Repairing the Anterior Cruciate Ligament in the Knee

Okay, if you already know about the ACL, or anterior cruciate ligament in the knee, skip down to the second paragraph.  If not, here's a short course in human anatomy:  the ACL is one of the 4 really big ligaments that help stabilize the knee joint.  It gets its name because it is in the front of the knee and has a couple of bundles of fibers that form a sort of cross configuration, hence 'cruciate.'  It is also one of the most commonly injured structures in the knee joint, and is often repaired surgically. 

Is surgical repair of the ACL necessary right after an injury takes place or can surgery be delayed for awhile?  That's one study Rick and I discuss this week on PodMed, based on a study in the British Medical Journal or BMJ.  The study followed 121 young, active adults with a mean age of 26 who sustained an ACL injury in a previously uninjured knee, and were randomized to one of two groups:  those receiving early ACL  reconstruction and those offered the option of having a delayed surgical reconstruction if needed.  Both groups received structured rehabilitation and were followed for five years.

The knee injury and osteoarthritis outcome score (KOOS4) was the primary outcome measure.  This score is the composite of five subscales.  Additional health and activity surveys were also employed, and mechanical stability of the knee joint assessed.  Finally, radiographic images were obtained at multiple points in the study.

Results of the study at five years demonstrated no significant difference between those knees reconstructed early versus those reconstructed later or not reconstructed at all.  This last bears repeating another way:  half of the group initially offered delayed reconstruction if needed chose not to have it at all, and all study measures were the same in this group as well as the early reconstruction and delayed reconstruction groups.  Hah!  as I expostulate to Rick in the podcast.  Yet more proof that aggressive early treatment of at least ACL injury alone often isn't needed, and I'll editorialize further.  Studies we've discussed in the past include many types of back surgery and knee surgery, but when studies looking at long term outcomes are reported they almost invariably come to the same conclusion:  there's a large cohort of people who have acute problems that will get better on their own over time, and who don't need the risks of surgery and the almost inevitable development of osteoarthritis in an opened joint capsule.  How can we tell who those folks are?  This study helps in establishing that delaying surgery won't compromise outcomes, so that's a place to start.  Delay surgery, begin rehabilitation, and see what happens.  Surgery can always be elected later if improvement isn't seen. How palatable is that advice in someone who's young and active?  I suspect more and more palatable as all of us are paying for more of our own medical care!

Other topics this week include one panning dual agent blockage of the renin-angiotensin pathway, also in BMJ, and two from NEJM: antibiotics for severe malnutrition and removal of the prostate or radiation for localized prostate cancer.  Until next week, y'all live well.

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{ 2 comments… read them below or add one }


healthy weight loss diet April 11, 2013 at 9:45 am

Everything is very open with a clear explanation of the challenges.
It was really informative. Your site is very helpful. Many thanks for sharing!


Belle March 21, 2013 at 12:25 pm

More posts of this qualtiy. Not the usual c***, please


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