Young Adults With Knee Injuries May Not Need Surgery

Current evidence supports nonsurgical management of knee injuries as a viable option for certain younger patients with meniscal or anterior cruciate ligament tears, according to authors of a new opinion paper. However, a surgeon emphasizes that the patient’s activity level must be considered.

Although published studies on younger patients are limited, overall data on anterior cruciate ligament (ACL) injuries suggest that approximately two thirds of patients (60%) do not pursue surgery if they begin with nonsurgical rehabilitation, wrote Jonas B. Thorlund, PhD, of the University of Southern Denmark, Odense, Denmark, and colleagues.

In an article published in Annals of Internal Medicine, Thorlund and colleagues noted that surgical vs nonsurgical management is based on shared decision-making; treatment availability and cost are often factors, along with considerations of the latest evidence.

A strategy of exercise first, with the possibility of surgery later, has shown similar outcomes to early surgery, they said. The authors also highlighted two studies comparing early surgery and exercise therapy in young adults with meniscal tears.

In these studies, approximately 30%-40% of the patients assigned to exercise therapy eventually opted for surgery. “In essence, two of three patients managed without surgery,” the authors wrote.

Consider Least Invasive Strategies

Trying the least invasive approach first is a good principle in medicine, especially if less invasive options may yield similar patient outcomes, Thorlund said in an interview.

“While ACL and meniscal surgery is generally considered safe, there is always a small risk of complications such as venous thromboembolism and infection. In addition, surgery is typically the most expensive alternative,” he said.

Although patients who start with rehabilitation always have the option of surgery later, data are limited on which patients will opt for later surgery, Thorlund said. “However, the current evidence suggests, that if you start with exercise/rehab and later opt for surgery your outcome seems to be the same about 1-2 years after starting your treatment,” he noted.

Factors that might make patients better candidates for nonsurgical management are hard to pin down, Thorlund told Medscape Medical News. “Generally, patients with ACL tears having a strong need for knee stability in their activities might opt for surgery,” he said. Young patients with meniscal tears for whom catching and locking of the knee is the most annoying symptom may opt for early surgery as well, he added.

Let Patient Lifestyle Drive Surgical Decision-Making

One of the critical issues in making determinations for ACL or meniscal surgery is activity level, rather than age, said Mark R. Hutchinson, MD, professor of orthopedics at the University of Illinois Chicago, in an interview.

“Just because you tore your ACL does not mean you need a reconstruction,” said Hutchinson, who was not involved in the article. For some patients, including younger adults, who are not engaged in activities with a high risk for recurrence, physical therapy may be reasonable to consider as an alternative to immediate surgery, he said.

“However, individuals who play competitive sports or frequently engage in regular twisting and cutting activities, such as basketball, will be at elevated risk of making things worse,” said Hutchinson. “Without surgery, you are much more likely to have recurrent episodes of instability, which in turn will lead to meniscal injury or permanent damage to the articular surface of the bone,” he said.

Hutchinson, an orthopedic surgeon himself, acknowledged that, historically, some orthopedic surgeons may have been too aggressive in scheduling surgery for isolated ACL tears for “low demand” patients who were not placing high demands on their knees. For those patients, a more conservative trial of physical therapy would have been reasonable, he said. “Another critical factor when considering early ACL reconstruction is the presence or absence of a meniscal tear,” he told Medscape Medical News.

Delaying meniscal repair in younger patients may lead to an unrepairable meniscus and meniscus dysfunction, essentially guaranteeing arthritis later in life, Hutchinson said. “Fortunately, data suggest that timely meniscal repair prevents or reduces the risk of future arthritis,” he said. For patients with both ACL and meniscal damage, prompt repair of both conditions enhances the success of the meniscal repair, and therefore further reduces the long-term risk for arthritis, he added.

As for additional research, “we must respect the challenges raised by recent literature that suggest that not all ACL injuries require surgical reconstruction and that nonoperative approaches may be reasonable in some patients,” Hutchinson told Medscape Medical News.

More research is needed to identify which patients are most likely to benefit from surgical or nonsurgical management; however, the main research gap is a lack of quality data to give to patients to help them make their own decisions about when or whether to have surgery, he said. Studies are needed to better inform patient selection and education, so patients understand their risk for future arthritis and the impact of surgery, or lack of, on their activity level and risk for recurrent injury, he said.

This article received no outside funding. Thorlund had no financial conflicts to disclose. Hutchinson had no financial conflicts to disclose.