The Early Versus Late Anterior Cruciate Ligament Reconstruction Debate: History Teaches Us That We Cannot Use Reason and Evidence to Fight and Win Against Conviction

I read both the article1Karikis I. Åhlén M. Sernert N. Ejerhed L. Rostgård-Christensen L. Kartus J. The long-term outcome after early and late anterior cruciate ligament reconstruction.Arthroscopy. 2018; 34: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar and the Editorial Commentary2Siegel M.G. Editorial commentary: “Defer no time, delays have dangerous ends” (Henry VI, Shakespeare): Delayed anterior cruciate ligament reconstruction has consequences.Arthroscopy. 2018; 34: 1918-1920Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar on the long-term outcome after early and late anterior cruciate ligament (ACL) reconstruction. I enjoyed both, and I cannot abstain from some considerations. In some circles, deep-seated opinions, probably entrenched in the fact that “it has always worked for me” (keeping aside any possible conflict of interests that we surgeons may have to continue to operate on as many patients as possible), fly in the face of well-performed Level I studies. In the Editorial Commentary, Dr. Siegel states that he is vindicated. I wonder why he ever felt faulted. The original Level I work by Frobel and collaborators never advocated that patients with a torn ACL should be denied surgery!3Frobell R.B. Roos E.M. Roos H.P. Ranstam J. Stefan Lohmander L. A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-342Crossref PubMed Scopus (566) Google Scholar, 4Frobell R.B. Roos H.P. Roos E.M. Roemer F.W. Ranstam J. Stefan Lohmander L. Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial.BMJ. 2013; 346: f232Crossref PubMed Scopus (297) Google Scholar Some features of ACL reconstruction have come to the forefront over the course of the last several years. Probably the most controversial recent findings, and the ones that have been substantiated by Frobell et al.’s large Level I study, are that surgical reconstruction is not required in all patients with torn ACL and that it is possible to return to sports activities without surgery.3Frobell R.B. Roos E.M. Roos H.P. Ranstam J. Stefan Lohmander L. A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-342Crossref PubMed Scopus (566) Google Scholar, 4Frobell R.B. Roos H.P. Roos E.M. Roemer F.W. Ranstam J. Stefan Lohmander L. Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial.BMJ. 2013; 346: f232Crossref PubMed Scopus (297) Google Scholar By the way, Frobell et al.’s investigation was adequately powered, had accurate and validated outcome measures assessment scales, and was undertaken for a clinically relevant length of time. Indeed, the main indication for surgery in ACL deficiency is the functional instability (i.e., a symptom) and not the laxity (i.e., a sign) produced by a torn ACL: the laxity, even rotatory laxity, does not necessarily translate into functional instability.5Johnson D.H. Maffulli N. King J.B. Shelbourne K.D. Anterior cruciate ligament reconstruction: A cynical view from the British Isles on the indications for surgery.Arthroscopy. 2003; 19: 203-209Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The will of patients to continue to participate in high-level sport is not in itself an indication for surgery.6Maffulli N. Binfield P.M. King J.B. Good C.J. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases.J Bone Joint Surg Br. 1993; 75: 945-949Crossref PubMed Google Scholar Given the lack of reliable predictors of instability in identifying which knees will become symptomatic (i.e., unstable), surgery should be considered after failure of a 6- to 12-week period of intensive rehabilitation with hamstring strengthening and proprioception training.7Li R.C. Maffulli N. Hsu Y.C. Chan K.M. Isokinetic strength of the quadriceps and hamstrings and functional ability of anterior cruciate deficient knees in recreational athletes.Br J Sports Med. 1996; 30: 161-164Crossref PubMed Scopus (90) Google Scholar This approach is the one proposed by Frobell et al.3Frobell R.B. Roos E.M. Roos H.P. Ranstam J. Stefan Lohmander L. A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-342Crossref PubMed Scopus (566) Google Scholar, 4Frobell R.B. Roos H.P. Roos E.M. Roemer F.W. Ranstam J. Stefan Lohmander L. Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial.BMJ. 2013; 346: f232Crossref PubMed Scopus (297) Google Scholar and validated by Level I studies and subsequent registry data.8Kiadaliri A.A. Englund M. Lohmander L.S. Carlsson K.S. Frobell R.B. No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: Registry enriched randomised controlled trial data.Br J Sports Med. 2016; 50: 558-563Crossref PubMed Scopus (21) Google Scholar With respect to osteoarthritis, terminology can also be twisted in favor of the deep-seated conviction that a blanket approach to immediate ACL reconstruction is the way to go. Karikis et al.1Karikis I. Åhlén M. Sernert N. Ejerhed L. Rostgård-Christensen L. Kartus J. The long-term outcome after early and late anterior cruciate ligament reconstruction.Arthroscopy. 2018; 34: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar describe radiographic alterations in their patients. There is a difference between degenerative joint changes and osteoarthritis. Although highly correlated, the 2 do not go hand in hand, and, above all, they are not synonymous. Degenerative joint changes can be, and are, present without clinical manifestations and can be, and often are, stationary and a chance finding, while osteoarthritis is a progressive clinical syndrome of which such degenerative joint changes are a feature. In the article by Karikis et al.,1Karikis I. Åhlén M. Sernert N. Ejerhed L. Rostgård-Christensen L. Kartus J. The long-term outcome after early and late anterior cruciate ligament reconstruction.Arthroscopy. 2018; 34: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar features of degenerative joint disease were described, and the authors go to great lengths to state how these were not necessarily associated with symptoms of osteoarthritis. Despite what some would wish us to believe, the effectiveness of early ACL reconstruction to prevent or slow down the onset of degenerative changes and its progression to osteoarthritis has not yet been proven5Johnson D.H. Maffulli N. King J.B. Shelbourne K.D. Anterior cruciate ligament reconstruction: A cynical view from the British Isles on the indications for surgery.Arthroscopy. 2003; 19: 203-209Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar: the studies supporting the misconception that ACL reconstruction slows down the progression or arrests the onset of degenerative joint disease were biased, as the entry criterion was just a tear of the ACL, not symptomatic instability. The fact that long-term symptomatic instability following an ACL tear leads to further internal derangement of the knee is not a novelty.9Binfield P.M. Maffulli N. King J.B. Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes.Injury. 1993; 24: 557-561Abstract Full Text PDF PubMed Scopus (64) Google Scholar In this respect, the work by Karikis et al.1Karikis I. Åhlén M. Sernert N. Ejerhed L. Rostgård-Christensen L. Kartus J. The long-term outcome after early and late anterior cruciate ligament reconstruction.Arthroscopy. 2018; 34: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar offers confirmative, not novel, evidence, at least to those of us who are cynical enough to read critically the available scientific evidence. Obviously, in patients with an acute ACL tear, particularly those participating in activities that require twisting or turning, it would not be ethical not to offer early surgery to prevent further injuries, such as meniscus tears and articular cartilage damage.5Johnson D.H. Maffulli N. King J.B. Shelbourne K.D. Anterior cruciate ligament reconstruction: A cynical view from the British Isles on the indications for surgery.Arthroscopy. 2003; 19: 203-209Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Frobell et al.’s3Frobell R.B. Roos E.M. Roos H.P. Ranstam J. Stefan Lohmander L. A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-342Crossref PubMed Scopus (566) Google Scholar, 4Frobell R.B. Roos H.P. Roos E.M. Roemer F.W. Ranstam J. Stefan Lohmander L. Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial.BMJ. 2013; 346: f232Crossref PubMed Scopus (297) Google Scholar, 8Kiadaliri A.A. Englund M. Lohmander L.S. Carlsson K.S. Frobell R.B. No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: Registry enriched randomised controlled trial data.Br J Sports Med. 2016; 50: 558-563Crossref PubMed Scopus (21) Google Scholar work is momentous: in common with other trials in trauma and orthopaedics that proved, using Level I evidence, that we are unnecessarily operating too much, this work has been widely criticized by the relevant subspecialty societies as not being representative of real life and not using the right outcome measures, and for the fact that the patients enrolled in this type of investigation are not representative of the general patient populace or that the surgeons are not properly trained.10Maffulli N. We are operating too much.J Orthop Traumatol. 2017; 18: 289-292Crossref PubMed Scopus (5) Google Scholar All these criticisms sound the last resort of organizations and individuals who do not wish to surrender to simple scientifically proven hard facts. History teaches us that we cannot use reason and evidence to fight and win against conviction. Is this the case in this particularly contested field? Download .pdf (.08 MB) Help with pdf files ICMJE author disclosure forms The Long-Term Outcome After Early and Late Anterior Cruciate Ligament ReconstructionArthroscopyVol. 34Issue 6PreviewTo compare long-term clinical and radiographic outcomes in patients undergoing either early (group A) or late (group B) surgery after anterior cruciate ligament (ACL) injury. Full-Text PDF Author Response Regarding “The Long-Term Outcome After Early and Late Anterior Cruciate Ligament Reconstruction”ArthroscopyVol. 34Issue 9PreviewWe thank both Dr. Siegel1 and Dr. Maffulli for their interest in our study.2 We don't think there is any controversy with either of these commentaries. Full-Text PDF