Early Surgery for acute ACL rupture tied to improved knee function, finds study

The seminal Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial found that non-operative treatment of rupture of the ACL, with exercise, was successful in at least half of these patients. Early reconstruction of the ACL had a similar functional outcome after two years of follow-up as rehabilitation and optional delayed ACL reconstruction. However, there is limited evidence available on the optimal approach from the patient's perspective for the management of ruptured ACL. Therefore, researchers of the Netherlands conducted a study to assess whether a clinically relevant difference exists in patients' perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens.

COMPARE was an open labelled, multicentre, parallel randomized controlled trial of 167 patients with acute rupture ACL admitted in six hospitals in the Netherlands, between May 2011 and April 2016. Researchers randomized 85 patients to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after three months. Researchers evaluated patients at three, six, nine, 12, and 24 months. The major outcomes assessed were patients' perceptions of symptoms, knee function, and ability to participate in sporting activities with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months.

Key findings of the study were;

• In the rehabilitation and optional delayed ACL reconstruction group, the researchers noted that about 41 (50%) patients underwent reconstruction during follow-up.

• After 24 months, they found that the early ACL reconstruction group had a significantly better but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4).

• After three months of follow-up, they noted that the International Knee Documentation Committee score was significantly better for the rehabilitation and optional delayed ACL reconstruction group.

• However, after nine months of follow-up, they found that the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group and become smaller by 12 months.

• In the early ACL reconstruction group, they reported four re-ruptures and three ruptures of the contralateral ACL during follow-up while in the rehabilitation and optional delayed ACL reconstruction group, they reported two re-ruptures and one rupture of the contralateral ACL.

The authors concluded, " In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two-year follow-up."

They further added, "This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction."

For further information:

https://www.bmj.com/content/372/bmj.n375