Treatment for Acute Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial
Frobell RB, Roos, HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS. BMJ. 2013, 346: f232. doi: 10.1136/bmj.f232
Anterior cruciate ligament (ACL) tears occur frequently in athletics, and carry with it the potential risk of osteoarthritis (OA). ACL injury is often treated with surgical reconstruction in an effort to reduce the risk of secondary injuries and progression to OA. Some people insist that an ACL reconstruction is needed as quickly as possible; however, the timing of surgery or the lack of surgery on longer-term outcomes has yet to be determined. The purpose of this extended follow-up of a randomizedclinical trial (link to original article) was to compare the outcomes of patients that had immediate ACL surgery versus those that had optional delayed ACL surgery. One hundred twenty patients (ages 18 – 35 years) all underwent similar rehabilitation, but were randomized to early (n = 61) or optional delayed (n = 59) ACL reconstruction surgery groups. Of those that were assigned to the optional delayed group, 51% (n = 30) opted for ACL surgery. At the 5 year follow-up, there were no group differences in patient-reported outcomes (i.e., knee, general health, Tegner activity scale), radiographic OA, or need for meniscal surgery. Mechanical knee stability (i.e., Lachman and pivot shift) was significantly better in knees assigned to early ACL surgery. Within ACL reconstructed knees, more patellofemoral radiographic OA was found in knees that received the patellar tendon in comparison to the hamstring tendon autograft procedures. Overall, 51% of participants underwent meniscal surgery during the 5-year follow-up and 24% of participants had radiographic knee OA.
This is the first randomized clinical trial to explore this important question and it appears that ACL surgery timing does not really seem to affect any major outcome at a 5 year follow-up. It is interesting to see that early ACL surgery does not necessarily provide better outcomes. Furthermore, of those assigned to the optional delayed surgery group, about 50% never needed surgery. There were no differences between those surgically repaired early, late, or with rehabilitation alone. This may emphasize the importance of the rehabilitation process, since all patients underwent similar rehabilitation processes. The study controlled for meniscal status, but did not report any correlations between meniscal status and outcomes, which would be interesting to see. Based on this study it may be safe to delay the ACL reconstruction to determine if the patient can tolerate conservative management through rehabilitation and successfully return to play after an ACL injury. I am extremely interested in following these same patients out to a later time point. But ultimately, an ACL tear may not necessitate surgery, and rehabilitation should be considered as a possible option. Has anyone had any success with conservative management of ACL injuries?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
Original Paper with 2-year Follow-up:Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (Clinical research ed.), 346 PMID: 23349407