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Monday, 26 August 2019 13:19

Are ACL reconstructions a thing of the past?

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The number of Australians undergoing ACL reconstruction in the past 15 years has risen to more than 70%, with the greatest increase amongst children under 14. The rupture of an ACL typically occurs in sports that require agility, when someone changes direction quickly leading to an excessive force through the ligament, rupturing it, such as soccer or AFL.

Australia has the highest reported rates of ACL injury and reconstruction in the world, but do we really need all of these reconstructions?

First we need to address why health care practitioners and the lay public believe surgery is needed after a rupture. This question has so many sides to cover and the question itself could be its own post doctorate thesis, but lets try and break it up into sizeable chunks.

First of all the role of the anterior cruciate ligament (ACL) is to prevent and stabilise the knee against twisting motion. If we lack this stability we can not engage or participate in activities that cause our knee to twist, so why not try and replicate the function of an ACL through surgery? This was the prevailing view in modern medicine, however this idea is now being flawed. Most of the research looking into ACL reconstructions never compared a reconstruction to a structured rehabilitation program, but to different types of ACL surgeries and different graft types. Of the 412 gold standard, randomly controlled trials (RCT) looking at ACL reconstruction, only 1 actually compared surgery to rehabilitation. This single RCT in 2013 found that “clinicians and young active adults should consider rehabilitation as a primary treatment option after an acute ACL tear”.

The belief that the ACL cannot repair itself due to lack of blood flow has been recently debunked with evidence emerging from 3 separate studies spanning from 1994, 2002 and 2012. It is found that if left alone the ACL can heal, despite popular belief that this was impossible.

There is an abundance of fear mongering in the mass media when a player injures their knees on the field, with commentators always speculating the worst, assuming the athlete has injured their ACL and will require surgery and need 9-12months of rehabilitation. By continually pushing this false narrative towards the lay public it will skew the perception of young athletes making them think that they need an ACL to compete at an elite level.

Can you return to pivoting sports without surgery?

Just because we do not have an ACL, does not mean our body can’t adapt to it. Through intense strengthening, neuro-muscular control, balance and sports specific training you can prime your body to be more than adequate to compensate for a lack of structural stability, ultimately making the ACL redundant. If you don’t believe this, have a look at the case of an English premier league player who returned to play without surgery after 8 weeks of a full thickness tear and remained problem free (Weiler et al 2015, Weiler 2016).

So when is surgery viable?

This is a very hard question to answer due to the lack of evidence. Traditionally we have been heavily biased around early ACL reconstructions so it’s hard to give a clear answer. However the evidence suggest that surgical vs non-surgical intervention has the same outcomes. A recent large review in 2016 showed that there was no significant difference between surgery and non-surgery at 2 to 5 years post injury. I guess the take home message is having surgery is not the end all and be all solution to getting back into pivoting sports and careful consideration for conservative treatment on a case by case basis is needed.