes may be categorized as recreational, interscholastic, intercollegiate, and professional. In general, the more intense the athletic competition, particularly taking into consideration the patient’s age and hours of sports per week, ACL reconstruction is recommended.
Sport-specific considerations correlate well with category I and category II sports. In general, patients who participate in football, basketball, volleyball, skiing, soccer, and rugby are, in our opinion, clear-cut candidates for reconstructive surgery.
Associated ligamentous injury may play a factor in recommending surgery as well as in the timing of surgery. ACL injury may occur concurrently with medial collateral ligament involvement. It is critical to recognize that the proximal medial collateral ligament (MCL) injury pattern may be associated with knee stiffness; therefore, full motion should be achieved before recommending ACL treatment. The MCL is typically treated nonoperatively. We rehab the MCL and use a brace for more significant MCL injuries, followed by elective ACL reconstruction. On the other side of the knee, the posterolateral corner may be injured with the ACL or a patient may sustain a bicruciate, that is, ACL/posterial cruciate ligament (PCL) injury. More significant trauma may be involved in bicruciate with collateral ligament injury or knee dislocations. Severe injuries may also be associated with patellar instability and/or patellar tendon rupture. As a generalization, the more severe the injury is, the more likely that ACL reconstruction will be recommended by a surgeon.
The last 20 years have witnessed a trend toward meniscal preservation. It is evident that there are higher failure rates in meniscal repair in the ACL-deficient knee.4 Some surgeons advocate a single versus staged procedure for meniscal repair with or without ACL reconstruction. It is recognized that lateral meniscal tears occur more commonly acutely, medial meniscal tears occur more commonly in chronic ACL-deficient knees, and the medial meniscus is more frequently associated with a displaced bucket handle tear.5
The timing of surgery plays an important role. Acute reconstructions should not be performed unless motion is recovered.6 We attempt to separate the post-traumatic and postsurgical inflammatory phases by deferring surgery until motion is recovered.
Historically, response to functional ACL bracing was considered a major factor in the determination of surgical versus nonsurgical treatment. Although Noyes7 popularized the rule of one-thirds (ie, one-third do well, one-third modify activity, and one-third require surgical treatment), perspectives are changing with regards to the use of bracing, and in fact, the majority of patients in our practice desire ACL reconstruction rather than to attempt functional knee bracing. There is little literature to assess how often recurrent instability should be considered as an indication for ACL surgery. It is important to differentiate between major and minor episodes. If someone is complaining of his knee “giving way” nearly every day, multiple times per day, it more likely is meniscal pathology. Major episodes of instability are usually associated with gross giving way and collapsing to the ground. Some surgeons feel that more than 2 major episodes annually are an indication for ACL reconstruction.
Late ACL reconstruction factors include preinjury sports participation, patient age, hours of sports per week, and side-to-side differences on KT-1000 testing. Arthritis and malalignment must be carefully considered; an osteotomy may be the preferred method of treatment with staged ACL reconstruction. In the arthritic patient with pain complaints, ACL reconstruction is less likely to be predictably beneficial. Patients who have more than 5-mm side-to-side translation on KT-1000 and are involved in more than 4 hours of sports per week are at high risk for reinjury, and those that are between 5 and 7 mm but are involved in less than 4 hours of sports per week are at moderate risk for reinjury.3
Patient compliance is a major consideration. It is critical to assess the patient’s compliance and determine whether he or she is committed to postreconstructive rehabilitation. This may impact the type of graft that is recommended. One needs to assess the patient’s goals and determine whether he or she is realistic and consistent with the surgeon’s goals and abilities.
Social considerations are also important. We have to consider timing relative to school vacations or relative to the next athletic season. We have seen patients who anticipate job or career changes and may have a change in their health insurance coverage. This may impact their desire to be reconstructed. Furthermore, if they change insurance and have a pre-existing condition, this may impact whether they may be covered on their next health insurance policy. Some patients have presented to our office desiring ACL reconstruction because of future anticipated changes in health care delivery systems, which may make it more difficult to have elective ACL reconstructive surgery. We have seen patients who anticipate leaving their parents’ health plan following the conclusion of their college education and desire ACL reconstruction. On occasion, we have had a parent present to the office desiring ACL reconstruction because they want to “play” with their children as they get older. Patients considering starting families may present to our office contemplating ACL reconstruction because of concerns about knee instability during pregnancy.
In summary, surgical considerations for ACL treatment involve high-risk sports, the competitive athlete, recurrent knee instability, and meniscal symptoms. In the acute injury, the activity lifestyle is probably the most important factor, whereas in the chronic ACL-deficient patient, recurrent instability is the most important factor.
1. Ciccotti MG, Lombardo SJ, Nonweiler B, Pink W. Nonoperative treatment of ruptures of the anterior cruciate ligament in middle aged patients. J Bone Joint Surg. 1994;76-A:1315-1321.
2. Mizuta H, Kubota K, Shiraishi M, Otsuka Y, Nagamota N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg. 1995;77-B:890-894.
3. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22(5):632-644.
4. Bach BR Jr, Dennis M, Balin J, Hayden J. Arthroscopic meniscal repair: analysis of treatment failures. J Knee Surg. 2005;18:278-284.
5. Bellabarba C, Bush-Joseph CA, Bach BR Jr. Patterns of meniscal injury in the anterior cruciate ligament-deficient knee: a review of the literature. Am J Orthop. 1997;26:18-23.
6. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19(4):332-336.
7. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate deficient knee. Part I: the long term functional disability in athletically active individuals. J Bone Joint Surg. 1983;65-A:154-162.