Rehabilitation challenges need for surgical ACL repair

By Lynda Williams, Senior medwireNews Reporter

Surgery is not always necessary for acute anterior cruciate ligament (ACL) injury in young, active patients, research suggests.

The 5-year randomized controlled trial found no significant difference in the long-term outcome of patients who underwent early ACL reconstruction plus rehabilitation or rehabilitation with the option of ACL surgery at a later date, despite only half of the delayed group undergoing repair.

"Our results do not apply to professional athletes or to less than moderately active people, but they should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute [ACL] tear," say Richard Frobell (Lund University Hospital, Sweden) and co-investigators.

The trial reports data for 120 adults (mean age 26 years) with acute ACL tear to a previously uninjured knee; 61 patients underwent early ACL reconstruction using patella tendon or hamstring tendon procedures, and 59 were assigned to receive delayed surgery where necessary. The groups received a comparable program of rehabilitation.

Just 51% of the patients assigned to the delayed arm of the trial underwent ACL reconstruction after a median of 867 days.

At 5 years, there was no significant difference between the early and delayed reconstruction groups in the average of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS₄), with a change from baseline of 42.9 and 44.9 points, respectively.

Nor were there any significant differences between the treatment groups in any of the KOOS subscales, Tegner activity scale, incident radiographic osteoarthritis of the knee, or the need for meniscus surgery.

Finally, assessing the patients by actual treatment received did not reveal significant differences in outcomes between the groups.

"Over the five year observation time of this trial, we did not find any evidence of one treatment being more harmful than the other," Frobell et al emphasize in the BMJ.

"Additional randomized controlled trials and large prospective long term cohort studies including surgically and non-surgically treated patients will contribute to our understanding of this common and disabling condition."

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