Non-operative treatment of ACL injury is associated with opposing subjective and objective outcomes over 20 years of follow-up

Abstract

Purpose The aim of this study was the evaluation of long-term clinical and radiological outcomes of non-operative treatment of anterior cruciate ligament (ACL) deficiency. The hypothesis was that conservative treatment would be associated with a deterioration of subjective and objective measures of joint health and disability over time. Methods From an initial sample of 41 patients conservatively treated for ACL rupture, 10 received secondary ACL reconstruction, 1 was excluded due to contralateral ACL injury, and 1 patient required total knee replacement and a high tibial osteotomy. Seven further patients were lost to follow-up. The remaining 21 patients (15 male, 6 female, mean age 53.1 ± 9.2 years at the last follow-up) were evaluated by the same two examiners 5-7, 10-13 and 20-22 years after the injury. The evaluation was based on objective and subjective scores, instrumented testing, radiographic examination and assessment of sports activity. Results While subjective patient satisfaction improved over time, objective scores stayed constant or deteriorated (radiologic evaluation). Instrumented knee laxity testing showed an initial tendency to increasing instability, followed by a decrease in anterior tibial translation in the second half of the observation period. Physical activity levels, particularly in high-risk sports, decreased significantly (p < 0.05) compared to preinjury levels. All patients developed significant arthritic degenerative changes over time compared to the uninjured contralateral knee. No correlation to activities in high-or low-risk pivoting sports was found. Conclusions Patient satisfaction with conservative treatment of ACL injuries is good in spite of objective measures indicating increasing degenerative changes. Level of evidence IV.

Acute ACL reconstruction shows superior clinical results and can be performed safely without an increased risk of developing arthrofibrosis

“…Non-operative treatment of an ACL injury remains an option and can yield satisfactory results [ 13 , 15 , 31 ], although the body of evidence is limited due to the scarcity of randomized studies. Frobell et al concluded that for adults with acute ACL injuries, there is no difference between surgical management (ACL reconstruction followed by structured rehabilitation) and non-operative treatment (structured rehabilitation only) in patient‐reported outcomes of knee function at 2 and 5 years after injury.…”

Patients Aged 50 Years and Older Have Greater Complication Rates After Anterior Cruciate Ligament Reconstruction: A Large Database Study

“…Ciccotti et al 18 reported an 83% satisfaction rate among patients 40 to 60 years old treated with nonoperative management, but 37% of patients experienced reinjury and all patients were required to modify their activities and lifestyle. Gföller et al 19 similarly found that subjective patient satisfaction improved over time after nonoperative management, but radiologic outcomes scores stayed constant or deteriorated and knee laxity testing showed increased instability over time. Physical activity levels also decreased significantly compared with preinjury levels.…”

“…Gföller et al. 19 similarly found that subjective patient satisfaction improved over time after nonoperative management, but radiologic outcomes scores stayed constant or deteriorated and knee laxity testing showed increased instability over time. Physical activity levels also decreased significantly compared with preinjury levels.…”

“…Physical activity levels also decreased significantly compared with preinjury levels. 19 Given that nonoperative treatment is associated with chronic degenerative changes, progressive instability, and high risk of reinjury, this approach may be unacceptable for many older patients with ACL deficiency who desire to return to previous activity levels.…”

Secondary Injuries After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review With Quantitative Analysis

“…This management has been shown to have poor objective results, including inferior patient-reported outcomes, evidence of advanced degenerative changes to the knee, increased ligamentous laxity, and the development of irreparable meniscal injuries. 17,43 In addition, return to preinjury level of play is unlikely after nonoperative management, as Ramski et al 43 reported that none of their patients treated nonoperatively returned to previous level of play as compared with 86% of those treated operatively.…”