A Glimpse - ACL surgery: when to do it?

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ACL surgery: when to do it?

Musahl, V., Diermeier, T., de SA, D. and Karlsson, J., 2020. ACL surgery: when to do it?. Knee Surgery, Sports Traumatology, Arthroscopy, 28, pp.2023-2026.

In today’s letter

• Best timings for ACL reconstruction

• Rapid Results = Ideally Early (within 1-3 weeks) ACL reconstruction is recommended as it leads to less muscle bulk loss and reduces time off work, however, delayed (6-12 weeks) showed similar knee function and pain scores at 6 months post-op

• 3 Reads to check out to further you knowledge about ACL surgery

• Meme of the week: Oh google, my good friend 😄 

Deeper look

Aim of the study

The authors aimed to give their rationale on when is the appropriate time to have an ACL surgery

Did you happen to know?

• Sports worldwide are underway again, bringing both elite and recreational athletes back into action.

• With more people playing sports again the ACL injury rate is steadily increasing

• To get back to sports after an ACL injury, it's important to have good knee stability, which is why early ACL reconstruction surgery is often recommended.

• After an ACL injury, people generally fall into three categories:

  1. Coper – They can return to their pre-injury activities without surgery or knee instability.

  2. Adapter – They lower their activity level to avoid feeling unstable.

  3. Non-coper – They can't return to previous activities because their knee feels unstable and may give out.

• A screening tool helps identify "copers" and "non-copers" using hop tests, quadriceps strength tests, knee function questionnaires, and tracking how often the knee "gives way."

• However, very few people actually fit the "coper" category long-term.

• For example, in one study of 345 athletes with ACL injuries, 146 were identified as possible "copers" (based on tests like hopping and knee stability).

• But after 10 years, 93% of these "copers" ended up needing ACL surgery anyway.

• So, for young and active people who want to return to sports that involve jumping, cutting, or pivoting, surgery is usually the best option.

• ACL reconstruction is the go-to treatment for those wanting to return to a high level of athletic performance

Return to Sport

• For elite athletes, getting back to their sport is the top priority after an ACL injury. However, only about 65% of people return to their pre-injury level after ACL surgery, and just 55% return to competitive sports.

• When it comes to top-level athletes (like football or basketball players), their return-to-sport rate is higher, ranging from 78% to 90%.

• In one study of 121 young, active people, some were treated with rehab and delayed surgery. Over 5 years, 40% chose to have surgery after 2 years, and 51% opted for surgery after 5 years.

• The delayed surgery group had more meniscus surgeries and lower rates of returning to their pre-injury sports level.

• Only 36% were able to return to the same level of activity after 2 years, and many could only handle recreational-level of sport.

To Delay Or Not To Delay Reconstruction?

• The best time to have ACL reconstruction surgery is still debated, and it depends on factors like other injuries (meniscus tears usually), the risk of stiff knees (arthrofibrosis), how quickly someone can return to full activity, and even costs if the person is self paid.

• Traditionally, people were told to wait at least 6 weeks before surgery to let the knee rest, reduce swelling, and regain motion. Early surgery was thought to increase the risk of knee stiffness (arthrofibrosis).

• After an ACL injury, the knee goes through a “double-hit” process: an internal inflammation and external quadricep shutdown (caused by blood in the joint).

• This inflammation releases cytokines into the joint, leading to swelling and pain.

• Osteoarthritis can develop after ACL injuries, whether treated with surgery or not. This may be due to the increase in inflammatory chemicals in the knee after injury.

• To manage inflammation and improve recovery, starting pre-rehabilitation early (to reduce swelling and restore knee movement) has become the gold standard

The Ideal Timings

• The definition of "early" ACL surgery varies in research. While timing isn't the only factor in preventing arthrofibrosis, delaying surgery can increase the risk of further injuries to the meniscus and cartilage from the knee giving way.

So, what exactly is "early" treatment?

• Studies define early surgery as anything between 48 hours and 3 weeks after injury.

• Although it might not be realistic to see patients within 48 hours, most people can be assessed within the first week of injury, making this 1-week period important to analyse.

• Eriksson and colleagues compared 70 active patients who had ACL surgery either "early" (within 8 days) or "delayed" (after 6-10 weeks). At the 3-month mark, there were no differences in knee movement between the groups.

• However, at 6 months, the early surgery group had less muscle loss in the thigh

• Overall patient-reported outcomes (like knee function and pain scores) were similar between early and delayed surgery.

• Economically, delayed surgery led to more sick days—89 compared to 57 for early surgery—resulting in higher indirect costs

Concluding Remarks

• Whether a casual athlete or a pro, the goal of ACL treatment should be the same: early ACL surgery to restore knee stability and function to help avoid issues like arthrofibrosis, further meniscal injuries, or osteoarthritis.

• While non-surgical options can be considered for less active people, offering anything less than early surgery to a young, active athlete would be a missed opportunity for optimal treatment.

3 Resources to check out

And learn more about ACL surgery & Rehab

1. ACL Melbourne protocol (PDF) - LINK 🇦🇺

2. ACL rehab for patients with hamstring grafts (PDF) - LINK 🏃‍♀️

3. ACL surgery (real surgery) - (VIDEO) - 🗡️

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