Cruciate ligament injury: does it required surgery? AHMAD FAIZAL BIN ABDULLAH MD (UKM) MS ORTHO(UKM) CMIA (NIOSH)

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1 Cruciate ligament injury: does it required surgery? AHMAD FAIZAL BIN ABDULLAH MD (UKM) MS ORTHO(UKM) CMIA (NIOSH)

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4 Anterior cruciate ligament 9 times more common to injured than PCL. Lead to unstable knee and pain. Patient complains: Unsteadiness gait Pain on climbing stair Difficulty squatting. Reduce walking distance

5 ACL foot prints 2 bundles Anteromedial bundle Posterolateral bundle Unique for both: Helps in AP translation of knee joint Prevent rotational stability.

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10 Prevalence of anterior cruciate injury More to sports injury. 30 to 81 per 100,000 people. A population based study of 56,659 people by Nordenvall et al showed an overall incidence of cruciate ligament injuries of 78 per 100,000 people

11 Diagnosis of injury to the ACL 1. Accuracy of 3 diagnostic tests for anterior cruciate tears. J Athl Train 2006; 41(1): Ostrowski J. Lachman test is best overall for ruling in and ruling out an ACL tear while the anterior drawer test is inconclusive either way. Lachman test has an 85% sensitivity and a 95% specificity.

12 2. Guidelines on anterior cruciate ligament injury. A multidisciplinary review by Dutch orthopaedic association. Acta Orthopaedica 2012; 83(4): Meuffels D, Poldervaart M, Diercks R, Fievez A, Patt T, Hart C et al. MRI of the knee has a 94% sensitivity and specificity in the diagnosis of a tear of the ACL

13 To operate or not to?

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15 Aim of treatments restore function, minimise symptoms, improve quality of life minimise the risk of future complications Renstron P. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sports: recent evidence and personal reflections. Br J Sports Med 2013; 47:

16 Level 1 evidence

17 1. Dunn W, Lyman S, Lincoln A, Amoroso P, Wickiewicz T, Marx R. The effect of anterior cruciate reconstruction on risk of knee reinjury. Am J Sports Med 2004; 32(8): ,576 active-duty army personnel showed that ACL reconstruction was protective against meniscal and cartilage injury. 3,795 subjects (58%) who had an ACL reconstruction and 2,781 subjects (42%) who were treated conservatively.

18 Those treated conservatively 32.6% underwent reoperations (meniscal, cartilage, ACL reconstruction surgery) as compared to 12.7% reoperations (meniscal and chondral surgery) in the ACL reconstruction group. Subsequent ACL reconstruction was done in 26% of the patients who were initially treated conservatively.

19 2. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears Richard B. Frobell, Ph.D., Ewa M. Roos, P.T., Ph.D., Harald P. Roos, M.D., Ph.D., Jonas Ranstam, Ph.D., and L. Stefan Lohmander, M.D., Ph.D. N Engl J Med 2010; Frobell et concluded: patients treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction. 121 young active adults with a mean age of 26 years.

20 All patients had similar structured rehabilitation and 62 patients were assigned to early ACL reconstruction while 59 were assigned to an option of having a delayed ACL reconstruction. Group conservatively : 51% needed a delayed ACL reconstruction. The meniscal surgeries rates, radiographic osteoarthritis and all functional scores were the same in both groups.

21 authors concluded that these results should encourage clinicians and young active adults to consider rehabilitation as the primary mode of treatment for an acute ACL tear. 50% of the patients will not need an ACL reconstruction if they are treated with structured rehabilitation

22 Level 2 evidence

23 1. Prevalence of Tibiofemoral Osteoarthritis 15 Years After Nonoperative Treatment of Anterior Cruciate Ligament Injury A Prospective Cohort Study. Neuman et al( LEVEL 2): Cohort study: follow up 100 consecutive patients with a complete tear of the ACL which was confirmed by arthroscopy for 15 years.

24 23% of the patients required a delayed reconstruction of the ACL between 6 months and 11 years 77% of patients not requiring an ACL reconstruction at 15 years follow-up.

25 Return to sports activity Swirtun et al ( LEVEL 1): 46 patients aged between 18 and 50 years, with an acute unilateral ACL tear 24 patients had conservative treatment and 22 had and ACL reconstruction no difference in activity level at a 5.6 years follow up. conservative group had a significantly better outcome in the knee The Effects of a Functional Knee Brace During Early Treatment of Patients With a Non operated Acute Anterior Cruciate Ligament Tear: A Prospective Randomized Study

26 Secondary osteoarthritis Ajuied et al ( LEVEL 1): showed a higher risk of OA in patient treated conservatively as compared to those treated surgically Anterior Cruciate Ligament Injury and Radiologic Progression of Knee Osteoarthritis A Systematic Review and Meta-analysis. Ajuied et al.

27 Secondary osteoarthritis Neuman et al ( LEVEL 2): patients treated by reconstruction of the ligament had a higher prevalence of OA. Prevalence of Tibiofemoral Osteoarthritis 15 Years After Nonoperative Treatment of Anterior Cruciate Ligament Injury A Prospective Cohort Study. Neuman et al

28 Secondary osteoarthritis Porat et al( LEVEL 2) showed that there was no difference in the prevalence between the two groups High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes. Porat et al.

29 CONCLUSION Mid term ( 5years) : No difference in the meniscal surgeries rates, radiographic osteoarthritis and all functional scores in young active patients treated with rehabilitation, early ACL reconstruction or delayed ACL reconstruction

30 15 years : outcome after a tear of the ACL in term of knee function, symptoms and OA are good even with conservative treatment. 50% of young active patients will need a delayed reconstruction of the ACL (level 1 study). cohort of patient in a general population who will need a delayed reconstruction of the ACL will only be about 23% (level 2 study).

31 Thank you

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