Several papers in this year's BASK (British Association for Surgery of the Knee) meeting (2012) reflect a real shift to the involvement of the informed patient in improving the outcome of knee surgery.

Patients have embraced the online medium with enthusiasm and are hungry to inform themselves about their knee problems and management options. Surgeons are striving hard to catch up with them. An informed patient can only be an asset to the surgeon but it is difficult to know how much information to include in the formal documentation that the patient is given prior to surgery.

An online publication of the 'informed consent' of one of the leading surgeons in cruciate ligament surgery - Patient Information Hand-out & Post-operative Instructions - has in my opinion too much information. What amount of information, these days, is relevant to the informed patient?

 

If I was having an ACL reconstruction I would want to know -

This second point is a real deal-breaker. It is my experience that many orthopaedic surgeons don’t know how to do a meniscal repair. I think that these questions are linked.

 

Patients should appreciate and therefore be informed that long term ACL deficiency increases the risk of meniscal tears and makes them less amenable to repair. This along with increased risk of chondral surface damage due to ingoing instability indirectly links ACL deficiency to premature knee arthritis. A recent paper (ref 1) (traditional non-anatomic technique) has attempted to quantify this risk:

  • If one has a normal medial meniscus and has ACL reconstruction with old traditional (non-anatomic) techniques, at 25 years after the surgery, there is a 36% incidence of arthritis
  • If the medial meniscus is torn and is removed at the time of the ACL reconstruction, at 25 years, there is a 70% incidence of arthritis
  • If the meniscus is removed and the torn ACL is not reconstructed, at 25 years, there is a 100% incidence of arthritis!

The papers highlight two key areas:

  1. Traditional non-anatomic ACL reconstruction does not prevent osteoarthritis. (hence the trend to more anatomic reconstructions).
  2. We should repair the meniscus wherever possible. ‘Save the Meniscus’ should be the gold standard.

When considering anatomic (or should I say 'more anatomic') ACL reconstruction, and traditional non-anatomic 'trans-tibial' ACL reconstruction, we must acknowledge Dr Freddie Fu and his pioneering work on anatomic ACL reconstruction. His work on 'double bundle' ACL anatomy and reconstruction has certainly made knee surgeons think more about tunnel placement and positioning of the graft. In the UK both lack of clinical results and the technical considerations of anatomic double- bundle reconstruction (tensioning issues, tunnel management, bone stock for revisions) means this is not a procedure for every patient or every surgeon. Dr Fu routinely performs single bundle reconstruction when the anatomy of the native knee does not accommodate double bundle reconstruction. For consent and patient information, when the patient is presented with the technique ‘anatomic’ ACL single or ‘anatomic’ double bundle, the key word is anatomic not the number of bundles.

At a recent meeting I attended in Munich (March 2012), a head-count suggested that there are a finite number of people who do anatomic ACL reconstruction. The vast majority of general orthopaedic surgeons still do the traditional trans-tibial technique. Many surgeons insist that their ACL patients are doing well using this technique. I agree their patients may feel stable and they might get back to sport but the procedure isn't restoring normality for them. Recent literature supports this. Some of the trans-tibial surgeons genuinely believe by adjusting the tibial tunnel they can reach the femoral ACL footprint. This has been shown to be difficult and even impossible with the risk of compromising the proximal medial tibia and plateau, as the tibial tunnel becomes more horizontal.

I don't think that patients are ready to decide on the choice between 'double bundle' or 'single bundle' ACL reconstruction - we surgeons do not yet know which will give the better outcome. But I do think the informed patient should be ready to make a selection of his surgeon based on whether the surgeon is an anatomic reconstructor (with independent femoral tunnel positioning) or a traditional trans-tibial reconstructor. So, the informed patient (and the informed surgeon) might rather want to know if their reconstruction is more anatomically correct and hopefully provide a more rotationally stable reconstruction.


References

1. Louboutin H, Debarge R, Richou J, Ait Si Selmi T, Donnell AT, Neyret P and Dubrana F. 2009. The Knee. 16:239-244. Osteoarthritis in patients with anterior cruciate ligament rupture: A review of risk factors.

Further reading:

1. Lohmander LS, Englund PM, Dahl LL, Roos EM. Am J Sports Med. 2007 Oct;35(10):1756-69. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis.

2. Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Am J Sports Med. 2009 Jul;37(7):1434-43. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review.

3. Oiestad BE, Holm I, Aune AK, Gunderson R, Myklebust G, Engebretsen L, Fosdahl MA, Risberg MA. Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med. 2010 Nov;38(11):2201-10

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