Similar outcomes seen with early vs. late ACL repairs

Raviraj A. J Bone Joint Surg Br. 92-B(4):521-526.

Early anterior cruciate ligament reconstruction yielded clinical and functional results similar to late repair, according to researchers from Bangalore, India.

In their study, A. Raviraj, MD, and colleagues explored the theory that delayed anterior cruciate ligament (ACL) reconstruction offers better functional outcomes than early repair.

The investigators randomized 105 consecutive patients to either the early (less than 2 weeks post-injury) or delayed (greater than 4 to 6 weeks post-injury) ACL repair using a quadrupled hamstring graft. All patients had grades 1 or 2 chondral lesions and/or meniscal tears that only required trimming. A single surgeon performed all of the procedures; all patients followed a standard rehabilitation program.

Six patients were lost to follow-up, leaving 48 patients in the delayed surgery group and 51 patients in the early group. No patients were competitive athletes. In the early group, the mean interval between injury and repair was 7 days. In the delayed group, the interval was 32 days. The study had a mean follow-up of 32 months.

To assess outcomes, Raviraj and colleagues used the Lysholm and Tegner scores, and measured range of motion. A blinded, uninvolved observer assessed stability with clinical tests and measurements using the KT-1000 arthrometer.

The investigators did not find a statistically significant difference between the groups regarding the Lysholm scores, Tegner activity scores or range of motion. Neither stability testing by clinical exam nor measurements with the KT-1000 arthrometer yielded any significant differences between the groups.

This is an interesting study in that it provides evidence that for soft tissue ACL reconstructions, waiting an additional couple of weeks after the injury does not appear to improve the outcome of the reconstruction. This is in some contrast to earlier studies that showed a decreased risk of postoperative arthrofibrosis in ACL reconstructions that were performed 3 or more weeks after the injury.

An explanation for this may be that the earlier studies dealt with central third patella tendon reconstructions whereas these were hamstring reconstructions. Additionally, surgeons are now likely more aggressive with pre- and postoperative range of motion exercises than they were in the past, which may mitigate the risk of postoperative stiffness.

This study should give surgeons a higher comfort level regarding performing ACL reconstructions with hamstring grafts prior to the traditional 3-week minimum wait after injury.

– Christopher C. Kaeding, MD
Judson Wilson Professor
Department of Orthopaedic Surgery
Co-Medical Director
Sports Medicine Center
Head Team Physician
Department of Athletics
The Ohio State University