Cruciate Ligament Rupture: Wait and See

4. February 2011

A rupture of the anterior cruciate ligament of an athlete means work for the surgeon. Most of the sports physicians wholeheartedly agreed on that. A publication in the renowned New England Journal now says that half of the surgeries are unnecessary. Really?

Often it’s an audible “plop” before the knee sags in – indication for one of the most frequent and at the same time most feared injuries during sports. It means a break of six months up to one year until intensive training will get the body back to where it was before the injury. Different from other injuries like for example of the collateral ligaments, a rupture of the anterior (as well as the posterior) cruciate ligament does not heal all by itself.

Wait instead of operate

If you want to continue your athlete’s career, you actually don’t have any alternative to surgery – a reconstruction of the cruciate ligament. Most of the patients are physically active again two years after the surgery, although quite often not on the same level. Or can you imagine an athletic life without cruciate ligament after all? A publication in the New England Journal of Medicine (NEJM) last summer shook up quite a few orthopedists and sports physicians. Because there Richard Frobell and his colleagues at the Swedish university at Lund actually claims that with a “wait and see” strategy without early surgery, impairments after two years are not any more than in those cases of a quick cruciate ligament reconstruction.

As proof and evidence he recruited 121 active patients in the age between 18 and 35 with a rupture of the anterior cruciate ligament, many of them contest athletes. Randomly but with agreement of the participants, he sent half of them to the surgeon, the other half was treated conservatively by physiotherapists. Only in case of problem or dissatisfying results, the patients got a later surgery. According to Frobell, the measure for the knee quality after two years is displayed best in the ”KOOS“-Score (Knee Injury and Osteoarthritis Outcome Score), which includes pain and other medical conditions, functionality of the knee in sports and every day’s life as well as life quality.

An immediate surgery thus made 39.2 KOOS points, conservative treatment with surgery option made 39.4 points. But out of 59 test persons with a waiting strategy, 23 afterwards decided for a new cruciate ligament, an average of about one year after randomization. According to these study results, the Swedish authors state that more than half of all surgeries could be canceled for the standard patient with ruptured cruciate ligament – an important factor for effective cost reduction in elaborate sports medicine.

More stable but not healthier

But the road does not seem to be quite that easy. In an editorial about the following article in the New England Journal, Bruce Levy of the Mayo Clinic in Rochester/USA does not treat his Swedish colleagues all that gently. For example, professional athletes would not be able to return to their prior shape without the surgery. In addition, the risk of damages of the meniscus due to the higher instability of the knee is a lot higher as well. In 2009, an article in the British Journal of Sports Medicine reports about an analysis with a follow-up after ten years that the knee with surgery is definitely more stable but not healthier, because the rate of arthritis – the result of smaller and larger injuries after the treated rupture of the cruciate ligament – is about the same.

Also the NEJM study says that meniscus injuries are by far less frequent in people with surgery than in people waiting. Peter Eysel at the university hospital Cologne as well is not convinced about the surgery depending on result. The Deutsche Ärzteblatt (German physicians’ magazine) quotes him: “The study does not elaborate on the individual needs regarding the fitness of the patient.” He recommends the surgery especially for young athletes to keep the knee stable. Michael Krüger-Franke at the ’Medizinisches Versorgungszentrum München am Nordbad’ (a healthcare center in Munich) recommends a ligament surgery; but not immediately after the injury but up to six weeks later. That “prevents very effectively from post-surgical scarring and adhesions in the knee joint, comprehensive studies have proven that. If you do the surgery immediately, the risk for such scarring is about 20 to 30 percent.”

Miracle cure stem cells

But perhaps there is a third way. “Healing Response“ is the magic word; the technology originates from Richard Steadman, Colorado/USA, well known among professional athletes. The physician opens the bone marrow at different spots and thus produces a good deal of blood. The ruptured cruciate ligament is reduced and escaping stem cells take over repair under careful stress. Advantage: The minimal-invasive surgery brings along fewer risks, the stay in the hospital is short and the full knee-performance refurbished quickly. But up to now there is only little data available to compare with other alternatives.

On an average, every six and a half minutes a cruciate ligament ruptures in Germany, almost always the anterior one. Women have an about eight times higher risk for injuries – say the statistics. And the risk for the other leg is significantly higher after a first rupture. It could be that genetic components play quite a role in those figures.

Fear is the co-training partner

Whether and when there will be a surgery depends on the patient and how sporty he or she is, but it also depends on the healthcare system. In America it takes an average of two to three months between rupture and surgery, in Scandinavia eight to ten. If you completely forgo the surgery and decide to bring the knee back into shape with intensive gymnastics, you will buy time and avoid the risks of surgery. But you also have to live with the fear even when forgoing competitive sports. Only 10 percent of the patients have problems during every day’s life. But about one third is still insecure whether the knee will be stable after a year and a half. After four years without cruciate ligament rupture it is eighty percent.

The team of physicians from Lund did not have any data about this fear in the New England Journal. Nonetheless there are indications in the patients’ history. Some of the test persons with a conservative treatment decided on a later surgery although they did not have any medical condition. Whether these surgical treatments rather benefit the mind than the joint – only additional long-term studies can clear that matter.

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