ACL reconstruction, exercise had similar outcomes to exercise, optional ACL reconstruction
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Key takeaways:
- ACL reconstruction plus exercise therapy had minimal outcome differences compared with exercise with optional ACL reconstruction.
- Results showed minimal patient-reported differences in radiographic OA scores.
Published results showed no differences in patient-reported outcomes between patients assigned to early ACL reconstruction plus exercise therapy and those assigned to early exercise therapy followed by optional delayed ACL reconstruction.
“After 11 years, we found no important differences in the primary trial outcome KOOS, in any of the five KOOS subscales, KOOS responder criteria, general physical or mental health status, current activity level or radiographic [osteoarthritis] OA between patients of the full analysis set assigned to early [ACL reconstruction] ACLR plus exercise and those assigned to initial exercise therapy with the option of having a later ACLR as needed,” L. Stefan Lohmander, MD, PhD, professor in the department of orthopedics at Lund University in Sweden, and colleagues wrote in the study.
Lohmander and colleagues randomly assigned 121 patients (mean age, 26 years; 74% men) with acute sports-related ACL tears to receive either early ACLR followed by exercise therapy (n=62) or early exercise therapy plus optional delayed ACLR (n=59). Researchers compared patient-reported and radiographic outcomes between the two groups.
Researchers considered change from baseline in the mean KOOS subscales of pain, symptoms, function in sports and recreation, and knee-related quality of life as the primary endpoint at 11 years.
Researchers found a marginal difference in the mean improvement of KOOS subscale scores from baseline to 11-year follow-up, with a 46-point and 45-point improvement in the early ACLR group and the initial exercise therapy with delayed ACLR group, respectively. Results showed patients who received early ACLR had a mean summed incident radiographic OA feature score of 2.4 vs. 1 for patients assigned to exercise therapy plus optional delayed ACLR.
“Although the mean incident-summed radiographic OA scores for the early ACLR group were higher than for the exercise plus optional ACLR group, this difference did not translate into a difference in patient-reported outcomes,” Lohmander and colleagues wrote in the study.
Perspective
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Researchers reported on the 11-year follow-up of a randomized clinical trial involving 121 young active adults (mean age 26 years; 74% male) with an acute sports-related ACL tear published in the New England Journal of Medicine Evidence.
According to the study, 88% of the cohort had follow-up at 11 years. Outcome measures included the four subscales of the KOOS. There was also radiographic assessment in the form of a mean summed incident radiographic feature score.
Overall, about two-thirds of the full cohort reported meeting the case definition for a patient-acceptable symptom state. From a mechanically stability standpoint of the knee, 67% of patients in the early ACL reconstruction group had a stable Lachman test compared to only 33% of those with exercise therapy alone. Forty-four percent of the early ACL reconstruction cohort had early radiographic findings of arthritis.
There are limitations to the study with some loss of follow-up, selection bias, lack of mention of meniscal status at the time of treatment and lack of reporting on adverse events. I also want to stress this is not our most difficult, high-risk patient population we treat. That would be athletes aged younger than 18 years who participate in cutting sports, especially our female athletes.
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