Reconstruction surgery is not always necessary for active young people who rupture their anterior cruciate ligament

Blikk på forskning utarbeides i samarbeid med Journal of Physiotherapy (Australia), som trykker forskningspresentasjonene under betegnelsen Critically appraised Papers, CAPs.

Synopsis

Summary of: Frobell RB, et al (2013) Treatment for acute anterior cruciate ligament tear: five year outcome of randomized trial. BMJ 346: f232. doi: 10.1136/bmj.f232. [Prepared by Nicholas Taylor, CAP Co-ordinator.]

Question: Does early anterior ligament (ACL) reconstruction plus early rehabilitation improve outcomes five years after injury in patients with an ACL ligament tear compared with rehabilitation with the option of delayed surgery?

Design: Randomised, controlled trial included blinded outcome assessment.

Setting: Two hospitals in Sweden.

Participants: Adults aged 18 to 36 years with an ACL tear not more than four weeks old to a previously uninjured knee were included. Key exclusion were playing professional sport, being less than moderately active, and having a full thickness meniscal lesion. Randomisation of 121 participants allocated 62 to the early ACL reconstruction group and 59 to a group having the option of delayed ACL reconstruction if needed. Interventions: Both groups received a similar rehabilitation program supervised by physiotherapists in outpatient clinics with goals for attaining range of motion, muscle function, and functional performance. In addition, the intervention group had ACL reconstruction surgery within ten weeks of injury. The comparison group with the option of delayed reconstruction had ACL reconstruction surgery when presenting with symptomatic knee instability.

Outcome measures: The primary outcome was the change in the Knee Injury and Osteoarthritis Outcome score (KOOS) at five years. The KOOS comprises an overall score and five subscales (pain, symptoms, activities of daily living, sport and recreation, and knee related quality of life) scored from 0 to 100 with higher scores indicating better results. Secondary outcome measures included the short-form health survey (SF-36), the Tegner Activity Scale, and radiographic osteoarthritis.

Results: 120 participants completed the study. 30 participants (51%) in the delayed optional ACL reconstruction group proceeded to have reconstruction surgery: 23 at a mean of 11.6 months after injury and the other seven at between two and five years. At five years, the change in KOOS in the early ACL reconstruction group was 42.9 units and the change in the comparison group was 44.9 units (mean difference 2.0 units, 95% CI –8.5 to 4.5 units). There were no between-group differences for any of the KOOS subscales, SF-36, numbers returning to pre-injury activity level (n = 14 in early ACL reconstruction, n = 12 in delayed optional ACL reconstruction group), or radiographic osteoarthritis (n = 9 in early ACL reconstruction group, n = 4 in delayed optional ACL reconstruction group).

Conclusion: After rupture of the ACL ligament early ACL reconstruction surgery did not provide better results than providing a program of rehabilitation with the option of having delayed surgery. Not all young active adults who rupture their ACL ligament require ACL reconstruction surgery. 

Commentary

Identifying the best treatment approach for an acute anterior cruciate ligament (ACL) injury is a holy grail for clinicians and researchers. ACL reconstruction has long been considered the treatment of choice for young, active people with an ACL injury. Surprisingly there are few randomised studies comparing the efficacy of surgery to other treatments. A recent systematic review suggests one in three people may not return to their previous level of sport after surgery (Ardern et al 2011). In the Frobell study a comprehensive assessment of knee impairments, activities, participation, and contextual factors was completed. There was no difference at five years between people who had early ACL reconstruction surgery and those who had rehabilitation with the option of delayed surgery, which echoed earlier positive results from the same cohort when they were assessed at two years (Frobell et al 2010). People who never had surgery also did just as well as people who had early or delayed surgery. Therefore, for a young, physically active adult with an acute ACL rupture, structured rehabilitation with the option for delayed surgery may be an appropriate approach, and may help avoid unnecessary surgery without compromising short- to medium-term outcomes. Patients who had early surgery had more stable knees when compared to those who had rehabilitation with or without delayed surgery. Damage to the meniscus, rather than the ACL injury or treatment provided, may be a critical factor in the development of post-traumatic osteoarthritis (Oiestad et al 2009). There may be risk in delaying or avoiding surgery, because there is more chance for an unstable knee to sustain meniscal injury. While no differences were found in radiographic signs of osteoarthritis at five years, subtle changes associated with long-term disability and disease may not be visible on X-ray (Chu et al 2010). Five years follow-up may not be long enough to make judgements about the efficacy of operative or non-operative treatment in stalling the progression of osteoarthritis. 

Clare Ardern, Lower Extremity and Gait Studies Program, School of Allied Health, La Trobe University, Australia 

References

Ardern C et al (2011) Br J Sports Med 45: 596–606.

Chu C et al (2010) Arthritis Rheum 62: 1412–1420.

Frobell R et al (2010) NEJM 363: 331–342.

Øiestad B et al (2009) Am J Sports Med 37: 1434–1443.