Treatment Options

The natural history of ACL deficiency is not completely understood, and comparison of operative and nonoperative management in the literature is often difficult.19 Numerous variables influence the decision-making process for nonsurgical or surgical management of these injuries. Patient age, activity level, and associated injuries all play a role in the choice of management.

The activity level of the patient, as described by Daniel et al4 is probably the most predictive factor regarding the need for reconstruction. Most patients with isolated ACL injury do well with activities of daily living. They typically can participate in limited sporting activities, but will have difficulty with vigorous activity. Daniel et al4 divided various sports and occupations into tiered levels based on the intensity of the activity. Sports that require jumping, pivoting, and hard cutting such as basketball, football, and soccer are considered level I sports. Sports such as baseball, racket sports, and skiing require lateral motion but less jumping and hard cutting than level I sports and are considered level II. Sporting activities that do not require cutting, pivoting or lateral motion such as jogging, running, and swimming are considered level III. Additionally, Daniel et al4 expanded this classification to include occupations that similarly require cutting and pivoting type maneuvers. The challenge to the surgeon is to decide which patients will benefit from operative or nonoperative management. Generally, patients who participate heavily in level I or II sports/occupations are considered candidates for reconstruction.

Age is an important consideration in the management of the ACL-injured knee. Patient age and activity level, however, are often coupled. Noyes et al20 reviewed the results of nonopera-

Examen Otoscopique Normal

Figure 51-7 A, Arthroscopic picture of intact anterior cruciate ligament (ACL) demonstrating wide tibial footprint. B, Anteromedial (AM) bundle of the ACL is retracted, exposing the posterolateral (PL) bundle.

Figure 51-7 A, Arthroscopic picture of intact anterior cruciate ligament (ACL) demonstrating wide tibial footprint. B, Anteromedial (AM) bundle of the ACL is retracted, exposing the posterolateral (PL) bundle.

tive management of ACL deficiency in a group of 103 patients, with an average age of 26. In their study, a significant number of their patients progressed to have persistent instability, further meniscal damage, and ultimately joint arthroses. Only a small subset could return to turning- or twisting-type activities. Similarly, Hawkins et al21 demonstrated that the results of nonoperative management in an active group of young patients with an average age of 22 were poor. In their cohort, 86% of the patients experienced persistent giving way, and overall 87.5% of these patients rated their knee as fair or poor. Conversely, Cic-cotti et al22 reviewed the results of nonoperative management in middle-aged patients between the ages of 40 and 60. They observed that over 80% of patients in this age group did well with nonoperative management consisting of a supervised physical therapy protocol. Patients in this age group who participated in a guided rehabilitation program and modified their activities had a satisfactory outcome without surgery. However, patients who wished to resume competitive sports requiring level I activities (e.g., pivoting) were dissatisfied with nonoperative management and required reconstruction. Overall, ACL reconstructions in the older population are less common. However, in older patients who wish to continue with vigorous or high-level activities, ACL reconstruction has been shown to be a successful option with results similar to those in younger patients.23,24 In individuals who are older and relatively sedentary, nonoperative management of ACL has been shown to yield satisfactory results, provided the patients are willing to accept a modest amount of instability and a slight risk of meniscal injury.25

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