Surgical reconstruction is superior to non-surgical rehabilitation for non-acute anterior cruciate ligament tears

1. Patients in the surgical reconstruction group demonstrated improved knee function at 18 months.

2. Approximately one-third of patients in the rehabilitation group underwent subsequent surgical reconstruction due to persistent symptoms.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Anterior cruciate ligament (ACL) tears are common musculoskeletal injuries that are treated via surgical reconstruction or non-surgical rehabilitation. Although both options may financially burden the healthcare system, the cost associated with surgical reconstruction is often more substantial. In the setting of a non-acute ACL injury, the effectiveness of surgical reconstruction versus rehabilitation has yielded conflicting results. This randomized controlled trial aimed to compare the safety and efficacy of surgical reconstruction versus rehabilitation in patients with non-acute, symptomatic ACL injury. The primary outcome was overall improvement in knee function, as defined by the Knee Injury and Osteoarthritis Outcome Score–4 domain version (KOOS4) at 18 months. According to study results, surgical reconstruction yielded superior clinical improvement than rehabilitation for patients with non-acute ACL injury. When each domain was assessed separately, surgical reconstruction remained significantly superior with regards to pain, symptoms, activities of daily living, sports and recreation, and knee-related quality-of-life. This study was strengthened by a relatively large sample size with individuals from across the UK, thereby increasing its generalizability.

Click to read the study in The Lancet

Relevant Reading: A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears

In-depth [randomized-controlled trial]: Between Feb 1, 2017, and Apr 12, 2020, 1403 patients were screened for eligibility across 29 orthopedic units in the UK. Included were patients with non-acute, symptomatic ACL injury (n=316) while those requiring immediate surgical attention (n=602) or had comorbid meniscal injuries were excluded. Patients with symptomatic ACL injuries were confirmed with MRI. Altogether, 248 patients (128 in surgical reconstruction and 120 in rehabilitation) were included in the primary analysis. At 18 months, patients assigned to the reconstruction group (73.0, standard deviation [SD] 18.3) reported a significantly greater KOOS4 score than those in the rehabilitation group (64.6, SD 21.6; mean difference 7.9, p=0.0053). 41% (61 of 160) of patients assigned to rehabilitation were switched to surgical management due to lack of improvement with initial treatment allocation. Moreover, the surgical group reported 1 intraoperative complication, compared to 2 in the non-surgical group. Most complications were mild and related to meniscal pathology. Findings from this study suggest that surgical management may be superior to rehabilitation for patients with symptomatic ACL injury.

Image: PD

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