"Why ACL Tears May not Require Surgery"

This study suggests that surgical reconstruction does not lead to greater improvement than rehabilitative training after knee ligament injury.

Two to five years after treatment, patients had similar muscle strength and function whether they had training alone or with surgery, Eva Ageberg, Ph.D., of the University of Lund, and colleagues reported in the Dec. 15
issue of *Arthritis & Rheumatism*.

The findings suggest that "reconstructive surgery is not a prerequisite for restoring muscle function," the authors concluded.

ACL injuries predispose patients with development of osteoarthritis later in life, the researchers said. They also noted that about 90% of ACL injuries in the U.S. are treated with surgical reconstruction despite an absence of "evidence to suggest that reconstruction of the ACL prevents or reduces the rate of early-onset OA," the authors noted.

Recovery of neuromuscular function has been suggested as a principal determinant of overall outcome after ACL injury and prevention of OA, they continued.

Appropriate training has been shown to improve muscle function; however, the extent to which muscle function improves after ACL injury has remained unclear.

Moreover, the role of reconstructive surgery in restoration of muscle function has not been established, according to the authors.

To examine the contributions of reconstructive surgery, the investigators conducted a multicenter clinical trial, randomizing 121 patients with ACL injury to training alone or to training plus reconstructive surgery.

The current analysis focused on a subset of 54 patients followed for two to five years after injury.

All the patients had complete ACL rupture and began treatment within four weeks of injury.

Self-reported activity level of the subgroup was moderate to high, as determined by scores on the Tegner Activity Scale.

All patients participated in a moderately aggressive supervised training program that lasted at least four months. Additionally, 36 of the 54 patients had surgical reconstruction with either patellar or hamstring tendons.

Muscle strength and function were assessed an average of three years after injury. The assessment consisted of three hop/jump tests and three tests of muscle power.

Scores for patients in the two treatment groups did not differ significantly on any of the individual tests or on the battery of tests combined.

The authors reported that 44% to 89% of patients in the nonsurgical group had normal values on the individual tests, as did 69% to 89% of patients who
had training plus surgery.

Additionally, 20 of 36 patients (56%) in the surgical group and eight of 18 (44%) in the nonsurgical group had scores within the normal range for the hop/jump tests combined (*P*=0.57).

The two groups had identical 44% rates of normal muscle power for the three tests combined.

Despite finding no significant differences between the groups, the authors said that "there is still no evidence as to whether surgical or nonsurgical treatment is best for these patients in the overall outcome."

A third of the total study group had not recovered normal function on the single-hop or muscle strength tests, they continued. Additionally, about half of the patients had not recovered normal function for the six-test battery.

"Abnormal function in these tests may be an important predictor of future [osteoarthritis] after ACL injury," they concluded.

The researchers noted as a study limitation the fact that more surgically treated patients participated in the follow-up assessment than training-only patients. The nonparticipants were younger, had a higher activity level, and better subjective scores.

"Because these factors are related to better muscle function," the researchers said, "and because more than half of the nonparticipants had been treated with training only, the finding of no differences between the
surgical and nonsurgical treatment groups would probably have been more conclusive if nonparticipants had participated."

The analysis was supported by the Swedish National Center for Research in Sports, the Swedish Research Council, the Swedish Rheumatism Association-Region Skane, the Local Research and Development Council of
Goteborg and Southern Bohuslan, and the Faculty of Medicine of the University of Lund.

The authors reported no conflicts of interest.

*Primary source: *Arthritis & Rheumatism
Source reference: Ageberg E, et al "Muscle strength and functional performance in patients
with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year follow-up" *Arthritis Rheum*. 2008; 59: 1773-1779.
*Additional Orthopedics

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