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Sports Medicine Australia National conference, Perth 2018

My highlights

The SMA National conference in Perth did not disappoint, with a brain exploding amount of information presented. First up of my highlights from this conference was physiotherapist Kieran Richardson discussing non-operative management of an ACL tear.

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Current world best practice for ACL reconstruction is an operating rate of 50% in Scandinavia. In Australia this rate is 90%!!! 😳 Are we over-treating in Oz?

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Even with a meniscal lesion on top of an ACL tear, they can be managed non operatively.

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10 myths of an ACL reconstruction

  1. Patella tendon reco is harmless- FALSE (Hardy, Casabianca et al. 2017)

  2. Hamstring tendon reco is harmless- FALSE (Hardy, Casabianca et al. 2017)

  3. You are stronger if you have a reco- FALSE (Xergia, McClelland et al. 2011, Thomas, Villwock et al. 2013)

  4. You are either a coper or non coper- FALSE- fluidity of patients moving from one category to another

    1. ​previous criteria to predict copers vs non-copers has used the ability to single leg hop with a brace by 4 weeks (Eastlack, Axe et al. 1999, Hurd, Axe et al. 2008, Kaplan 2011)

    2. Fluidity is the key: "noncopers" can become "copers" at one year (Moksnes, Snyder-Mackler et al. 2008)

  5. Having a torn ACL means you can’t return to pivoting & landing sports - FALSE (Hurd, Axe et al. 2009, Grindem, Eitzen et al. 2012)

  6. Positive ligament tests mean knee is unstable- FALSE- need to be tested in dynamic tasks. (Hurd, Axe et al. 2009, Smith, Postle et al. 2014, Weiler, Monte-Colombo et al. 2015)

    1. Anteroposterior laxity is not a good test for functional stability because it does not take into account muscle strength and neuromuscular ability

    2. Knee laxity tests should be dynamic rather than static. (Vergis and Gillquist 1998)

  7. Having a reco means less OA- FALSE

    1. accelerated OA in ACL absent knee (Oiestad, Engebretsen et al. 2009)

    2. However recent RCT with 5 years follow up found no radiographic differences among patients with:

      1. Early ACL reconstruction

      2. Delayed reconstruction, OR

      3. No ACL reconstruction (rehabilitation alone) (Harris, Driban et al. 2015)

  8. Having a reco is like a 2nd trauma to the knee- TRUE (Larsson et al 2017)

  9. Your graft will be fully healed in 9-12months- FALSE can take upto 4yrs! (Sanchez, Anitua et al. 2010, Janssen, van der Wijk et al. 2011, Pauzenberger, Syre et al. 2013, Nagelli and Hewett 2017)

  10. Once your ACL is torn, it’s torn for good- FALSE it can repair. (Costa-Paz, Ayerza et al. 2012, Malanga, Giradi et al. 2001, Fujimoto, Sumen et al. 2002, Ihara and Kawano 2017)

    1. Remarkably a recent study has shown (including patients of a similar age and demographic to NW) an acutely injured ACL may eventually spontaneously heal allowing return to athletic activity, with follow-up MRI between 25 and 36 months showing an end to end continuous ACL with homogeneous signal. (Costa-Paz, Ayerza et al. 2012)

    2. Acutely torn meniscus can also heal (Ihara, Miwa et al. 1994)

 

References

  • Costa-Paz, M., M. A. Ayerza, I. Tanoira, J. Astoul and D. L. Muscolo (2012). "Spontaneous healing in complete ACL ruptures: a clinical and MRI study." Clinical orthopaedics and related research 470(4): 979-985.

  • Eastlack, M. E., M. J. Axe and L. Snyder-Mackler (1999). "Laxity, instability, and functional outcome after ACL injury: copers versus noncopers." Med Sci Sports Exerc 31(2): 210-215.

  • Fujimoto, E., Y. Sumen, M. Ochi and Y. Ikuta (2002). "Spontaneous healing of acute anterior cruciate ligament (ACL) injuries - conservative treatment using an extension block soft brace without anterior stabilization." Arch Orthop Trauma Surg 122(4): 212-216.

  • Grindem, H., I. Eitzen, H. Moksnes, L. Snyder-Mackler and M. A. Risberg (2012). "A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course." The American journal of sports medicine 40(11): 2509-2516.

  • Hardy, A., L. Casabianca, K. Andrieu, L. Baverel and T. Noailles (2017). "Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature." Orthop Traumatol Surg Res 103(8s): S245-s248.

  • Harris, K., J. B. Driban, M. R. Sitler, N. M. Cattano and J. M. Hootman (2015). "Five-year clinical outcomes of a randomized trial of anterior cruciate ligament treatment strategies: an evidence-based practice paper." Journal of athletic training 50(1): 110-112.

  • Hurd, W., M. Axe and L. Snyder-Mackler (2009). "Management of the athlete with acute anterior cruciate ligament deficiency." Sports health 1(1): 39-46.

  • Hurd, W. J., M. J. Axe and L. Snyder-Mackler (2008). "A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 1, outcomes." Am J Sports Med 36(1): 40-47.

  • Ihara, H. and T. Kawano (2017). "Influence of Age on Healing Capacity of Acute Tears of the Anterior Cruciate Ligament Based on Magnetic Resonance Imaging Assessment." Journal of computer assisted tomography 41(2): 206-211.

  • Ihara, H., M. Miwa, K. Takayanagi and A. Nakayama (1994). "Acute torn meniscus combined with acute cruciate ligament injury. Second look arthroscopy after 3-month conservative treatment." Clin Orthop Relat Res(307): 146-154.

  • Janssen, R. P., J. van der Wijk, A. Fiedler, T. Schmidt, H. A. Sala and S. U. Scheffler (2011). "Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction." Knee Surg Sports Traumatol Arthrosc 19(8): 1299-1306.

  • Kaplan, Y. (2011). "Identifying individuals with an anterior cruciate ligament-deficient knee as copers and noncopers: a narrative literature review." J Orthop Sports Phys Ther 41(10): 758-766.

  • Larsson, S., A. Struglics, L. S. Lohmander and R. Frobell (2017). "Surgical reconstruction of ruptured anterior cruciate ligament prolongs trauma-induced increase of inflammatory cytokines in synovial fluid: an exploratory analysis in the KANON trial." Osteoarthritis Cartilage 25(9): 1443-1451.

  • Malanga, G. A., J. Giradi and S. F. Nadler (2001). "The spontaneous healing of a torn anterior cruciate ligament." Clin J Sport Med 11(2): 118-120.

  • Moksnes, H., L. Snyder-Mackler and M. A. Risberg (2008). "Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation." J Orthop Sports Phys Ther 38(10): 586-595.

  • Nagelli, C. V. and T. E. Hewett (2017). "Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations." Sports Med 47(2): 221-232.

  • Oiestad, B. E., L. Engebretsen, K. Storheim and M. A. Risberg (2009). "Knee osteoarthritis after anterior cruciate ligament injury: a systematic review." Am J Sports Med 37(7): 1434-1443.

  • Pauzenberger, L., S. Syre and M. Schurz (2013). ""Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future." Arthroscopy 29(10): 1712-1721.

  • Sanchez, M., E. Anitua, J. Azofra, R. Prado, F. Muruzabal and I. Andia (2010). "Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology." Arthroscopy 26(4): 470-480.

  • Smith, T. O., K. Postle, F. Penny, I. McNamara and C. J. Mann (2014). "Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment." Knee 21(2): 462-470.

  • Thomas, A. C., M. Villwock, E. M. Wojtys and R. M. Palmieri-Smith (2013). "Lower Extremity Muscle Strength After Anterior Cruciate Ligament Injury and Reconstruction." J Athl Train.

  • Vergis, A. and J. Gillquist (1998). "Sagittal plane translation of the knee during stair walking. Comparison of healthy and anterior cruciate ligament--deficient subjects." Am J Sports Med 26(6): 841-846.

  • Weiler, R., M. Monte-Colombo, A. Mitchell and F. Haddad (2015). "Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence." BMJ case reports 2015: bcr2014208012.

  • Xergia, S. A., J. A. McClelland, J. Kvist, H. S. Vasiliadis and A. D. Georgoulis (2011). "The influence of graft choice on isokinetic muscle strength 4-24 months after anterior cruciate ligament reconstruction." Knee Surg Sports Traumatol Arthrosc 19(5): 768-780.

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