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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 13-May-2011, Vol 124 No 1334

Against anterior cruciate ligament reconstructions—and response by orthopaedic surgeon
The Accident Compensation Corporation (ACC) promotes the surgical treatment of anterior cruciate ligament (ACL) ruptures (ACC1331 Diagnosis and management of soft tissue knee injuries best practice guideline). This is despite evidence showing that more than 80% of such injuries will heal without treatment (J Comput Assist Tomogr 1996 Mar-Apr;20[2]:317), and despite the Cochrane Library finding no randomised trials to support modern methods of Anterior Cruciate Ligament reconstruction (Cochrane Library 2005 Issue 2:CD001356).
Last year ACC spent more that $10 million on ACL reconstructions which at best was a waste of money but more worryingly may well have predisposed a generation of young knees to future pathology. It is time for the Ministry of Health to proscribe this procedure. It is of no benefit to the patient, so why is it being done?
Primum non nocere (first, do no harm).
Nicholas Cooper
General Practitioner
Epsom, Auckland

Response by orthopaedic surgeon
Anterior cruciate ligament ruptures are a common injury, especially in our young sporting population, and if left untreated they often lead to chronic instability. Full thickness midsubstance tears rarely heal.1,2 Instability is the commonest indication for ACL reconstruction, improving knee function in greater than 90% with the majority of patients3,4 returning to aggressive sporting and working activities, especially those activities that involve twisting or rapid change of direction.
ACL rupture is rarely an isolated event and is often associated with significant damage to the articular surface and underlying bone as shown in early MRIs of the acutely injured knee. To suggest that ACL reconstruction in isolation is responsible for the development of long-term osteoarthritis is not substantiated in the literature4 and ignores the severity of the injury.
The Knee Society of the New Zealand Orthopaedic Association has worked closely with ACC to develop guidelines for treating patients with ACL ruptures, which fit with ‘best practise’. This collaborative effort has improved the access and quality of care for those patients with incapacitating instability secondary to ACL rupture.
To suggest that the Ministry of Health should proscribe this procedure is both inappropriate and misinformed.
Gary Hooper
Orthopaedic Surgeon
Christchurch

References:
  1. Beynnon BD, Ryder SH, Konradsen L, et al. The effect of anterior cruciate ligament trauma and bracing on knee proprioception. Am J Sports Med 1999;27(2):150–5.
  2. Pattee GA, Fox JM, Del Pizzo W, Friedman MJ. Four to ten year followup of unreconstructed anterior cruciate ligament tears. Am J Sports Med 1989;17(3):430–5.
  3. Joseph C, Pathak SS, Aravinda M, Rajan D. Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL-deficient athlete and non-athlete population – an Indian experience. Int Orthop; Feb 2008,32(1):57–61
  4. Andersson D, Samuelsson K, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy. 2009 Jun;25(6):653–85. Review.
     
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