The Role of Patient Characteristics in the Success of Nonoperative Treatment of Anterior Cruciate Ligament Injuries

Abstract

Background: Anterior cruciate ligament (ACL) tears can either be treated nonoperatively with physical therapy and then treated operatively if persistent instability is present, or be directly treated operatively. Advantages of early ACL reconstruction surgery include shorter time from injury to surgery and potentially fewer meniscal injuries, but performing early ACL reconstruction in all patients results in surgery in patients who might not need ACL reconstruction. It is important to assess in which patients nonoperative treatment is successful and which patients will require ACL reconstruction and thus might be better treated surgically in an earlier phase. Purpose: To identify patient characteristics that predict the success of nonoperative treatment. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: All patients with complete ACL injuries who were evaluated between 2014 and 2017 at our clinic were included. The minimum follow-up was 2 years. The initial treatment and ultimate ACL reconstruction were reviewed. Univariate analysis was performed using Mann-Whitney U tests and chi-square tests and multivariate analysis using binary logistic regression. Results: A total of 448 patients were included with a median age of 26 years and median Tegner level of 7 and mean Tegner level of 6.4. At initial consultation, 210 patients (47%) were treated nonoperatively with physical therapy and 126 of these patients (60%) ultimately required ACL reconstruction. Nonoperative treatment failed in 88.9% of patients <25 years of age, 56.0% of patients 25 to 40 years, and 32.9% of patients >40 years ( P < .001); and 41.9% of patients with Tegner level 3 to 6, and 82.8% of patients with Tegner level 7 to 10. Age <25 years (odds ratio [OR], 7.4; P < .001) and higher Tegner levels (OR, 4.2; P < .001) were predictive of failing nonoperative treatment in multivariate analysis. Patients in the failed nonoperative group had longer time from diagnosis to surgery than the direct reconstruction group (6.2 vs 2.2 months; P < .001), and more frequently had new meniscal injuries (17.4% vs 3.1%; P < .001) at surgery. Conclusion: Nonoperative treatment of ACL injuries failed in 60% of patients and was highly correlated with age and activity level. In patients aged 25 years or younger or participating in higher-impact sports, early ACL reconstruction should be considered to prevent longer delay between injury and surgery, as well as new meniscal injuries.

Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis

“…A recent study showed that approximately 60% of patients require ACL reconstruction after nonoperative treatment, but rates increase to 90% for those aged <25 years and 83% for those participating in Tegner level ≥7 sports. 54 As such, it is important to be aware that early surgery is likely to be cost-effective when the likelihood to require surgery is high.…”

“…The American Journal of Sports Medicine 2023;51(4):1106-1116 DOI: 10.1177/03635465211069356 Ó 2022 The Author(s) delaying these procedures is that this increases the time from injury to surgery, may lead to quadriceps atrophy, 52 and potentially increases the risk of meniscal and chondral damage. 11,54 Therefore, it might be advantageous to indicate patients early for surgery to enable a faster return to work or sports activities. Furthermore, recent studies with modern surgical techniques and rehabilitation protocols did not associate early surgery with higher risk for postoperative stiffness (Table 1).…”

Folgen einer vorderen Kreuzbandruptur – Ein systematisches Umbrella-Review

“…Für die konservative Therapie stehen im hochambitionierten Bereich neben einzelnen Fallbeispielen/Studien kaum Daten zur Verfügung [80][81][82]. Darüber hinaus wird die Analyse dadurch erschwert, dass in vielen Untersuchungen konservativ versorgten Kreuzbandpatienten grundsätzlich eine Reduktion des sportlichen Anspruchs empfohlen wird [81,83]. Erstaunlicherweise sind die Unterschiede im Vergleich zu einer gematchten operativ versorgten Gruppe trotz dieser Empfehlung nicht signifikant [80,81].…”

Rare Fracture Knee Dislocation Treated with Ligament Repair and Novel Arcuate Fracture Repair Technique

“…Recently, patients have reported low pain scores, minimal awareness of their injured knee, and short recovery times 7,20-24 . For severe knee dislocations, arthroscopic ligament repair may be performed in a single-stage fashion for certain tear types 13,25-28 , thus avoiding the issues involved in a staged reconstruction 29-33 .…”