Editor’s Choice: “Doc, What Would You Do if This Was Your Knee?”
Many orthopaedic surgeons come from an active background, often including competitive sports and other “high energy” activities. Injury is no stranger to many of us. In fact, it is often a youthful injury that put us in contact with an orthopaedic surgeon and spurred us to consider a career as a physician. Once we gain exposure to the various specialties in medical school rotations, we often find that orthopaedic surgeons are the most contented lot and have abundant enthusiasm for their patient-care activities… and we join the tribe.
Knee injury is common to many sporting activities, and of the various types of knee injuries, ACL rupture is among the most common. Many orthopaedists have experienced it firsthand. During my surgical education, ACL repair was in its infancy and we were navigating the transition between extra-articular and intra-articular reconstruction. Early in my academic career, I could identify many colleagues who had an ACL tear (diagnosed by physical exam with perhaps an arthrogram to check for meniscal tears, in those days prior to MRI) who had not undergone surgical reconstruction. This was my own personal situation. Now that the diagnosis is highly reliable and highly reproducible outpatient arthroscopic reconstruction is available, I suspect this is no longer the case. However, for patients who have lower functional expectations and demands in their future, nonoperative treatment should still be an option.
In the August 6, 2014 JBJS, Grindem et al. do the orthopaedic community a huge service by providing data from a prospectively enrolled and carefully followed cohort of 143 patients with ACL rupture who were treated both operatively and non-operatively. This study design carries all the limitations associated with any cohort study, with selection bias being a big factor. The findings that the 100 patients who selected reconstruction were younger and had expectations of higher-level sport activity are not surprising. This same surgically treated cohort was more likely to experience knee re-injury, probably due to increased exposure from level-I sports. The 43 nonsurgical patients returned to level-II sports in the first year much more quickly and in the second year were more likely to return to level-III sports than their surgically treated counterparts. In essence, there were no major differences between the two populations at two years in terms of knee extensor and flexor weakness. Those findings are no doubt highly correlated to patient factors such as rehabilitation compliance.
I conclude that there is still a role for non-operative management of ACL rupture in patients who select this route during a shared decision making process. We know that there seems to be a higher risk of subsequent meniscal injury in people without an ACL, but many patients are willing to accept this risk.
Donald Fithian tells us what he thinks of this study in an accompanying JBJS commentary. What do you think?