Frobell, N Engl J Med 2010 - A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears

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A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears

Frobell, Lohmander, et al.·N Engl J Med·2010·920 citations·RCT

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Frobell and colleagues tested whether adding early ACL reconstruction to structured rehabilitation gives better 2‑year knee outcomes than rehabilitation with reconstruction kept for later if needed, in young active adults with an acute tear.

Randomized trial of 121 young, physically active adults with an acute ACL rupture, followed for 2 years.

Methods

Design: Randomized controlled trial
Patients: 121 young active adults
Acute ACL injury
Aged 18 to 35
Tegner activity level 5 to 9
Groups: Structured rehabilitation plus early reconstruction (62)
Structured rehabilitation with optional delayed reconstruction (59)
Follow-up: 2 years
Primary outcome: Change in KOOS4 from baseline to 2 years
KOOS4 is the mean of the pain, symptoms, sport and recreation, and knee‑related quality of life subscales (0 worst to 100 best)
Outcomes: All five KOOS subscales
SF‑36
Tegner Activity Scale
Knee stability (Lachman, pivot shift, KT‑1000)
Return to preinjury activity
Adverse events

Key Findings

KOOS4 improved by a mean of 39.2 points with early reconstruction and 39.4 points with the delayed option, a nonsignificant difference of 0.2 points (95% CI −6.5 to 6.8, p = 0.96).
None of the secondary outcomes differed significantly between the randomized groups.
Of the 59 patients assigned to the delayed option, 23 (39%) went on to reconstruction and 36 (61%) had rehabilitation alone.
Patients assigned to early reconstruction had less laxity at 2 years (exploratory endpoint).
Return to preinjury activity or higher did not differ significantly between groups (44% after early reconstruction vs 36% with the delayed option, p = 0.37).
In a post hoc analysis by treatment received, self‑reported 2‑year outcomes did not differ significantly among early reconstruction (60), delayed reconstruction (23) and rehabilitation alone (36).

Board pearl

Early reconstruction was not superior to a rehabilitation‑first strategy with reconstruction only if needed, and the rehabilitation‑first strategy meant far fewer reconstructions.

Authors' conclusion

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.

A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears

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A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears

Frobell, Lohmander, et al.·N Engl J Med·2010·920 citations·RCT

Free Full Text·DOI·PubMed

||

Frobell and colleagues tested whether adding early ACL reconstruction to structured rehabilitation gives better 2‑year knee outcomes than rehabilitation with reconstruction kept for later if needed, in young active adults with an acute tear.

Randomized trial of 121 young, physically active adults with an acute ACL rupture, followed for 2 years.

Methods

Design: Randomized controlled trial
Patients: 121 young active adults
Acute ACL injury
Aged 18 to 35
Tegner activity level 5 to 9
Groups: Structured rehabilitation plus early reconstruction (62)
Structured rehabilitation with optional delayed reconstruction (59)
Follow-up: 2 years
Primary outcome: Change in KOOS4 from baseline to 2 years
KOOS4 is the mean of the pain, symptoms, sport and recreation, and knee‑related quality of life subscales (0 worst to 100 best)
Outcomes: All five KOOS subscales
SF‑36
Tegner Activity Scale
Knee stability (Lachman, pivot shift, KT‑1000)
Return to preinjury activity
Adverse events

Key Findings

KOOS4 improved by a mean of 39.2 points with early reconstruction and 39.4 points with the delayed option, a nonsignificant difference of 0.2 points (95% CI −6.5 to 6.8, p = 0.96).
None of the secondary outcomes differed significantly between the randomized groups.
Of the 59 patients assigned to the delayed option, 23 (39%) went on to reconstruction and 36 (61%) had rehabilitation alone.
Patients assigned to early reconstruction had less laxity at 2 years (exploratory endpoint).
Return to preinjury activity or higher did not differ significantly between groups (44% after early reconstruction vs 36% with the delayed option, p = 0.37).
In a post hoc analysis by treatment received, self‑reported 2‑year outcomes did not differ significantly among early reconstruction (60), delayed reconstruction (23) and rehabilitation alone (36).

Board pearl

Early reconstruction was not superior to a rehabilitation‑first strategy with reconstruction only if needed, and the rehabilitation‑first strategy meant far fewer reconstructions.

Authors' conclusion

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.

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