Knee surgery could be held off for some ath­letes, study finds

Austin American-Statesman - - FRONT PAGE - By Mal­colm Rit­ter

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.

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