No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomized controlled trial data
Kiadarliri AA, Engulnd M,Lohmander LS, Carlsson KS, & Frobell RB. Br J Sports Med. Published Online First: March 2, 2016; DOI: 10.1136/bjsports-2015-095308
Take Home Message: An early anterior cruciate ligament reconstruction fails to provide improved quality-of-life years and costs compared with people who are provided an optional delayed reconstruction treatment strategy.
There is a lingering debate about whether or not a patient should have an anterior cruciate ligament (ACL) reconstruction as well as when to have surgery. The KANON trial (randomized controlled trial of young active adults with an ACL injury) failed to identify any differences in patient-reported outcomes or radiographic outcomes between those who were randomized to early reconstruction or an optional delayed surgery. Given the lack of differences, the authors of this study aimed to analyze the same data to determine if there were any differences in costs or quality-of-life years. The authors randomized 121 people to early ACL reconstruction (within 10 weeks; n=62) or optional delayed reconstruction (n=59; 51% of this group opted for surgery later). The authors determined the cost for each participant based on public databases, which recorded health resource use (e.g., operation, outpatient visits) and days of sick leave for periods > 14 days or related to disability pension payments. There were no statistically significant differences between early or optional delayed reconstruction for costs, quality-of-life years, or net benefits. Rehabilitation alone was more cost-effective without any differences in quality-of-life years
These authors found no differences in cost-effectiveness or quality-of-life years between individuals who completed rehabilitation with either delayed or early ACL reconstruction. These findings only re-emphasize the importance of an individualized approach to surgical decisions. Oftentimes patients believe that earlier surgery is better. These findings, in combination with other research, demonstrate that this common belief is a misnomer. Certain individuals will succeed with either delayed surgery or no surgery at all. Future research needs to focus on criteria to identify these individuals. Delaying surgery showed no differences in quality-of-life years or costs. Therefore, delaying surgery should be more often considered. It would be interesting to see if concomitant injuries affect the likelihood of optional delayed surgical participants seeking reconstruction, as well as to see if there are associations between “giving way” episodes and radiographic osteoarthritis in longer term follow ups. Ultimately, delayed optional reconstruction could be considered as a more common clinical course due to comparable findings with an early ACL reconstruction.
Questions for Discussion: How do you currently advise ACL injured patients regarding surgery? What are other things that you take into consideration when thinking about surgical reconstruction for patients that you work with?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban