Is Reconstruction the Best Management Strategy for Anterior Cruciate

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Is reconstruction the best management strategy for anterior cruciateligament rupture? A systematic review and meta-analysis comparinganterior cruciate ligament reconstruction versus non-operative treatment

T.O. Smith a,, K. Postle a, F. Penny b, I. McNamara c, C.J.V. Mann d

a University of East Anglia, Norwich, UKb Norfolk and Norwich University Hospital, Norwich, UKc Nottingham University Hospitals NHS Trust, Nottingham, UKd Norfolk and Norwich University Hospital & University of East Anglia, Norwich, UK

a b s t r a c ta r t i c l e i n f o

Article history:

Received 30 April 2013Received in revised form 28 August 2013Accepted 14 October 2013

Keywords:

Anterior cruciate ligamentSurgical managementPhysiotherapyClinical decision-makingCost-effectiveness

Aims:The purpose of this study was to determine the optimal clinical and cost-effective strategy for managingpeople following ACL rupture.Methods:A systematic review of the published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, psycINFO and theCochrane Library)and unpublishedliterature(OpenGrey,the WHO InternationalClinicalTrialsRegistry Platform,Current Controlled Trials and the UK National Research Register Archive) was conducted on April 2013. Allrandomised and non-randomised controlled trials evaluating clinical or health economic outcomes of isolatedligament reconstruction versus non-surgical management following ACL rupture were included. Methodologicalquality was assessed using the PEDro appraisal tool. When appropriate, meta-analysis was conducted to pooldata.Results: Froma total of 943 citations, sixteen studies metthe eligibility criteria. These included 1397 participants,825 who received ACLreconstruction versus592 who were managednon-surgically. The methodological qualityof the literature waspoor. Thendings indicated that whilst reconstructedACL offers signicantly greater objec-tive tibiofemoral stability (p b0.001), there appears limited evidence to suggest a superiority between recon-

struction versus non-surgical management in functional outcomes. There was a small difference between themanagement strategies in respect to the development of osteoarthritis during the initial 20 years followingindex management strategy (Odds Ratio 1.56;p = 0.05).Conclusions: The current literature is insufcient to base clinical decision-making with respect to treatmentopinions forpeoplefollowing ACLrupture.Whilstbased on a poor evidence,the currentevidencewouldindicatethat people following ACL rupture should receive non-operative interventions before surgical intervention isconsidered.

2013 Elsevier B.V. All rights reserved.

1. Introduction

Anterior cruciate ligament (ACL) rupture is a common sportinginjury which occurs during contact and non-contact multi-directionalactivities[1]. It is most frequently seen in young and physically activeindividuals[2]. The principle function of the ACL is to limit anteriorposterior translation of the tibia on the femur.

Considerable debate remains within the literature regarding theoptimal means of managing individuals following an ACL rupture.Some authors have advocated early ACL reconstruction to restore the

kinematics of the tibiofemoral joint, reduce the risk of joint instabilitythereby decreasing the possibility of secondary joint damage and thedevelopment of osteoarthritis[3]. Such proponents suggest that onlysurgical intervention will provide an active, physically demanding indi-vidual with adequate stability to permit pivotal sporting activities [3].However, others have suggested that a rigorous neuromusculoskeletalrehabilitation programme will provide an effective recovery for thispopulation, without increasing the risks of degenerative damagein thelonger term [4]. Furthermore, the increased risk of operative com-plications such as arthrobrosis, infection, graft failure and donor sitemorbidity, pain, and surgical costs associated with operative interven-tion, may be considered a disadvantage compared to non-surgical man-agement[3].

Whilst uncertainty has existed regarding the optimal managementfor this population, no recent systematic review or meta-analysis has

The Knee 21 (2014) 462470

Corresponding author at: Queen's Building, University of East Anglia, NorwichResearch Park, Norwich, NR4 7TJ, UK. Tel.: +44 1603 593087; fax: +44 1603 593166.

E-mail address:[email protected](T.O. Smith).

0968-0160/$ see front matter 2013 Elsevier B.V. All rights reserved.

http://dx.doi.org/10.1016/j.knee.2013.10.009

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been performed to compare the outcomes of operative compared tonon-operative treatment. A previous Cochrane review has been under-taken[5], however this is now over nine years old, with considerablesubsequent data being published. Therefore there remains uncertainty,based on the current literature, regarding the superiority of ACL recon-struction to non-operative management of this population. The purposeof this study was to test the null hypothesis that there is no statisticallyor clinically signicant difference between ACL reconstruction and non-

operative treatment for the management of ACL rupture. Through this,the paper will determine the optimal clinical and cost-effective strategyfor managing people following this knee injury.

2. Materials and methods

The methods adopted for this review were based on the recom-mended PRISMA checklist guidelines[6].

2.1. Search strategy

The primary search strategy was of publishedliterature from theelec-tronic databases: AMED, CINAHL, EMBASE, Pubmed, psycINFO, MEDLINEandthe Cochrane Library,searched from their inceptionto 1stApril2013.

Secondary search strategies includedreviewingthe unpublished and trialregistry electronic databases OpenGrey, the WHO International ClinicalTrials Registry Platform,Current Controlled Trials and the UK NationalRe-search Register Archive. Finally, the reference lists of each included studyand review papers on this topic were reviewed.

2.2. Eligibility criteria

Studies were deemed eligible if they were randomised or non-randomised controlled trials evaluating clinical or health economic out-comes of surgical versus non-surgical management of ACL rupture.Studies were included if they either randomised participants to surgicalor non-surgical management, or compared clinical outcomes in amatched-cohort study design.

Surgical management was considered undertaken when partici-pants underwent ligament reconstruction (hamstring/quadriceps/Achilles tendon/bone-patella-tendon-bone grafts or allografts). Studieswhere an ACL ligamentrepair was performed wereexcluded. Conserva-tive (non-surgical) management consisted of any intervention whichwas non-invasive in nature. Therefore physiotherapy, physical therapyand rehabilitation programmes consisting of exercise, bracing, taping,electrotherapy and muscle stimulation interventions and graded returnto exercise and activities were included. Interventions such as diagnos-tic arthroscopy were considered non-surgical interventions.

Anterior cruciate ligamentrupturewas denedif thestudy provideda convincing report of diagnosis based on history, clinical presentationand/or radiological investigation (Magnetic Resonance Imaging (MRI)or arthroscopy. Furthermore, studies where participants sustained a

meniscal or collateral ligament injury were included, however studieswhich included patients who also underwent meniscal repair or collat-eral ligament reconstruction were excluded. Studies where ACL andposterior cruciate ligaments were ruptured together were excluded.Both childhood and adult populations were included although wereplanned to be analysed separately.

All studies were included irrespective of publication language, year ofpublication or quality of the methods. Animal studies or biomechanicalcadaveric studies were excluded.

2.3. Identication of eligible studies

The titles and/or abstracts of each identied citation were reviewedindependently by two reviewers (TS/KP). The full text of each potentially

eligible paper was ordered, and subsequently reviewed. If the full-text of

the paper satised the eligibility criteria, this was included in the nalreview.

2.4. Data extraction

Data extraction from each included study was performed by two re-viewers independently (KP/FP). Data extracted included: sample size,cohort age, gender-mix, duration from injury to intervention, concomi-

tant injuries, surgical and post-surgical interventions, non-surgical in-terventions, follow-up period and outcomes.

2.5. Outcome measures

The primary outcomemeasure wasfunctional outcomeas measuredwith reliable and valid patient-reported outcome measures such as theLysholm Knee Score[7], International Knee Documentation CommitteeScore[8] or Tegner Activity Score[9] for example. The primary end-point was the 12 month follow-up assessment for these measures.

Secondary outcomes include: time to return to sport/occupationalpursuits; functional performance as measured by tests such as timedagility tests, hop-test or step tests; health economic analysis; and com-plications including reduced range of motion, muscle atrophy, residualpain, ACL re-rupture and requirement for secondary operations.

2.6. Critical appraisal

Each included study was appraised using the PEDro Critical AppraisalTool. This isa validatedand reliable appraisaltoolfor clinical trials [10,11].It consists of 11 questions assessing the recruitment, allocation, power,blinding and data analysis aspects of clinical trials. Each included studywas assessed using this tool by two reviewers (KP/FP) independently.

Any disagreementbetween the two independent reviewers in papereligibility, data extraction or critical appraisal evaluation was resolvedthrough discussion. If consensus could not be reached, this was resolvedby a third reviewer (TS).

2.7. Data analysis

Initially inter-study heterogeneity was assessed visually using thedata extraction table and forest-plot results. If inter-study homogeneitywas demonstrated in participant characteristics, intervention, follow-up period and data collection methods, a meta-analysis was deemedappropriate (Table 1).

Table 1

MEDLINE search strategy.

1. exp Anterior Cruciate Ligament/2. exp (Reconstructive Surgical Procedures/or reconstruction*.mp.) and (cruciate or

ACL).mp.3. exp Surgical Procedures, Operative/4. surg$.tw.

5. operat$.tw.6. OR/357. exp Rehabilitation/8. exp Physical Therapy Modalities/9. "Physical Therapy (Specialty)/10. Braces/11. Immobilization/12. rehabilitat$.tw.13. physiotherapy.tw.14. physical therapy.tw.15. (non-surg$ or nonsurg$ or non-operat$ or nonoperat$ or conserv$).tw.16. (immobilis$ or immobiliz$ or therap$ or exercis$ or brace or bracing).tw.17. OR/71618. ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or

placebo.ab. or drug therapy.fs. or randomly.ab. or trial.ab. or groups.ab.)19. AND/1,2,6,17,1820. (animals not (humans and animals)).sh.21. 20 NOT 19

463T.O. Smith et al. / The Knee 21 (2014) 462470


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Records identified through database

searching (n=931)

Additional records identified

through other sources (n=12)

Records after duplicates removed

(n=943)

Records screened

(n=943)

Records excluded

(n=919)

Full-text articles

assessed for eligibility

(n=24)

Full-text articles excluded, with

reasons

(n=8)

None reconstruction ( n=7)

Publication of dataset at

difference time-points (n=1)

Studies included in qualitative synthesis

(n=16)

Fig. 1.PRISMA ow-diagram depicting the search strategy results.

Table 2

PEDro critical appraisal tool results.

Study Criteria

1 2 3 4 5 6 7 8 9 10 11

Ageberg et al.[30] X X X X X X Diekstall and Rauhut[28] X X X X X Fink et al.[24] X X X X X X X Fink et al.[25] X X X X X X Fink et al.[26] X X X X X Fink et al.[37] X X X X X Frobell et al.[21] X X X X Karanikas et al.[22] X X X X Kessler et al.[36] X X X X X X X Meuffels et al.[23] X X X X Mihelic et al.[32] X X X X X X Moksnes and Risberg[27] X X X X X X

Seitz et al.[33]

X X

X X X

X

Streich et al.[35] X X X X X Swirtum et al.[31] X X X X X Wittenberg et al.[29] X X X X X X X

- satised; X not satised criterion.Criteria1. Eligibility criteria were specied.2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received).3. Allocation was concealed.4. The groups were similar at baseline regarding the most important prognostic indicators.5. There was blinding of all subjects.6. There was blinding of all therapists who administered the therapy.7. There was blinding of all assessors who measured at least one key outcome.8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.9. All subjects for whom outcome measures were available receivedthe treatment or control condition as allocated or, where this was not the case, data for at least one keyoutcome wasanalysed by intention to treat.10. The results of between-group statistical comparisons are reported for at least one key outcome.

11. The study provides both point measures and measures of variability for at least one key outcome.

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Statistical heterogeneity was deneda prioriusing the Chi-squaredand I-squared statistical tests. As recommended by Deeks et al. [12],whenp0.10 andI-squared 20% a random effects model was under-taken, whilst when p N 0.10 and I-squared b20% a xed-effects modelwas conducted. For continuous outcomes, mean difference (MD) orstandardised mean difference (SMD) was calculated. For dichotomousoutcome measurements, theodds ratio (OR) wascalculated. Foreach sta-tistic, a 95% condence interval andp-values were presented.

Separate analyses were planned to assess childhood and adultpopulations and the difference between bonepatellatendonboneand hamstring grafts). A sensitivity analysis was also planned to assessrandomised controlled trial data compared to non-randomised con-trolled trial data to account for a difference in study quality.

Allstatisticalanalyses wereconducted on RevMan (Review Manager(RevMan) [Computer program]. Version 5.1. Copenhagen: The NordicCochrane Centre, The Cochrane Collaboration, 2011).

3. Results

3.1. Search results

The results of the search strategy are presented inFig. 1. This highlighted that from atotal of 943 citations, 16 studies met the eligibility criteria and were included in the re-view. Seven studieswere excluded asthey presented thendings of ACLrepair as opposed

to reconstruction[1319]. Two papers were identied originating from the same study.Frobell et al. [20]presented a two year follow-up data from their cohort, which wassubsequently presented in Frobell et al. [21]with ve year follow-up data. Data wereextracted from both, but these were categorised as one study.

3.2. Assessment of methodological quality

A summary of thecritical appraisal resultsis presented in Table 2. The resultsindicatethat the current evidence-base presents with a high risk of bias and is methodologicallyweak. Only one study [21] has compared the results of reconstruction versus non-

surgical management through a randomised controlled trial design. The remaining 15studies adopted retrospective matched and non-matched comparisons. Of the studies,12 demonstrated that their two groups were similar at baseline. Major recurrent limita-tions included not blinding assessors to participant's group allocation, since this wasonly clearly documented in two studies[22,23]. Whilst no studies blinded their partici-pants or clinicians to group allocation,this is excusable as would be impossible to achieve.The analysis undertaken by the studies was of merit, with all measuring at least one out-come for 85% or more of their cohort. All but Fink et al.'s[24]study presented between-group comparisonsfor theirdataset. Pointand distribution measurementswere presentedfor at least one key outcome in all studies.

3.3. Study characteristics

A summary forthe study characteristics is presented in Table 3. The16 studies includ-ed 1397 participants, 825 who received ACL reconstruction versus 592 who were man-aged non-surgically. The mean age of the cohorts was 30.9 years (standard deviation =4.8 years). The cohort included809 males and 322 females with four studies not present-ing the gender mix of their cohorts[22,2527]. The mean duration from injury to com-mencing intervention was between 17 days[28]and 35 months[29]. All participants,irrespective of group allocation, were diagnosed with an ACL rupture with diagnostic ar-throscopy in 11 studies[22,2426,28,29,32,33,3537]. Three studies based ACL diagnosison history, physical examination and MRI results [21,27,30]. Two studies documentedthat clinical diagnosis was veried by either MRI or arthroscopy, but did not present thefrequency in which either investigation was performed within their cohorts[23,31].

Anterior cruciate ligament reconstruction was performed with a bonepatellatendonbone graft in all but three papers which used both bonepatellatendonboneand hamstring grafts [21,22,30].Non-operative interventions consisted of an exercise-

based rehabilitation programme with graded return to sports when appropriate. Non-operative treatment arms were not identied in six studies[21,24,25,2931].

Study follow-up periods ranged from one year [27]to 20 years[32].

3.4. Meta-analysis

To minimise the risk of multiplicity in data reporting, the meta-analysis results wereanalysed by three separate follow-up intervals. The results of all meta-analyses aresummarised by these time intervals inTable 4.

Table 4

Meta-analysis results.

Outcome N Effect estimate (95% CI) p-Value I[2]

One to four y ear follow-upKOOS (ADL) 223 1.89 [2.24, 1.55] b0.001 0Complication: Reducedexion range of motion 181 5.22 [1.80, 15.08] 0.02 0Complication: Extension lag 181 8.32 [2.00, 34.65] 0.004 0Subjective instability 391 0.55 [0.01, 31.87] 0.77 96Positive Anterior Drawer Test 181 0.15 [0.05, 0.45] 0.0007 0Positive Pivot Shift Test 181 0.17 [0.04, 0.68] 0.01 73Subsequent injury following intervention 391 0.05 [0.02, 0.18] b0.001 0Return to pre-injury level of activity 223 1.23 [0.71, 2.13] 0.46 0Knee extension torque 87 5.27 [1.90, 12.45] 0.15 0Knee exion torque 87 4.13 [0.99, 9.24] 0.11 0KT-1000 displacement measure 223 2.67 [4.42, 0.91] 0.003 92

Five to 10 year follow-upOAK Score 168 11.44 [7.87, 15.01] b0.001 0Return to pre-injury level of activity 204 1.50 [0.80, 2.81] 0.21 0KT-1000 displacement measure 168 1.30 [1.71, 0.89] b0.001 1

Positive Pivot Shift Test 203 0.07 [0.01, 0.58] 0.01 86Positive Lachman Test 203 0.28 [0.20, 0.40] b0.001 14Subsequent injury following intervention 376 0.24 [0.06, 1.00] 0.05 69Development of Osteoarthritis 638 0.61 [0.17, 2.11] 0.43 85Subsequent partial meniscectomy 204 0.77 [0.40, 1.48] 0.44 0

Over 10 year follow-upIKDC (overall rating normal or nearly normal) 119 2.35 [0.67, 8.22] 0.18 74IKDC (overall rating abnormal or severely abnormal) 260 0.41 [0.11, 1.45] 0.17 74IKDC (rating of normal knee outcomes) 180 6.86 [2.66, 17.68] b0.001 0IKDC (rating of near normal knee outcomes) 180 2.22 [0.03, 154.57] 0.71 93IKDC (rating of abnormal knee outcomes) 180 0.73 [0.38, 1.40] 0.35 0IKDC (rating of severely abnormal knee outcomes) 180 0.19 [0.02, 1.72] 0.14 79Lysholm Knee Score 201 2.87 [17.02, 22.76] 0.78 94Positive Pivot Shift Test 130 0.20 [0.01, 2.94] 0.24 90Development of Osteoarthritis 361 1.56 [1.00, 2.44] 0.05 0Subsequent partial meniscectomy 130 0.18 [0.07, 0.46] 0.0003 0

CI Condence Intervals;I2 Inconsistency Value;IKDC International Knee Documentation Committee score;KOOS (ADL) Knee Injuryand Osteoarthritis Outcome Score (Activities

of Daily Living) subset; OAK score

Orthopdische Arbeitsgruppe Knie score.



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3.4.1. Primary outcome

Function wasassessed at a 12monthinterval using theKnee Injury andOsteoarthritisOutcome Score (KOOS) [33] measurement. Theactivities of daily living (ADL) subsetnd-ings indicated statistically signicantly greater functional outcome in the non-operativelymanagedgroup (MD= 1.89; 95% CI: 2.241.55;p b 0.001). However, the mean differenceof 1.89 isa clinically insignicantvalue,with a minimalimportant change for this domainconsidered as seven to eight points[33].

3.4.2. Secondary analysis: 1 to 4 year follow-up

Six studies formed the basis of the one to four year analysis[21,22,2730].

Theresults of themeta-analysis indicated a statistically signicantlygreater likelihoodof reduced knee range of motion (b100 degrees exion) (OR: 5.22; 95%CI: 1.80to 15.08)and extension lag (b20 full extension) (OR: 8.32; 95% CI: 2.0 to 34.7) in those who re-ceived reconstruction compared to the non-operative group.

There wasa small butstatisticallysignicantly greaterlikelihoodof a positive anteriordrawer(OR: 0.15; 95%CI: 0.05 to 0.45), positive pivot shift (OR:0.17;95% CI:0.04 to 0.68)and for experiencing a subsequent meniscal injury (OR: 0.05; 95% CI: 0.02 to 0.18) inthe non-operatively managed group. Furthermore, the non-operative groups had greaterKT-1000 tibial displacement measurements at this follow-up period compared to the re-constructed group (MD = 2.67 mm; 0.91 to 4.42;p = 0.003).

There was no statistically signicant difference in the numbers of participantswho returned to pre-injury levels of activity, knee extensionor exion torque or reportedsubjective instability symptoms betweenthe management groupsat this follow-up period(p N 0.05;Table 4).

Secondary operations were reportedin one study at fouryearfollow-up.DiekstallandRauhut[28]reported no statistically signicant difference in the requirement for second-ary operations including meniscal debridement, notchplasty and revision ACL reconstruc-tion betweentheirACL reconstructionand non-operative groups(OR: 0.54; 95%CI: 0.14to2.05).

3.4.3. Secondary analysis: 5 to 10 year follow-up

Six studies formed the basis of the ve to 10 year analyses[21,31,2426,34].As perthe earlierfollow-upanalysis,KT-1000 tibial displacementmeasurement(MD:

1.30 mm; 95% CI: 17 to 0.89;p b0.001), positive pivot shift (OR: 0.07; 95% CI: 0.01,0.58),positive Lachmantest(OR: 0.28; 95%CI: 0.20 to 0.40) andsubsequent injury follow-ing initial management (OR: 0.24; 95% CI: 0.06, 1.00) remain statistically signicant, withsuperior results for the reconstructed group.

In contradiction to the earlier follow-up the Orthopdische Arbeitsgruppe Knie (OAK)score results indicated statistically signicantly greater functional outcomes for the recon-structed group at this later follow-up period (MD = 11.4; 95% CI: 7.87 to 15.01;p b 0.0001).

There was no statistically signicant difference between the management strategiesfor the likelihood of participants returning to pre-injury sporting participation (OR: 1.5;95% CI: 0.8 to 2.81) or the development of osteoarthritis (OR: 0.61; 95% CI: 0.67 to 8.77).

Only Frobell et al. [21]reported ACL re-ruptures in their cohort. In this ve yearfollow-up, three patients re-ruptured their ACL reconstructions (5%) whilst one patient,

who was initiallyallocated to the non-operative group but subsequently underwentACL re-construction during the follow-up period, also re-ruptured (2%). There was no statisticallysignicantdifferencebetweenthe ACLreconstruction andnon-operative management strat-egy groups in respect to subsequent surgical procedures (i.e. partial meniscectomy) follow-ing their initial management (OR: 0.77; 95% CI: 0.40 to 1.48).

The frequency of ACL reconstructions performed in the originally non-operativelymanaged cohorts was reported in one study at ve year follow-up[21].This reportedthat 30 (51%) participants who were initially non-operatively managed subsequentlyunderwent ACL reconstruction for recurrent symptoms and functional limitations.

3.4.4. Secondary analysis: greater than 10 year follow-up

Five studies formed the basis of the 10 year and over follow-up analyses[23,32,3537].There was no statistically signicant difference between the reconstructed versus

non-operative groups in the frequency ofnormaland nearly normal(OR: 2.35; 95% CI:0.67 to 8.22) or abnormal and severely abnormal (OR:0.42, 95% CI: 0.11, 1.45) participantsubjective response results in International Knee Documentation Committee (IKDC) rating.It was possible to analyse the individual sub-categories of IKDCscore (normal;near normal;

abnormal; severely abnormal) in two studies[36,37]. On meta-analysis, whilst there was astatistically signicantly higher probability of a normaloutcome in the ACL reconstructiongroup compared to non-operative cohorts (OR: 6.86; 95% CI: 2.66 to 17.68), there was nosignicant difference between the management strategies in the other IKDC outcomes atthis longer-term follow-up (Table 4).

There was no statistically or clinically signicant difference between the groupsin Lysholm Knee Score at this later follow-up period (MD = 2.87; 95% CI: 17.02 to22.76). Unlike earlier follow-up periods, there was no statistically signicant differencein the proportion of participants in eachgrouppresentingwith a positive pivot shift result(OR: 0.20; 95%CI: 0.01 to 2.94). There washowever a small andborderlinestatistically sig-nicant difference in the likelihood of developing osteoarthritis, where the reconstructedgroup presented with a slightly greater chance of developing this sequelae compared tothe non-operative group (OR: 1.56; 95% CI: 1.00 to 2.44; p = 0.05).

The frequency of ACL reconstructions performed in originally non-operative patientswas reported in one study[37]. At 12 year follow-up, two patients required ACL recon-struction (8%).

Twostudies reported thefrequency of additional surgicalprocedures following initial

management,all being partial meniscectomy,at 10to 15yearfollow-up. There wasa small

but statistically signicant difference suggesting participants who underwent ACL recon-struction had a lower probability of subsequent partial meniscectomy compared tothose initially managed non-operatively (OR: 0.18; 95% CI: 0.07 to 0.46).

3.5. Sensitivity and subgroup analysis

There was insufcient data to perform a sensitivity meta-analysis of solely randomisedcontrolled trial data. Similarly, due to the presentation of bonepatellatendonbone andhamstring graft data together, it was not possible to perform a subgroup analysis for thisdifference in autograft techniques as part of the meta-analysis. No studies recruited child-

hood populations, and therefore subgroup analyses of adults versus paediatric cohortswere not conducted.

4. Discussion

The ndings of this study indicate that whilst ACL reconstructionoffers greater objective tibiofemoral stability, there appears limitedevidence to suggest superiority between reconstruction versus non-operative management in the functional outcomes of people followingACL rupture. There is limited evidence of a difference between themanagement strategies in subsequent injury or surgical interventionsrequirements, with the exception of a lower incidence of partialmeniscectomy at longer-term follow-ups (10yearand over). Thereis lim-ited evidence to suggest a difference between themanagement strategiesin the development of osteoarthritis during the initial 20years followingindex management strategies. However, the evidence-base is severitylimited in methodological quality, being based on a number of retrospec-tive case-control studies and only one randomised controlled trial [21].Therefore the ndings from this meta-analysis should be viewed withgreat caution until the evidence-base is further developed. Based onthis, currently, the null hypothesis of no statistical and clinical signicantdifference between ACL reconstruction and non-operative managementstrategies is therefore supported.

As acknowledged, only Frobell and colleagues [20,21] have conduct-ed a randomised controlled trial to investigate this research question.Their results support the ndings of this meta-analysis, reporting nostatistically signicant difference between the ACL reconstruction tonon-surgical interventiongroups at two andve years in functional out-comes (KOOS, Tegner Activity Scale), frequencyof subsequent meniscal

injury, development of osteoarthritis (pN0.05), but a lower incidence ofpositive pivot shift and Lachman test ndings in the ACL reconstructedcohort (p b 0.001). Whilst this provides valuable evidence to supportclinical decision-making, the authors reiterate the need for further,well-designed randomised controlled trials to develop the evidence-base in this eld. Basedon thendings of this systematic review, the au-thors reiterate Frobellet al.'s [21] conclusions. Thisis particularlyimpor-tant given that there remains some clinical uncertainty regarding theoptimal management strategy for this population. This is typied byKapoor et al.'s [38] national survey of orthopaedic surgeons in theUnited Kingdom. In this sample of 192 surgeons, 58% reported theywould recommend ACL reconstruction for a 22 year old gentlemanwith a recent ACL rupture, compared to 24% who would manage sucha patient conservatively, whilst 18% would initially manage this patient

conservatively and re-assess at ve to 12 weeks[38].Studies have attempted to predict which patients will benet from

either non-surgical management and which will require ligamentreconstruction[39]. Moknses and Risberg[27]suggested that youngerpatients and those with higher pre-injury activity levels were morelikely to return to higher-level physical activities after ACL reconstruc-tion than older patients. Wittenberg et al. [29] stated that patientsover theage of 50years whoare not active,sportingparticipants shouldbe managed non-operatively initially, and only in those where non-operative interventions have failed should operative intervention beundertaken. Swirtum and Renstrm[31]highlighted that people witha lower (internal) locus of control (belief that the outcome is directlyrelated to patient behaviour) had a signicantly better outcome thanpeople with a high (external) locus of control (belief that the outcome

is under the control of others e.g. surgeon, physiotherapist, chance and



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luck). This therefore impacts on the patient's engagement in copingstrategies,complianceto their intervention and overall attitudetowardstheir abilityto recover from the injury. Stratication of these potentiallyimportant variables is required to better inform treatment decision-making given the current literature's limited difference in outcomesfor reconstruction to non-operative management (Table 4).

Farshadet al. [40] modelled the cost-effectiveness of ACLreconstruc-tion to conservative treatment basedon a literaturereview of four stud-

ies[28,34,36,37]. They reported an incremental cost-effectiveness of4890 US dollars/quality-adjusted life year (QALY) in favour of ACLreconstruction[40]. However, this only assessed direct economic costsand was modelled on a Swiss health system. No studies have directlyassessed, rather thanretrospectively modelled, the health economicim-plications of operative versus non-operative management. This paucityof literatureis of great concern fora number of reasons.Firstly, there is adifference in direct economic costs between people managed surgicallyversus non-surgically[40]. This direct difference in cost can be attribut-ed to greater costs associated with the hospital occupancy, operativeprocedure, multi-disciplinary care, initially greater subsequent disabili-ty and risk of surgical complications, in addition to the rehabilitationcosts which may include pre- and post-operative interventions[40].This can be contrasted to the non-operative rehabilitation costs associ-ated with lower risk of initial complications, as highlighted in thesemeta-analyses' ndings (Table 4). In respect to indirect economiccosts, this population is typically young and of working age. According-ly, the speed of their functional restoration to re-commence work is ofgreat importance. This is important given Frobell et al.'s [21] ndingsthat51% of their initially non-operative cohort subsequentlyunderwentACL reconstruction within ve years. However, it remains unclearwhether thispopulation's capability to work, and return to the function-al activities their jobs may require, is equal between the interventions[41].Finally, non-operative patients may have a greater economic costassociated with subsequent injury, future operative intervention poten-tially due to reduced tibiofemoral stability and potential differences inthe development of degenerative tibiofemoral changes. There is cur-rently uncertainty as to whether ACL reconstruction or non-operativemanagement reduce or increase the incidence of subsequent operative

procedures at mid- to longer-term follow-up (Table 4). Given theseuncertainties, future research must include health economic analysesof direct and indirect costs to better understand whether there is adifference in both clinical and cost-effectiveness between these twointerventions.

As typical of thispopulation, Table 3 demonstrates that the studypop-ulations contain a proportion of patients with meniscal injuries. The inci-dence of these was largely equal between the studies, and therefore therisk of such heterogeneity was minimal, ensuring meta-analysis wasappropriate for this variable. However, the importance of meniscal injuryas a concomitant injury shouldnot be underestimated. Authors have sug-gested that the key factor in respect to minimising the risk of developingtibiofemoral osteoarthritis following ACL rupture is the integrity of themeniscus [32,4244]. People following ACL rupture have a higher risk

of developing osteoarthritis, and this risk is signicantly greater in thepresence of a medial or bicompartment meniscal lesion[32,45]. The pres-ence of a secondary injury was also identied as resulting in poorerfunctional outcomes in Swirtum and Renstrm's[31]study. Further in-vestigation with sufciently powerful cohorts is required to investigatethe validity of this credible hypothesis as this may have a major implica-tion on stratifying the management of patients dependent on their con-comitant injuries with an ACL rupture[46].

Beynnon et al.[46]reported the increased likelihood of developingosteoarthritis was only demonstrated at the 10 years and over follow-up period. This may be attributed to the longer duration requiredto demonstrate a signicant difference in this outcome. Nonetheless,this difference may be reected in a difference in transverse planerotatory instability of the knee. In both Streich et al. [35]and Jonsson

et al.'s [47] ndings, participants with a positive pivot shift results

demonstrated signicantly greater signs of radiographic osteoarthritison longer-term evaluation. Therefore the importance of this instabilitymay become more apparent with a greater number of studies presentinglater follow-updata in the future. Further evaluation of this measure withlarger cohorts may be a valuable re-assessment in future meta-analyses.

In the studies which reported long-term follow-up of ACLreconstruc-tion (more than 10years), theACLreconstruction techniques undertakendo not mirror current understanding in anatomic ACL reconstruction

(e.g. over-the top position, transtibial drilling). The non-anatomic ACLreconstructions seen in the current evidence-base, may havelittle capa-bility to restore physiologic knee kinematics, which may itself causesecondary osteoarthrosis[48]. This is a limiting factor for the evaluatedlong-term studies following (non-anatomic) ACL reconstruction.Furthermore, specic details regarding the techniques adopted andmethods to quantify and conrm variables such as graft and tunnel po-sitioning with 3-D computer tomography would be valuable[49]. Thiswould ascertain whether surgical technique is an important variableto outcomes when comparing ACL reconstruction to non-operativeapproaches. Futurestudies must thereforefocus on more recentACL re-construction techniques, with methods to quantify the accuracy of ACLreconstruction,in terms of a potential lower rate of secondarydegener-ative joint alterations in the long-term follow-up.

Theresults clearly indicatedthatpeople whodo notundergo ACL re-construction demonstrate greater objective tibiofemoral displacementthan those undergoing surgery. Thisnding would appear logical, how-ever the results indicate that objective measurement of tibiofemoraldisplacement does not impact on the functional capability and subjec-tive reporting of instability, indicating that participant muscle controland co-ordination in patients that do not undergo surgery can compen-sate adequately for this loss of ligament integrity. However, a majorlimitation to the evidence-base was the poor description of the non-operative management strategies. Papers generally reported that inter-ventions were based on range of motion or strengthening exerciseregimes. Studies poorly described whether these programmes werebased on open- or closed-kinetic chain exercises, whether propriocep-tive or perturbation training was included and what milestones wereestablished to ensure that participants were not progressed inappropri-

ately to minimise risks of subsequent intra-articular injury. Thesefactors may be important variables which should be considered whenplanning future trials.

A number of authors acknowledged the potential difculty ofrecruiting to a trial of non-operative interventions for participantswho are young, physically activeand haveexpectations of surgical man-agement[27]. Meuffels et al.[23]acknowledged ethical concerns withsurgeons randomising participants they would have alternatively re-constructed to receive non-operative intervention, citing the absenceof rigorous research to substantiate these decisions. The difculty inrecruiting and randomising participants into such a trial design was re-iterated by Frobell et al.[50], the only research team to have conducteda randomised controlled trial in thiseld.They estimated that nearly sixtimes the sample size were required for screening to recruit sufcient

participants into such trials. Interestingly, the most common reasonsfor not consenting to participate in a trial were unwillingness to under-go surgery (56%) rather than unwillingness to riskconservative treat-ment (20%). However, these arguments are insufcient justicationsfor the absence of randomised controlled trials in this area. Takingaccount of these difculties and undertaking sufcient preliminary fea-sibility study work are imperative to ensure that all known designuncertainties can be accounted for when developing a denitive trialto answer this clinical and health-economic research question.

5. Conclusions

The current literature would suggest limited difference in clinicaloutcomes between people managed non-operatively versus with

an isolated ACL reconstruction following ACL rupture. There is limited



8/9

evidence of a difference between the management strategies in subse-quent injury or surgical interventions requirements, withthe exceptionof a lower incidence of partial meniscectomy at longer-term follow-up(10yearand over). However, these ndings are based on a methodolog-ically limited evidence-base, and should therefore be viewed withconsiderable caution. Therefore based on the current ndings, peoplefollowing ACL rupture should be trialled with non-operative interven-tion, but with a lower threshold for reconstruction for younger and

physically active people.

6. Funding

None.

7. Conicts of interest statement

None declared by either author.

8. Ethical approval

None required for this study design.

Acknowledgements

We would like to thank the Library Staff at the Norfolk and NorwichUniversity Hospital's Sir Thomas Browne Library for their assistance ingathering the papers required for this study.

References

[1] Rust DA, Gilmore CJ, Treme G. Injury patterns at a large Western United Statesski resort with and without snowboarders: the Taos experience. Am J Sports Med2013;41:6526.

[2]Swenson DM,Collins CL,Best TM,Flanigan DC,FieldsSK, Comstock RD.Epidemiologyof knee injuries among U.S. high school athletes, 2005/20062010/2011. Med SciSports Exerc 2013;45:4629.

[3]Kwok CS, Harrison T, Servant C. The optimal timing for anterior cruciate liga-ment reconstruction with respectto therisk of postoperative stiffness. Arthroscopy2013;29:55665.

[4] Smith TO, Davies L, Hing CB. Early versus delayed surgery for anterior cruciateligament reconstruction: a systematic review and meta-analysis. Knee Surg SportsTraumatol Arthrosc 2010;18:30411.

[5] Linko E, Harilainen A, Malmivaara A, Seitsalo S. Surgical versus conservativeinterventions for anterior cruciate ligament ruptures in adults. Cochrane DatabaseSyst Rev 2005;2:CD001356.

[6]Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting itemsfor systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol2009;62:100612.

[7] Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with specialemphasis on use of a scoring scale. Am J Sports Med 1982;10:1504.

[8]Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ, Committee IKDC. The Inter-national Knee Documentation Committee Subjective Knee Evaluation Form: norma-tive data. Am J Sports Med 2006;34:12835.

[9]Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. ClinOrthop Relat Res 1985;198:439.

[10] Foley NC, Bhogal SK, Teasell RW, Bureau Y, Speechley MR. Estimates of quality and

reliability with the physiotherapy evidence-baseddatabase scale to assess the meth-odology of randomized controlled trialsof pharmacological and nonpharmacologicalinterventions. Phys Ther 2006;86:81724.

[11] Maher CG,Sherrington C, HerbertRD, Moseley AM,Elkins M. Reliabilityof the PEDroscale for rating quality of randomized controlled trials. Phys Ther 2003;83:71321.

[12] Deeks JJ,HigginsJPT, Altman DG.Analysingdata andundertakingmeta-analyses.In: Higgins JPT, Green S, editors. Cochrane handbook for systemic reviews ofinterventions. Chichester, UK: Wiley-Blackwell; 2011. p. 24396.

[13] Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-surgical treatmentof acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up. J Bone Joint Surg Am 1989;71:96574.

[14] Andersson C, Odensten M, Gillquist J. Knee function after surgical or nonsurgicaltreatment of acute rupture of the anterior cruciate ligament: a randomized studywith a long-term follow-up period. Clin Orthop Relat Res 1991;264:25563.

[15] ClancyJr WG,Ray JM,ZoltanDJ. Acute tears of theanterior cruciateligament.Surgicalversus conservative treatment. J Bone Joint Surg Am 1988;70:14838.

[16] Meunier A, Odensten M, Good L. Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: a randomized study witha 15-year follow-up. Scand J Med Sci Sports 2007;17:2307.

[17] Odensten M, Hamberg P, Nordin M, Lysholm J, Gillquist J. Surgical or con-servative treatment of the acutely torn anterior cruciate ligament. A random-ized study with short-term follow-up observations. Clin Orthop Relat Res1985;198:8793.

[18] Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treat-ment of recent injuries to the ligaments of the knee. A prospective randomizedstudy. J Bone Joint Surg Am 1987;69:11206.

[19] Zysk SP, Reor HJ. Operative or conservative treatment of the acutely tornanterior cruciate ligament in middle-aged patients. A follow-up study of133 patients between the ages of 40 and 59 years. Arch Orthop Trauma Surg2000;120:5964.

[20] Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trialof treatment for acute anterior cruciate ligament tears. N Engl J Med2010;363:33142.

[21] Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatmentfor acute anterior cruciate ligament tear: ve year outcome of randomised trial.BMJ 2013;346:f232.

[22] Karanikas K, Arampatzis A, Brggeman G-P. Konservative vs. operativeBehandlungsmethode nach einer ACL-Ruptur: Einuss auf die muskulrenKraftfhigkeiten der unteren Extremitt. Sportveri Sportschad 2005;19:1521.

[23] Meuffels DE, FavejeeMM, VissersMM, HeijboerMP, Reijman M, VerhaarJA. Ten yearfollow-up study comparing conservative versus operative treatment of anterior cru-ciate ligament ruptures. A matched-pair analysis of high level athletes. Br J SportsMed 2009;43:34751.

[24] Fink C, Hoser K, Benedetto P. Sportfahigkeit nach vorderer Kreuzbandrupturoper-ative versus nicht operative Therapie. Akt Traumatol 1993;23:3715.

[25] Fink C, Hoser K, Benedetto KP. Arthroseentwicklung nach Ruptur des vorderenKrezbands. Unfallchirurg 1994;97:35761.

[26] Fink C, Hoser C, Benedetto KP, Hackl W, Gabl M. Langzeitergebnisse nachkonservativer oder operative Therapie der vorderen Krezbandruptur. Unfallchirurg

1996;99:9649.[27] Moksnes H, Risberg MA. Performance-based functional evaluation of non-operative

and operative treatment after anterior cruciate ligament injury. Scand J Med SciSports 2009;19:34555.

[28] Diekstall P, Rauhut F. berlegungen zur Differentialindikation der vorderenKreuzbandplastik. Ergebnisse nach Ersatz des vorderen Krezbandes im Vergleichzur Spontenprognose. Unfallchirurg 1999;102:17381.

[29] Wittenberg RH, Oxfort HU, Plafki C. A comparison of conservative and delayed sur-gical treatment of anterior cruciate ligament ruptures. A matched pair analysis. IntOrthop 1998;22:1458.

[30] Ageberg E, Thome R, Neeter C, Silbernagel KG, Roos EM. Muscle strength andfunctional performance in patients with anterior cruciate ligament injury treatedwith training and surgical reconstruction or training only: a two to ve-year followup.Arthritis Rheum 2008;59:17739.

[31] Swirtun LR, Renstrm P. Factors affecting outcome after anterior cruciate liga-ment injury: a prospective study with a six-year follow-up. Scand J Med Sci Sports2008;18:31824.

[32] Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of ante-rior cruciate ligament reconstruction: a comparison with non-operative treatmentwith a follow-up of 1720 years. Int Orthop 2011;35:10937.

[33] RoosEM, RoosHP, Lohmander LS,EkdahlC, Beynnon BD.Knee Injury andOsteoarthritisOutcome Score (KOOS)development of a self-administered outcome measure.

J Orthop Sports P hys Th er 1998;28 :8896.[34] Seitz H, Chrysopoulos A, Egkher E, Mousavi M. Langzeitergebnisse nach

vorderem Kreuzbandersatz im Vergleich zue konservativen Therapie. Chirurg1994;65:9928.

[35] Streich NA, Zimmermann D, Bode G, Schmitt H. Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufciency. A retrospectivematched-pair long-term follow-up. Int Orthop 2011;35:60713.

[36] Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS. Function, osteo-arthritis and activity after ACL-rupture: 11 years follow-up results of conserva-tive versus reconstructive treatment. Knee Surg Sports Traumatol Arthrosc2008;16:4428.

[37] Fink C, Hoser C, Hackl W, Navarro RA, Benedetto KP. Long-term outcome of opera-tive or nonoperativetreatment of anteriorcruciate ligamentruptureis sports activ-ity a determining variable? Int J Sports Med 2001;22:3049.

[38] Kapoor B, Clement DJ, Kirkley A, Maffulli N. Current practice in the management

of anterior cruciate ligament injuries in the United Kingdom. Br J Sports Med2004;38:5424.[39] Kaplan Y. Identifying individuals with an anterior cruciate ligament-decient knee

as copers and noncopers: a narrative literature review. J Orthop Sports Phys Ther2011;41:75866.

[40] Farshad M, Gerber C, Meyer DC, Schwab A, Blank PR, S zucs T. Reconstruction versusconservative treatment after rupture of the anterior cruciate ligament: cost effec-tiveness analysis. BMC Health Serv Res 2011;11:317.

[41] Shea KG, Pfeiffer R, Wang JH, Curtin M, Apel PJ. Anterior cruciate ligament injury inpediatric and adolescent soccer players: an analysis of insurance data. J PediatrOrthop 2004;24:6238.

[42] Lohmander LS, Englund PM, DahlLL, RoosEM. The long-termconsequenceof an-terior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med2007;35:175669.

[43] Ferretti A, Conteduca F, De Carli A, Fontana M, Mariani PP. Osteoarthritis of the kneeafter ACL reconstruction. Int Orthop 1991;15:36771.

[44] Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fateof the ACL-injured patient. A prospective outcome study. Am J Sports Med1994;22:63244.

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[45] Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, et al. Pro-spective trial of a treatment algorithm for the management of the anterior cruciateligament-injured knee. Am J Sports Med 2005;33:33546.

[46] Beynnon BD, Johnson RJ,Abate JA,FlemingBC, NicholsCE. Treatment of anterior cru-ciate ligament injuries, part I. Am J Sports Med 2005;33:1579602.

[47] Jonsson H, Riklund-Ahlstrm K, Lind J. Positive pivot shift after ACL reconstructionpredicts later osteoarthrosis: 63 patients followed 59 years after surgery. ActaOrthop Scand 2004;75:5949.

[48] Getgood A, Spalding T. The evolution of anatomic anterior cruciate ligament recon-struction. Open Orthop J 2012;6:28794.

[49] Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH. A simpleevaluation of anterior cruciate ligament femoral tunnel position: the inclinationangle and femoral tunnel angle. Am J Sports Med 2011;39:26118.

[50] Frobell RB, Lohmander LS, Roos EM. The challenge of recruiting patients with ante-rior cruciate ligament injury of the knee into a randomized clinical trial comparingsurgical and non-surgical treatment. Contemp Clin Trials 2007;28:295302.

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Is Reconstruction the Best Management Strategy for Anterior Cruciate

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