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Anterior Cruciate Ligament Injuries

The New England Journal of Medicine recently published a review on anterior cruciate ligament management, reporting a random controlled trial

http://www.nejm.org/doi/full/10.1056/NEJMoa0907797?query=TOC

It is almost impossible to do a random controlled trial (rct) on anterior cruciate ligament (acl) injuries.

The initial difficulty is that the ultimate measure must be an outcome assessment when the subjects (who are usually in early adulthood when injured) are older than 40, then older than 70 to see if they are more prone to osteoarthritis than average.

A second variable is how much proprioception was lost as a result of the original injury. There is strong evidence that the greater the loss of proprioception, so the worse the long-term outcome, whatever the surgical treatment. But there are no standardised comparative tests of proprioception with the required reproducibility and high sensitivity.

Thirdly the acl injuries are usually related to one or more of a number of other injuries to the radjacent  anatomy, the knee co-laterals, meniscii, posterior cruciate ligament or the patella-femoral joint complex. Unless the rct is standardised for these it will be invalid.

Finally outcomes will depend on a number of life-style variables such as return to sport (and which sports), BMI at various stages of life, other injuries to same and other limb, concomitant illnesses, use of alcohol, smoking and chronic septic foci.

Therefore the variables are huge.

But one additional and not insignificant factor which alters the practice of surgery, and often biases rct selection, is patient demand for the “treatment of their choice” as gleaned from the popular press. This demand is often not resistible by the clinician, and becomes disturbing where the clinical objectivity has been perverted by headline-seeking pronouncements in the popular press.

Anterior cruciate ligament injuries (and their treatment) are frequently exposed in the lay press because of the high cult status of many injured sportspersons.

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