Who Really Needs ACL Reconstruction? I Have the Answers - Fact - PowerPoint PPT Presentation

Who Really Needs ACL Reconstruction? I Have the Answers - Fact versus Fiction Lynn Snyder-Mackler ScD, PT, SCS, ATC, FAPTA University of Delaware Newark, DE

University of Delaware Disclosure: I DO NOT have a financial relationship with any commercial interest.

Learning Objective Introduce evidence-based treatment pathways management of Acute ACL injury in Level I-II athletes that incorporates ACLR, temporary return to play (to finish a competitive season) and non-operative management

What are successful outcomes? (Lynch BJSM 2015) • Return to sports (previous activity) – Does this really happen? – MOON cohort • 63% college AFB and 69% HS FB. 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all. • 72% of soccer players – Ardern et al meta analysis 2011 • 63% return to pre-injury level of sports, 44% to competitive sports R37HD037985-12 NIH MERIT AWARD

What are successful outcomes? (Lynch BJSM 2015) • Return to sports (previous activity) – NFL • Shah et al AJSM 2010 • 61% 31/49 returned to the NFL a mean of 11 months after surgery Feucht et al. 2014 94% of primary and 84% of revision expect to return to the same level of activity with no (A) or slight (B) restrictions

What are successful outcomes? (Lynch BJSM 2015) • No re-injury (Does this really happen?) – Contralateral ACL • 12-25% - higher in younger and females – OA • 45-70% at 15 years. Higher in those who returned to strenuous sports (98% say they have no or slight increased risk – Revision ACL • Worse outcomes short term • More OA and disability long term

This is what non-operative management or delayed reconstruction outcomes should be compared to!

Are PTs/Surgeons appropriately counseling patients?

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes All patients educated on outcomes of operative or non-operative management Is the patient planning ACLR?* Non-Operative Operative NO YES Management Management Temporary RTS/Delayed ACLR Is patient planning No screening accelerated RTS? necessary Has patient had > 1 episode YES of giving way? NO Pre-rehabilitation YES NC** NO including progressive neuromuscular and Screen once impairments are resolved (QI strength training Progressive neuromuscular and > 70%, effusion < trace, full ROM, pain- strength training and running free hopping, and no repairable meniscus) progression without agilities (10 perturbation training sessions) D/C after impairments NC** PC** resolved; provide post-op instructions, including 10 perturbation training sessions with how/when to Schedule Functional testing to guide agilities, strength training, running, and post-op IE HEP instruction return to sport progressions Integration of progressive Functional testing for return to sport (QI, Surgery agilities and sport specific 4 hops, KOS-ADLS, and GRS all > 90% progression as appropriate, instruct in HEP; re-check RTS activity progression Return for post-op PT monthly (i.e., practice, contact drills, etc.)

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes All patients educated on outcomes of operative or non-operative management Is the patient planning ACLR?* Non-Operative NO Management Temporary RTS/Delayed ACLR Is patient planning accelerated RTS? Has patient had > 1 episode YES of giving way? NO YES NC** NO Screen once impairments are resolved (QI Progressive neuromuscular and > 70%, effusion < trace, full ROM, pain- strength training and running free hopping, and no repairable meniscus) progression without agilities (10 perturbation training sessions) NC** PC** 10 perturbation training sessions with Functional testing to guide agilities, strength training, running, and HEP instruction return to sport progressions Integration of progressive Functional testing for return to sport (QI, agilities and sport specific 4 hops, KOS-ADLS, and GRS all > 90% progression as appropriate, instruct in HEP; re-check RTS activity progression monthly (i.e., practice, contact drills, etc.)

Why Consider Non-Operative Management? • Some patients may wish to delay or avoid surgery • Different practice patterns in different parts of the world • Surgical reconstruction and return to sports activities are not an effective strategy for preventing early onset knee OA • Not all patients need to have reconstructive surgery

Does surgical delay help/hurt/ make no difference? • Frobell et al BMJ 2013 (5 year) • FINDINGS : The 5 year report shows that there was no difference in any outcome between those who were operated on straight away, those who were operated on later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than operating right away

What about prehab? • Eitzen et al JOSPT • FINDINGS : A 5-week progressive exercise therapy program in the early stage after ACL injury led to significantly improved knee function before the decision making for reconstructive surgery or further non-operative management. The compliance to and tolerance for the program was high, with few adverse events.

300 patients followed prospectively – 150 at each location 12 AM June 6, 2010 Lofoten Islands, Norway • Screening • 10 sessions of perturbation • Functional testing • Surgery or no surgery • 6 month, 1 year, 2 year, 5 and 10 year follow-up

Benchmarked to MOON (Failla et al AJSM 2016)

Benchmarked to NKLR and IKDC norms (Grindem et al BJSM 2015) • DOC showed superior 2-year patient-reported outcomes compared with NKLR (usual care). • 86–94% of the ACLR patients who underwent progressive preoperative and postoperative rehabilitation at the sports medicine clinic had 2-year postoperative patient-reported outcomes (IKDC) comparable to the IKDC norm of a general population.

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes All patients educated on outcomes of operative or non-operative management • Some athletes can return without ACLR • Just because you have ACLR, doesn’t mean you will return to sports at all, and most likely not at the same level of performance • Your risk of re-injury is high in the near term, higher if you are younger, higher (ipsilateral) if you are male and (contralateral) if you are female • Regardless of surgery, your risk of OA is high in the long term • If you need revision surgery risk of OA is higher

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes All patients educated on outcomes of operative or non-operative management Is the patient planning ACLR?* Non-Operative NO Management Temporary RTS/Delayed ACLR Is patient planning accelerated RTS? Has patient had > 1 episode YES of giving way?

Giving Way Episodes • Must inquire about true giving way episodes with ADLS – Outside of initial injury or continued sports participation • True giving way includes: – Tibiofemoral shifting – Usually associated with pain and subsequent swelling – May lead to LOB or fall • Does not include: – Pseudo-buckling – Uncontrolled hyper-extension

Impairment resolution • If no, begin PT treatments to achieve full range of motion Full Range • Re-measure of Motion - If yes, proceed In Knee - If no, continue treatment • If < 70%, start NMES and treat for strength deficits Quad Strength - Re-measure strength with Burst test • If > 70%, proceed but patient needs NMES and TEs until > 80% Assessment • If > 80%, maintain current TE program and proceed • If yes, proceed Effusion Trace or • If more than trace, begin PT treatments to resolve; Less then re-measure