conservative treatment and ACL tear: a need for more scientific evidence?
Dear Sir,
We would like to thank Dr Mrak for his appropriate comment relating
to our work.
The indication for operation was not the subject of the analysis but,
as points out Dr Mrak, remains vague for some patients and therefore to
some doctors. The prime indication for anterior cruciate ligament
reconstruction is symptomatic instability; the aim of anterior cruciate
ligament reconstruction is to restore functional stability without
compromising other joint function (ie, full range of movement and no
pain). [1] Therefore what holds for a twenty-year old young patient
practising contact sports may not for a thirty-year old patient who is
sedentary and has no complaints regarding his knee (no episode of
instability) and this whether or not the knee is unstable on clinical
examination. Therefore, the indication may sometimes be equivocal and is
best chosen after discussion with the patient. Meniscal injury at MRI scan
may weight for the operation. The reason why indication for reconstruction
is not clear cut is that we lack scientific evidence that it prevents from
late osteoarthritis, and this is the second point we would like to
discuss.
The scientific basis for anterior ligament reconstruction is that
early stabilization reduces the incidence of meniscal pathology, which may
in turn have a protective effect on cartilage damage. However, so far and
to the best of our knowledge, there is evidence that operative treatment
yields better functional results, but there is no evidence that anterior
cruciate ligament reconstruction prevents from late osteoarthritis and
this despite few randomized controlled clinical trials and meta-analysis.
[2-4] Now the reason why we lack sound scientific ground to rely on when
offering someone a reconstruction is due to the difficulty to conduct
surgical randomized controlled clinical trials and this is our third
point. [5]
We appreciate Dr Mrak’s comment that conservative groups should be
included with treatment groups. However, in surgery, as opposed to
pharmacological trials, there is sometimes such an easy and visible
evidence that link the pathology, the treatment and the results that it
proves very difficult ‘no to treat’ the patients. Chalmers said:
“randomize the first patient” but due to learning curve, reluctance of
surgeons for evaluation and the ‘impossible’ state of equipoise necessary
to randomized trials, we don’t and then it’s too late! Nowadays it would
seem almost unethical not to reconstruct a patient who has a symptomatic
unstable knee due to ACL tear.
[2] Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus
non-operative treatment of recent injuries to the ligaments of the knee. A
prospective randomized study.
J Bone Joint Surg Am. 1987 Oct;69(8):1120-6.
[3] Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-
surgical treatment of acute rupture of the anterior cruciate ligament. A
randomized study with long-term follow-up.
J Bone Joint Surg Am. 1989 Aug;71(7):965-74.
[4] Hinterwimmer S, Engelschalk M, Sauerland S, Eitel F, Mutschler W.
[Operative or conservative treatment of anterior cruciate ligament
rupture: a systematic review of the literature] Unfallchirurg. 2003
May;106(5):374-9. German.
[5] McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised
trials in surgery: problems and possible solutions.BMJ. 2002 Jun
15;324(7351):1448-51
Rapid Response:
conservative treatment and ACL tear: a need for more scientific evidence?
Dear Sir,
We would like to thank Dr Mrak for his appropriate comment relating
to our work.
The indication for operation was not the subject of the analysis but,
as points out Dr Mrak, remains vague for some patients and therefore to
some doctors. The prime indication for anterior cruciate ligament
reconstruction is symptomatic instability; the aim of anterior cruciate
ligament reconstruction is to restore functional stability without
compromising other joint function (ie, full range of movement and no
pain). [1] Therefore what holds for a twenty-year old young patient
practising contact sports may not for a thirty-year old patient who is
sedentary and has no complaints regarding his knee (no episode of
instability) and this whether or not the knee is unstable on clinical
examination. Therefore, the indication may sometimes be equivocal and is
best chosen after discussion with the patient. Meniscal injury at MRI scan
may weight for the operation. The reason why indication for reconstruction
is not clear cut is that we lack scientific evidence that it prevents from
late osteoarthritis, and this is the second point we would like to
discuss.
The scientific basis for anterior ligament reconstruction is that
early stabilization reduces the incidence of meniscal pathology, which may
in turn have a protective effect on cartilage damage. However, so far and
to the best of our knowledge, there is evidence that operative treatment
yields better functional results, but there is no evidence that anterior
cruciate ligament reconstruction prevents from late osteoarthritis and
this despite few randomized controlled clinical trials and meta-analysis.
[2-4] Now the reason why we lack sound scientific ground to rely on when
offering someone a reconstruction is due to the difficulty to conduct
surgical randomized controlled clinical trials and this is our third
point. [5]
We appreciate Dr Mrak’s comment that conservative groups should be
included with treatment groups. However, in surgery, as opposed to
pharmacological trials, there is sometimes such an easy and visible
evidence that link the pathology, the treatment and the results that it
proves very difficult ‘no to treat’ the patients. Chalmers said:
“randomize the first patient” but due to learning curve, reluctance of
surgeons for evaluation and the ‘impossible’ state of equipoise necessary
to randomized trials, we don’t and then it’s too late! Nowadays it would
seem almost unethical not to reconstruct a patient who has a symptomatic
unstable knee due to ACL tear.
[1] ACL reconstruction: best practice. Available at:
http://www.boa.ac.uk/PDF%20files/BASK/ACL%20best%20practice.pdf
[2] Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus
non-operative treatment of recent injuries to the ligaments of the knee. A
prospective randomized study.
J Bone Joint Surg Am. 1987 Oct;69(8):1120-6.
[3] Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-
surgical treatment of acute rupture of the anterior cruciate ligament. A
randomized study with long-term follow-up.
J Bone Joint Surg Am. 1989 Aug;71(7):965-74.
[4] Hinterwimmer S, Engelschalk M, Sauerland S, Eitel F, Mutschler W.
[Operative or conservative treatment of anterior cruciate ligament
rupture: a systematic review of the literature] Unfallchirurg. 2003
May;106(5):374-9. German.
[5] McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised
trials in surgery: problems and possible solutions.BMJ. 2002 Jun
15;324(7351):1448-51
Competing interests:
None declared
Competing interests: No competing interests