26/01/17. ACL injury in handball. Treatment of acute ACL injury. Young people with old knees. Women, soccer and knee injuries. Treatment options?

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1 Treatment of acute ACL injury ACL injury in handball Professor Ewa Roos Research Unit for Musculoskeletal Function and Physiotherapy University of Southern Denmark, Odense, Denmark Courtesy: Grethe Myklebust, Norway Women, soccer and knee injuries 106 women, 19 yrs at injury ACL injury during soccer 1986 At 12 yr f-up, mean age 31: 51% OA Lohmander %OA 20 Young people with old knees Women soccer ACL injury 12 yr f-up Men soccer ACL-injury 14 yr f-up Age class Men & Women meniscal injury yr follow up Englund 2003, von Porat 2004, Lohmander 2004 Treatment options? 6 26/01/17 1

2 Treatment options ACL tear Short-term outcomes: Symptoms, function Associated injuries Return to sport Long-term outcomes: Symptoms, function Associated injuries Osteoarthritis The KANON study RCT, n= 121 Young ac>ve adults with acure ACL injury Structured rehab plus early ACL Structured rehab with the op>on for later ACL rec if needed KOOS4 primary outcome 2, 5 and 10 yr follow-up Baseline Rehab+early reconstruc1on N=62 Rehab+op1onal delayed reconstruc1on N=59 Age Female 19% 34% BMI Injured in sports 100% 97% Meniscal tear 63% 51% Tegner ac>vity level 9 (7-9) 9 (7-9) Tegner 7=recrea>onal soccer, Tegner 9=compe>>ve soccer (excl. Professional players) Rehabilita>on 6 months goal based rehabilita1on program Neuromuscular exercise Supervised Especially trained clinicians (9 clinics) 2

3 Surgical s Patella tendon bone, n=25 (41%) Hamstrings gra], n=36 (59%) Short-term (2 yr) results Data available from 121/121 pa>ents Surgical s N=121 Op>onal delayed N=59 Early N=62 2 yrs Rehab only N=36 Rehab+delayed N=23 Rehab+early N=61 Rehab visits N=121 2 yrs Op>onal delayed N=59/59 53±35 visits Early N=60/62 63±37 visits 3

4 26/01/17 Summary of 2 yr results No difference between groups in: Pain, symptoms, function or quality of life Return to sport Number of meniscal procedures 23/59 (39%) underwent delayed ACL reconstruction Conclusion: A strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy reduced the frequency of surgical reconstructions with 60% 4

5 26/01/17 These 2 yr RCT results challenges our current belief that ACL reconstruction is the preferred treatment for everyone. They suggest consideration of a strategy of rehabilitation and later reconstruction if needed. 10 year follow-up show the same results Surgical group more mechanically stable No difference in pain, symptoms, funciton or quality of life No difference in return to sport No difference in OA development Conclusion: These results should encourage clinicians and young adult patients to consider rehabilitation as a primary treatment option after acute ACL tear 15 yr f-up after ACL tear 100 patients, Tegner 7 (3-9), acute ACL tear were recruited were followed up at 15 yrs Neuman et al. 2008, Ageberg et al yr f-up after ACL tear Advised NOT to return to sport Advised NOT to undergo ACL reconstruction Advised to have highly specified supervised neuromuscular exercise Neutral Neuman et al. 2008, Ageberg et al

6 15 yr f-up after ACL tear OA after ACL Tear 23% had undergone ACL reconstruction 70-85% had at least 90% of uninjured leg in isometric strength and functional capacity (one leg hop) 68% had an asymptomatic knee 16% radiographic OA Conclusion: Favorable outcome after nonoperative management of acute ACL tear % Radiographic OA no repair suture autograft allo/synth graft Neuman et al. 2008, Ageberg et al Years Follow-up Lohmander et al. AJSM 2007 This 15 year follow-up study challenges the belief that surgical reconstruction is warranted for a good long-term outcome following ACL injury Treatment options? 33 Summary ACL studies At 2 years, a strategy of optional delayed surgery decreased the number of ACL reconstructions with 60% At 2, 5 and 10 years, there was no difference in pain, function or quality of life when comparing the groups having early reconstruction, delayed reconstruction or neuromuscular rehab only. There were neither differences in return to sport or associated meniscal procedures At 15 years, when advised not to return to sport, not undergo reconstruction, but have extensive supervised neuromuscular training only 16% developed OA 6