Torn ACL: Treatment methods with and without surgery (1/3)
(Dr. med. Andreas Krüger in interview with Rosanna Di Bello @blog.hirslanden.ch)
Source: blog.hirslanden.ch
Knee injuries are the most frequent skiing accidents on the slopes, accounting for about 30% of all accidents. Right at the top of the statistics is the rupture of the cruciate ligament. There are various criteria that are taken into account when making individual decisions about treatment.
We were able to meet two patients of Dr. Andreas Krüger, attending physician at Klinik im Park and Klinik Hirslanden in Zurich. Both love skiing and both injured their anterior cruciate ligament. Their stories could not be more different. Former junior skier vs. hobby skier, surgery vs. conservative treatment.
How everything happened and which treatment was chosen can be found out in our two patient interviews:
Patient 1: "Torn ACL: I was treated conservatively without surgery"
Patient 2: "Torn ACL: I decided to have surgery"
In the following interview, Dr. med. Andreas Krüger explains to us why the torn cruciate ligament is a typical ski injury. At the same time, he explains when conservative and when operative treatment makes sense.
Dr. Krüger, we were pleased to meet two of your patients. Both suffered a cruciate ligament injury while skiing. What was surprising was the type of accident Mrs. Oehri had. A sporty young woman who fell over her own child in slow motion and tore her anterior cruciate ligament.
Does the athleticism of the person have an influence on the degree of cruciate ligament rupture injury?
Dr. Andreas Krüger: In many cruciate ligament ruptures, the athleticism (i.e. fitness) plays only a subordinate role. Decisive for the degree of injury are the accident mechanism and the force applied. Typical knee accidents when skiing happen not only on the piste, but also when standing in line at the lift, for example when a fall occurs with a fixed lower leg and the ski binding does not release.
Three mechanisms are frequently found:
The lower leg and the thigh are rotated against each other.
The knee experiences a x-leg malposition.
A combination to which the knee does not respond well with muscular stabilization.
In addition, it must be mentioned that mental and physical fatigue often has a significant influence on the degree of injury. In principle, accident rates are higher after lunch and on the last trip.
Is the torn cruciate ligament a typical skiing accident? Why is that?
Dr. Andreas Krüger: Skiing is one of the sports that puts a strain on the knees. Among skiers, both children and adults, the knee is the most frequently injured part of the body. According to the Swiss Council for Accident Prevention (bfu), around 69,000 skiers are injured on Swiss slopes every year, with around 1/3 of accidents involving the knee. The anterior cruciate ligament rupture with 38% of all knee injuries is the most frequently occurring specific diagnosis (Brucker et. al, Alpiner Skibreiten- und Skileistungssport, 2014).
Why this is so can be explained by the mechanism described above. Depending on the fall, the fixation of the lower leg and the rotation of the thigh can put a lot of strain on the knee and therefore also on the cruciate ligaments.
Is there anything that can be done before skiing to minimize the likelihood of injury?
Dr. med. Andreas Krüger: An essential factor is the preparation for the ski season and risk minimization. A well-trained musculature that knows when and how to function can help to reduce the probability of accidents in the risk area.
The right ski equipment and the correct adjustment of the binding by expert hands are actually a matter of course.
Two of your patients suffered a similar injury. But they chose different treatments. When is the surgical measure suitable, when the conservative measure?
Dr. med. Andreas Krüger: Whether a conservative or surgical measure is suitable for the patient depends on various criteria: biological age (how old does he feel), / actual age, presence of a meniscus injury, intensity of pain, sports practice (stop-and-go sports such as tennis, football or harmonious rhythmic movements such as swimming, golf), knee stability and last but not least the personal demands of the patient.
Crucial for the success of conservative treatment is the integrity of the meniscus and cartilage as well as the other ligaments in the knee. Recent studies have shown If the knee has a torn cruciate ligament as well as a meniscus and/or cartilage injury, the result is better if the knee is operated. The cruciate ligament is usually replaced by the body's own tendon. In this case, the operation also serves to protect the meniscus in order to avoid or minimise secondary diseases such as arthrosis, which is promoted by an additional meniscus injury.
That means in summary:
Good resilience directly after accident
Low performance requirements for the knee joint
No further injury to meniscus or cartilage
High requirement profile with stop-and-go sports, subjective instability
Additional injuries to meniscus, cartilage or other ligaments
Is one type of treatment less painful than the other?
Dr. med. Andreas Krüger: The surgical method is more painful directly after the operation only in individual cases, although this can be well controlled by modern anaesthetic procedures. Later, the course and symptoms are very similar.
What do you have to be aware of when you decide on one or the other measure?
Dr. med. Andreas Krüger: The Swiss Medical Board recommends treating cruciate ligament ruptures with conservative measures during the first three months, as there is a 30% chance that the cruciate ligament will heal without surgery. With good initial subjective knee stability, a knee joint that can be well loaded again without surgery can result. However, the factors time, muscular shrinkage and the risk of secondary meniscus injury with persistent instability must be considered. The secondary meniscus injury caused by the persistent knee instability is one of the most decisive factors for the long-term prognosis.
If the cruciate ligament does not heal during conservative treatment, secondary damage to the meniscus or cartilage may occur. In these cases, surgical treatment is also recommended.
According to the criteria of the international knee specialists, the recommendation for the surgical intervention is certainly the right decision for the patient Natalija Oehri.
How does the rehabilitation look like? Are there differences?
Dr. Andreas Krüger: The rehabilitation is divided into different phases.
In the first phase, the pain and swelling are mainly treated.
In the next phase, the focus is on promoting muscular stabilization.
The last phase is concerned with increasing the load on the knee. The knee is prepared specifically for the upcoming load. Before patients are allowed to resume their usual sports activities, they are subjected to the Ready-to-Sport test, in which at least 90% of the strength and stability of the uninjured opposite side must be achieved.
After the surgical treatment, walking sticks are used for three weeks to provide partial relief with full weight bearing in the extended position. With additional meniscus suture, the patient must relieve the load for four weeks and then gradually build up the load until the sixth week.
The non-surgical method requires a similar effort in physiotherapy, but the load is applied according to the complaints and swelling with permitted full load with the knee brace in place.
