Advertisement

Editorial Commentary: A Revisit of an Old Clinical Dilemma—To Operate or Not to Operate on Acute Knee Anterior Cruciate Ligament Injuries

      Abstract

      There is a feeling among knee surgeons that operating on an acute anterior cruciate ligament injury will increase the incidence of arthrofibrosis. A recent systematic review and meta-analysis of 7 recent articles compared early versus delayed anterior cruciate ligament reconstruction. The conclusions were that the clinical and stability results were comparable in both groups.
      First, let me disclose that I have always been a proponent of early anterior cruciate ligament (ACL) reconstruction. This approach was formed early on in my career when we performed a lot of acute repairs of ACL proximal lesions in skiers. My second question, after “How did you hurt your knee?,” was “When did you eat last?” As we know, ACL injuries in skiers are different than those that occur during football and basketball. Patients with ACL injuries that occur during skiing have a 50% meniscal injury rate, but mostly of the lateral meniscus, and a higher rate of medial collateral ligament injuries. They often present to the clinic while bearing weight with minimal swelling and a good range of motion. There were many advantages of early surgery in this subgroup of ACL injuries: only 1 rehabilitation program to endure, less muscle atrophy, a lower incidence of chondral and meniscal injuries, and generally faster recovery. My experience was similar to that of Hunter et al.,
      • Hunter R.E.
      • Mastrangelo J.
      • Freeman J.R.
      • Purnell M.L.
      • Jones R.H.
      The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction.
      who reported that their results of early surgery on ACL injuries that occurred during skiing were the same as those of rehabilitation and delayed surgery.
      I did take to heart the cautionary article of Shelbourne and Patel
      • Shelbourne K.D.
      • Patel D.V.
      Timing of surgery in anterior cruciate ligament-injured knees.
      in 1995 that stated: “Factors such as mental preparation of the patient; school, work, family, and social schedules; preoperative condition of the knee [i.e., minimal or no swelling, good strength, good leg control, and full range of motion (ROM) including full hyperextension]; and associated ligamentous and/or meniscal injuries all have to be taken into consideration.” We were always keenly aware of the patient who would not do well with early intervention. In these cases, we followed the traditional path of pre-habilitation to regain full motion and to reduce the pain and swelling, followed by late ACL reconstruction.
      A recent publication by Shelbourne et al.
      • Shelbourne K.D.
      • Benner R.W.
      • Gray T.
      Results of anterior cruciate ligament reconstruction with patellar tendon autografts: Objective factors associated with the development of osteoarthritis at 20 to 33 years after surgery.
      stated that in a 20- to 30-year follow-up of ACL reconstructions, patients who had meniscal and/or chondral injuries or limited extension postoperatively had the highest incidence of late osteoarthritis. In my opinion, early surgery, when possible, will avoid these problems and give the best long-term results.
      Now, does the review “Effect of the Timing of Anterior Cruciate Ligament Reconstruction on Clinical and Stability Outcomes: A Systematic Review and Meta-analysis” by Lee, Lee, Lee, and Hui
      • Lee Y.S.
      • Lee O.-S.
      • Lee S.H.
      • Hui T.S.
      Effect of the timing of anterior cruciate ligament reconstruction on clinical and stability outcomes: A systematic review and meta-analysis.
      add anything to this controversy? First, it was difficult to come to conclusions because it combined both a meta-analysis and a systematic review on a small number of studies (7) with considerable overlap in the definition of acute versus delayed. Acute ranged from 9 days to 5 months, and delayed ranged from 10 weeks to greater than 24 months.
      Even though the 7 studies were of high quality and were published in reputable journals, the inconsistency of the reporting of results is interesting. All reported range-of-motion and KT-1000 results (MEDmetric) for acute versus delayed. Of the studies, 2 reported Knee Injury and Osteoarthritis Outcome Scores and only 1 used the International Knee Documentation Committee scale. The Lysholm and Tegner scales were used in 6 studies, but no study used an ACL-specific activity evaluation such as the Marx scale.
      The conclusions of the study showed good clinical outcomes of both acute and delayed reconstructions. Does this add to our current knowledge, and would I change my practice based on this information? My answer is maybe, in that it updates our knowledge with the most recent literature. I also believe that because acute ACL repair with or without augmentation is making a comeback, this study will support that paradigm.
      • Murray M.M.
      • Flutie B.M.
      • Kalish L.A.
      • et al.
      The bridge-enhanced anterior cruciate ligament repair (BEAR) procedure: An early feasibility cohort study.
      • DiFelice G.S.
      • van der List J.P.
      Regarding “Acute proximal anterior cruciate ligament tears: Outcomes after arthroscopic suture anchor repair versus anatomic single-bundle reconstruction”.

      Supplementary Data

      References

        • Hunter R.E.
        • Mastrangelo J.
        • Freeman J.R.
        • Purnell M.L.
        • Jones R.H.
        The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction.
        Arthroscopy. 1996; 12: 667-674
        • Shelbourne K.D.
        • Patel D.V.
        Timing of surgery in anterior cruciate ligament-injured knees.
        Knee Surg Sports Traumatol Arthrosc. 1995; 3: 148-156
        • Shelbourne K.D.
        • Benner R.W.
        • Gray T.
        Results of anterior cruciate ligament reconstruction with patellar tendon autografts: Objective factors associated with the development of osteoarthritis at 20 to 33 years after surgery.
        Am J Sports Med. 2017; 45: 2730-2738
        • Lee Y.S.
        • Lee O.-S.
        • Lee S.H.
        • Hui T.S.
        Effect of the timing of anterior cruciate ligament reconstruction on clinical and stability outcomes: A systematic review and meta-analysis.
        Arthroscopy. 2018; 34: 592-602
        • Murray M.M.
        • Flutie B.M.
        • Kalish L.A.
        • et al.
        The bridge-enhanced anterior cruciate ligament repair (BEAR) procedure: An early feasibility cohort study.
        Orthop J Sports Med. 2016; 4 (2325967116672176)
        • DiFelice G.S.
        • van der List J.P.
        Regarding “Acute proximal anterior cruciate ligament tears: Outcomes after arthroscopic suture anchor repair versus anatomic single-bundle reconstruction”.
        Arthroscopy. 2017; 33: 693-694

      Linked Article