Matthew Holt

Knee Trauma, again

One of my favorite topics is back in the news. Apparently ACL repairs may be unnecessary. Here’s the WSJ Health Blog write up about the NEJM study. Two groups of active young people with torn ACLs were split. Half got immediate ACL repair, half got rehab and later repair if they needed it. Of the second group around 39% needed surgery but when the two groups (surg vs surg when rehab wasn’t enough) were assessed there was no difference.

Mostly this is a big duh! A simple ACL tear doesn’t need fixing unless you are going to go skiing, play soccer, volleyball or some other sport that needs it. I had a left knee simple ACL tear in my early 30s, had it fixed after 6 months wait & rehab and went back to all those sports. (Although I never seriously tested it in a twisting sport before repair).

Then several years later I had both a right knee ACL tear and a few weeks later multiple trauma to my left knee—3 ligament tears and other damage. (Advice to you all; snowboard around the tree not into it). My left knee has never recovered (nor will it) to take part in those twisting sports so I never had the right one fixed (I did get a new ACL & PCL in left knee as I need to be able to walk again!). But the right knee with no ACL is fine for walking, running, biking and even controlled pivoting for snowboarding—where the leg is locked in place vis a vis the other one.

But if I try to twist in a gentle soccer kickabout on my right knee I fall on my ass. So for my earlier ACL repair I suspect that I would have been in the group that needed surgery anyway (the 39%). So if you don’t want to or don’t need to play those sports OR if you do the rehab and are fine, you don’t need a repair, But if you do need to play those sports and rehab alone doesn’t work, then you do.

The question is how many people are getting the ACL repair but never gave rehab a try? Probably quite a few, and for them rehab with the option of surgery is a good idea.

But the real question is how many people are getting ACL repairs when they’re not participants in those sports? Anyone know?

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12 replies »

  1. I have created a new piece of equipment for post-op hip and knee exercise, called the leg-PAC, I’m a PT and don’t know how many orthopedic surgeons are aware that their patients often exhibit significant hip weakness following surgical repairs…even after undergoing intensive PT. One reason for this is that until I created the Leg-PAC device it was difficult to position for strengthening the hip extensor muscles. Many elderly people cannot “bridge” or attain prone positioning easily, therefore strengthening of the hip extensor muscles is often neglected by therapists. I have been attempting to educate other PT’s regarding the need to strengthen these muscles, but often they are so busy just trying to “get through the list” they do not take the extra time to provide these exercises. I understand that many PT’s are working parents, rushing to finish their hospital work on time, but I have found that these exercises can improve gait significantly, when provided on a daily basis. Recent PT studies support this observation.

  2. Probably the same person who favored the government spending money on comparative effectiveness research….something that the brain-dead proponents of HSAs ignore along with 30 years of research on user fees…

  3. Hey Mathew:
    Maybe if people were spending their own money on health care they’d have an incentive to make an accurate assessment of their requirements for an intact ACL and decide accordingly. Here’s a crazy idea, what about coupling a catastrophic plan with a tax-advantaged savings account that can accrue balances year after year to pay for things like torn ACL’s. Think about how that would affect the decision making process upstream from surgery. Who knows, maybe they’d think carefully about whether they needed an MRI? Think about the effect that globalizing this incentive structure across all non-catastrophic medical spending….
    However, I seem to recall someone on this site who seemed to think that turning the government into a giant HMO that coupled centralized, bureaucratic rationing and algorithmic third-party payment was the best way forward.
    Anyone recall who that was?

  4. First off… MRI’s are clearly not necessary for the majority of knee injuries. The literature is pretty clear. A physical exam by a competent sports medicine professional is frequently more accurate in terms of diagnosis of most knee injuries han an MRI. MRIs are useful to rule out concomitant injuries if there is a high index of suspicion, or if a patient is very difficult to examine, etc. ( I am an orthopod, and do not own an MRI machine) . I see over 100 patients a week in the office and recommend that 4-6 consider surgery…
    With regards to your final questions. It’s truly not a straight forward, nor well investigated answer. Patients with functional instability who do not respond to PT and who do not wish to alter their lifestyle are good candidates for an ACL reconstruction. There is a very rough “rule of thirds” that applies in ACL injured patients. 1/3 will barely notice any issues and should not require a reconstruction. 1/3 of patients will be symptomatic but will alter their lifestyle to adjust to their limitations and thus avoid surgery. 1/3 will have significant instability with most any activity and are good candidates for surgery to avoid instability with daily activities.
    That said, people who work on roofs, climb ladders, rock climb or in general work in precarious situations routinely should consider a reconstruction early on to minimize risk of serious personal injury.
    Hope this helps.

  5. This is also a great example of why HSAs are such a great idea. Guarantee you if they had an HSA they would make the 3 hour drive to Canada once every three months and save the $900

  6. Sometimes it isn’t greed, at least I don’t think they have a stake in it. Just had a doctor talk his patient, my insured, out of getting her Femara from Canada. $500 in US roughly $200 up north. Says she can’t be sure what is in it. Has anyone heard any stories of Canadians getting sick or dropping dead in mass from bad Rx? We aren’t talking fortunes here but $3600 a year is serious money for a small group.
    What does a doctor have to gain in a sitution like this? 4 different United States have approved this pharmacy including inspections. If the doctor was taking risk or their could be repruciussion on them I understand erroring on the side of caution, thus the need for tort reform, but when they push high cost alterntaives for no reason…

  7. Lesson, never consult with the guy who’s going to get paid for the fix – in medicine or any profession.

  8. What model Porshe do you Drive Tim? What color did you go with, red never seemed very doctory

  9. “Please don’t suggest that every knee twist doesn’t need an MRI and some sort of surgery.”
    It might be useful to know what structures are damaged, and how much, before you start your rehab program. Not sure how you’ll know that without an MR. Also, it might be useful to know how many therapy sessions it takes to rehab the typical acute non-operative ACL, what that rehab course costs, and how that cost compares with what the average orthopedist gets paid for an ACL repair.
    Full disclosure: I manage an orthopedic surgery office. Which means I know the answers to these things. But far be it from me to interfere with the “yet one more thing we can stop greedy doctors from doing to OTHER PEOPLE” narrative.

  10. gentle soccer kickabout, you must play different over the pond, it never stays gentle for more then 5 minutes. I see 5 years olds and 70 year olds slide tackling in rec games.
    As a consumer who would you believe to tell you these things? We already know comming from the insurance company they would be suspect if not outright dismissed. Independent third party but who would pay for it. If the insurance company pays your back to the trust gap, if an employer paid the cost would that be trusted? Probably dependent on employee/employer relationship.
    Government does health advisories all the time and hardly anyone listens to those. Make THCB required daily reading for everyone?

  11. Ortho docs and radiologists make more than $500 K average per year. They have alimony, Porshe payments, payments on their surgery centers and MRI machines and payments to their children’s therapists to make. Please don’t suggest that every knee twist doesn’t need an MRI and some sort of surgery. Worse yet, please don’t suggest that the RBRVS values for these often unnecessary procedures are too high. Why are you trying to let science get in the way of good old fashioned, someone else pays for my surgery capitalism? Jeez!

  12. I don’t have the numbers you’re looking for, but here’s another variation on the knee story. So many times people hurt their knees on a weekend, get seen in the ER and are told to contact their doctor Monday to get an MRI. Well, if many ACL’s, meniscal tears and collateral ligament tears may heal quite nicely with time and rehab, what’s the point of setting up the expectation that an MRI needs to be done right away? There’s a lot of low hanging cost cutting fruit in this one joint alone!