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Abstract

The optimal management of a torn anterior cruciate ligament (ACL) of the knee is unknown. We conducted a randomized, controlled trial involving 121 young, active adults with acute ACL injury in which we compared two strategies: structured rehabilitation plus early ACL reconstruction and structured rehabilitation with the option of later ACL reconstruction if needed. The primary outcome was the change from baseline to 2 years in the average score on four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS)--pain, symptoms, function in sports and recreation, and knee-related quality of life (KOOS(4); range of scores, 0 [worst] to 100 [best]). Secondary outcomes included results on all five KOOS subscales, the Medical Outcomes Study 36-Item Short-Form Health Survey, and the score on the Tegner Activity Scale. Of 62 subjects assigned to rehabilitation plus early ACL reconstruction, 1 did not undergo surgery. Of 59 assigned to rehabilitation plus optional delayed ACL reconstruction, 23 underwent delayed ACL reconstruction; the other 36 underwent rehabilitation alone. The absolute change in the mean KOOS(4) score from baseline to 2 years was 39.2 points for those assigned to rehabilitation plus early ACL reconstruction and 39.4 for those assigned to rehabilitation plus optional delayed reconstruction (absolute between-group difference, 0.2 points; 95% confidence interval, -6.5 to 6.8; P=0.96 after adjustment for the baseline score). There were no significant differences between the two treatment groups with respect to secondary outcomes. Adverse events were common in both groups. The results were similar when the data were analyzed according to the treatment actually received. In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy substantially reduced the frequency of surgical reconstructions. (Funded by the Swedish Research Council and the Medical Faculty of Lund University and others; Current Controlled Trials number, ISRCTN84752559.) 2010 Massachusetts Medical Society

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Most cited references 21

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Clinical practice. Anterior cruciate ligament tear.

David Wright, Kurt Spindler (2008)

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The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions.

Martin Lind, Frank Menhert, Dan B Pedersen (2009)

Anterior cruciate ligament (ACL) reconstruction is presently evolving rapidly. In order to monitor the developments in surgical methods and clinical outcome, a national clinical database for knee ligament reconstructions was established in 2005 in Denmark. This study presents the first data with 2 year follow-up from the Danish ACL registry. All orthopaedic departments performing ACL reconstructions in Denmark, including private clinics, report to the registry. The database includes both surgery- and patient-related data. The surgeon reports anamnestic, objective knee laxity and operative data including graft and implant choices. At 1 year control, complications, reoperations, and objective knee laxity are recorded. The patient registers the Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner function score preoperatively and at 1, 5 and 10 years follow-up. During the first 30 months, 5,872 knee-ligament reconstructions were registered. A total of 4,972 were primary ACL reconstructions, 443 were ACL revisions and 457 multiligament reconstructions. A total of 85% of all knee ligament reconstruction were reported to the database. A total of 71% of primary ACL reconstruction used hamstring tendon grafts and 21% used patella tendon graft. Meniscus injuries were treated in 35% of all patients. A total of 17% had significant cartilage lesions. At 2 years follow-up 3% of primary reconstructions were revised. Follow-up KOOS demonstrated specific differences between primary ACL, revision ACL, and multiligament reconstructions. Sports/recreation score were 40, 32, 28 and quality of life score were 40, 32, 33 for the respective groups. This study presents the first follow-up data from a national ACL registry. These data will become new international reference materials for outcome measures before and after ACL surgery. The database will enable future monitoring of ACL reconstruction techniques and outcome.

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Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis.

Caroline Tournoux-Facon, David Biau, R Nizard … (2006)

To compare bone-patellar tendon-bone autografts with hamstring autografts for reconstruction of the anterior cruciate ligament. Medline, WebSPIRS, Science Citation Index, Current Contents databases, and Cochrane Central Register of Controlled Trials. Review methods All randomised controlled trials reporting one or more outcome related to stability (instrumented measurement of knee laxity, Lachman test, or pivot shift test) and morbidity (anterior knee pain, kneeling test, loss of extension, or graft failure). Study quality was assessed by using a 5 point scale. Random effect models were used to pool the data. Heterogeneity in the effect of treatment was tested on the basis of study quality, randomisation status, and number of tendon strands used. 24 trials of 18 cohorts (1512 patients) met the inclusion criteria. Study quality was poor for nine studies and fair for nine studies. The weighted mean difference of the instrumented measurement of knee laxity was 0.36 (95% confidence interval 0.01 to 0.71; P = 0.04). Relative risk of a positive Lachman test was 1.22 (1.01 to 1.47; P = 0.04), of anterior knee pain 0.57 (0.44 to 0.74; P < 0.0001), of a positive kneeling test 0.26 (0.14 to 0.48; P < 0.0001), and of loss of extension 0.52 (0.34 to 0.80; P = 0.003). Other results were not significant. Morbidity was lower for hamstring autografts than for patellar tendon autografts. Evidence that patellar tendon autografts offer better stability was weak. The poor quality of the studies calls into question the robustness of the analyses.