Thursday, August 12, 2010

The whys - and why nots - of ACL reconstruction

Interesting and important piece last week on the New York Times "Phys Ed" blog on ACL injuries and whether the most aggressive treatment (surgery) is always best. Research just published in the New England Journal of Medicine raises real doubts. Patients who had ACL reconstruction- an expensive and relatively complicated operation - were followed in a study by researchers from the University of Sweden along with a second group that opted to forgo surgery and be treated with physical therapy only.

Surprising outcome. The Times reports, that “more than half the A.C.L. reconstructions” currently being conducted on injured knees “could be avoided without adversely affecting outcomes.”

The article continues, "Part of the reason for A.C.L. surgery’s popularity is that by most measures, it works. In the current study, most of the group members who had reconstructive surgery reported that their injured knees felt healthy after two years and that they had returned to activity — not, in most cases, at the same level as before their injuries, but they were active. Significantly, their knees also were notably more “stable” than the joints that hadn’t been surgically fixed. Stability is, in theory, desirable. A stable knee rarely gives way.

The article, though, goes on to explain that sports docs and researchers are split on the importance of a 'stable" knee. There seems to be agreement that it's very important for athletes in pivot, cut, change direction sports like basketball and lacrosse. In straight-ahead activities like running and biking, it appears to be less important. (There's even disagreement about that, though.)

I say the decision to have surgery on a damaged ACL is more complicated. A few years ago, I wrote an article about a spike in Tommy John surgeries being performed on high school pitchers. I interviewed James Andrews and Lewis Yocum, two prominent sports orthopedists, about the increase in the number of such patients showing up in their operating rooms. Yocum expressed his concern that sometimes he was operating on kids with limited futures in baseball. Maybe a year or two more of high school ball and that was it.

"Just because we have a hammer doesn't mean everything is a nail. Obviously, the surgery isn't designed for everybody," Yocum said.

The parallel carries only so far. And every kid deserves the best knee that modern medicine can provide. But everything isn't a nail.

Hat tip to my pal Ed Wiest.


Brian McCormick said...

Spoke to a doctor that I train, and he wondered if the increase in ACL surgeries was due to a very large increase in the number of surgeons able to perform ACL surgeries. It used to be a very serious procedure with only a limited number of people to perform the surgery. Now, there are plenty of available surgeons with the expertise to reconstruct a knee. So, is the increase of surgeons due to an increased need for surgery or is the increased reliance on surgery due to the number of surgeons available and wanting to perform the surgery?

kevin said...

just because we have a hammer doesn't mean everything is a nail. Obviously, the surgery isn't designed for everybody,"