Knee surgery could be held off for some athletes, study finds
NEW YORK — Attention, weekend athletes: Don’t be too quick to agree to surgery for a common type of knee ligament tear.
A study of Swedish amateur athletes — mostly soccer players — found that those who got an ACL reconstruction right away plus physical therapy fared no better than athletes who started out with rehab and got the surgery later, if needed.
Of those in the rehab-first program, fewer than half went on to get the surgery within two years, researchers reported in today’s issue of the New England Journal of Medicine.
“It seems that if you start out with rehabilitation only … you have a good chance of ending up with an equally good outcome as if you had early ACL surgery,” said Richard Frobell of Lund University Hospital in Sweden, an author of the work.
“Maybe we will be surprised that a lot of people actually do not need an ACL reconstruction.”
Frobell stressed that the study did not include professional athletes. They usually seek surgery to get back into action quickly.
Each year, about 200,000 Americans have surgery to replace the anterior cruciate ligament, or ACL, which is crucial for knee stability. It can get torn in sports such as football and soccer that require planting the foot and pivoting.
Doctors already knew that not every patient with a torn ACL needs surgery; a middleage jogger or cyclist can often get by with a knee brace and rehabilitation, experts say. Frobell said his work suggests that the same strategy might work for athletes who want to return to more strenuous sports such as soccer, at least on lower competitive levels.
Some patients with a damaged ACL can cope well at a high level. But doctors can’t reliably predict which patients will turn out to be “copers.”
Doctors and patients currently decide on whether to do the surgery based on factors such as what physical activities the patient plans to pursue and the overall health of the knee, said Dr. Bruce Levy, a Mayo Clinic surgeon.
The outpatient procedure involves replacing the ACL with tissue from the patient or a cadaver. Risks include infection and stiffness that may require more surgery. The surgery costs $10,000 or more, depending on whether cadaver tissue is needed.
The new study focused on 121 Swedish amateur athletes, ages 18 to 35. They had new, complete ACL ruptures. Half were randomly assigned to get surgery right away plus physical therapy, and the other half to start with the rehab to improve the knee. The rehabilitation required about 60 sessions on average, two or three times a week, Frobell said. That works out to about five to seven months.
Two years later, both groups reported about the same amount of improvement in ratings for things such as pain, performance in sports and how much their knee interfered with their lives. About 40 percent of each group had returned to their previous level of sports intensity, as measured by that activity’s stress on the knee.
Among those treated with physical therapy first, those who eventually got the surgery turned out no better than those who didn’t.
Levy urged “a little bit of caution,” noting that the patients were followed for only two years, so “we really don’t know long-term the benefits or consequences of each of the two strategies they tested.”
Also, the rehabilitation group showed more signs of trouble with the meniscus, a rubbery, cushioning disc in the knee, noted surgeon Dr. Kurt Spindler of Vanderbilt University. That could raise their risk of eventually getting osteoarthritis, he said.
Frobell said researchers will also study five-year outcomes and look for early signs of arthritis with X-rays and other medical imaging.