Perspective

Results at 20-year follow-up support nonoperative ACL rupture treatment

However, there was no evidence of superiority of ACL reconstruction vs. nonoperative care.

At 2 decades after patients in a study with ACL rupture underwent operative or nonoperative treatment, researchers found no significant differences between the groups for the presence of knee osteoarthritis, functional outcomes and any meniscectomy surgery, according to results published in The American Journal of Sports Medicine.

“Although the nonoperative group showed less objective stability, there was no difference in knee osteoarthritis, occurrence of meniscectomies and functional outcomes compared to the operative group 20 years after an ACL rupture,” Daan T. van Yperen, MD, of the department of orthopaedic surgery at Erasmus University Medical Center in Rotterdam, The Netherlands, told Orthopedics Today. “A nonoperative treatment should be considered, even in a population of high athletes.”

van Yperen, Duncan E. Meuffels, MD, PhD, and their colleagues pair-matched 25 patients with ACL ruptures treated nonoperatively (n=25), which involved structured rehabilitation and lifestyle adjustments, with 25 patients with ACL ruptures treated operatively with a single-incision, arthroscopic, transtibial bone-patellar tendon-bone technique. The surgeons in the operative group used Acufex tibial and femoral aimers (Smith & Nephew) for tunnel placement.

At 10-year and 20-year follow-up, researchers assessed radiological knee OA, functional outcomes, meniscal status and knee stability in both groups.

After 20 postoperative years, results showed knee OA occurred in 80% and 68% of patients treated operatively and nonoperatively, respectively. However researchers found no differences between the two groups in terms of functional outcomes and meniscectomy surgery. The median IKDC subjective score was 81.6 in the operative group and was 78.2 in the nonoperative group. Researchers noted there were normal or near normal IKDC objective scores for 84% of the operative group and for 20% of the nonoperative group. Results showed a negative pivot-shift test in 68% of the operative group and in 13% of the nonoperative group, as well as a negative Lachman test in 48% of the operative group and in 4% of the nonoperative group.

Commenting on the results, van Yperen said it was interesting that the presence of knee laxity in patients in the nonoperative group did not lead to more knee OA or decreased function in the long-term.

“We thought that, due to the ACL reconstruction, knee function and stability would be restored to near normal and prevent [patients] from developing knee OA over time,” van Yperen said. “Apparently, that is not the case shown by our study and several others.”

To learn more about the effect of nonoperative and operative treatment of ACL injuries, van Yperen and colleagues began a randomized clinical trial that includes 167 patients.

“We would like to be able to develop a treatment algorithm to predict which patients need an ACL reconstruction and which patients could do well without operative treatment,” van Yperen said. – by Casey Tingle

Disclosure: van Yperen reports no relevant financial disclosures.

At 2 decades after patients in a study with ACL rupture underwent operative or nonoperative treatment, researchers found no significant differences between the groups for the presence of knee osteoarthritis, functional outcomes and any meniscectomy surgery, according to results published in The American Journal of Sports Medicine.

“Although the nonoperative group showed less objective stability, there was no difference in knee osteoarthritis, occurrence of meniscectomies and functional outcomes compared to the operative group 20 years after an ACL rupture,” Daan T. van Yperen, MD, of the department of orthopaedic surgery at Erasmus University Medical Center in Rotterdam, The Netherlands, told Orthopedics Today. “A nonoperative treatment should be considered, even in a population of high athletes.”

van Yperen, Duncan E. Meuffels, MD, PhD, and their colleagues pair-matched 25 patients with ACL ruptures treated nonoperatively (n=25), which involved structured rehabilitation and lifestyle adjustments, with 25 patients with ACL ruptures treated operatively with a single-incision, arthroscopic, transtibial bone-patellar tendon-bone technique. The surgeons in the operative group used Acufex tibial and femoral aimers (Smith & Nephew) for tunnel placement.

At 10-year and 20-year follow-up, researchers assessed radiological knee OA, functional outcomes, meniscal status and knee stability in both groups.

After 20 postoperative years, results showed knee OA occurred in 80% and 68% of patients treated operatively and nonoperatively, respectively. However researchers found no differences between the two groups in terms of functional outcomes and meniscectomy surgery. The median IKDC subjective score was 81.6 in the operative group and was 78.2 in the nonoperative group. Researchers noted there were normal or near normal IKDC objective scores for 84% of the operative group and for 20% of the nonoperative group. Results showed a negative pivot-shift test in 68% of the operative group and in 13% of the nonoperative group, as well as a negative Lachman test in 48% of the operative group and in 4% of the nonoperative group.

Commenting on the results, van Yperen said it was interesting that the presence of knee laxity in patients in the nonoperative group did not lead to more knee OA or decreased function in the long-term.

“We thought that, due to the ACL reconstruction, knee function and stability would be restored to near normal and prevent [patients] from developing knee OA over time,” van Yperen said. “Apparently, that is not the case shown by our study and several others.”

To learn more about the effect of nonoperative and operative treatment of ACL injuries, van Yperen and colleagues began a randomized clinical trial that includes 167 patients.

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“We would like to be able to develop a treatment algorithm to predict which patients need an ACL reconstruction and which patients could do well without operative treatment,” van Yperen said. – by Casey Tingle

Disclosure: van Yperen reports no relevant financial disclosures.

    Perspective
    Freddie H. Fu

    Freddie H. Fu

    Long-term follow-ups are needed more than ever to help us understand our outcomes and thus give a clear perspective to our patients. While most principles never change, surgical techniques have been subject to research and development findings, so we can see the mistakes of the past and should learn lessons for the future.This study highlights excellent 20-year results in knee stability after nonanatomic ACL reconstruction compared to nonoperative treatment. However, activity levels, as well as prevalence of OA, did not show significant differences between the groups over time. The results are not surprising, as our old-fashioned techniques sought to supply optimal primary stability but ignored anatomy and dynamity of the ACL. Factors like bone bruises, meniscal injuries and reactive cytokines have also been shown to speed up the development of posttraumatic OA after ACL injuries. To date, we still do not know the distinct influence of these factors on our outcomes. Moreover, long times to surgery, as in countries with socialized medicine system, may lead to an adaption to injury and subsequent modification of activity patterns, which ultimately distorts the assessment of outcome measurements over time. For this reason, European results thus far may not be comparable to results of long-term studies conducted in the United States. By staying close to nature and evolving our techniques further, I am sure we will see different long-term outcomes 20 years from now.

    • Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
    • Orthopedics Today Editorial Board Member

    Disclosures: Fu reports he is a board or committee member for the American Academy of Orthopaedic Surgeons, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine and the World Endoscopy Doctors Association; is an employee of Medicrea; and receives publishing royalties, financial or material support from SLACK Incorporated and Wolters Kluwer Health/Lippincott Williams & Wilkins.