Sports Medicine Research: In the Lab & In the Field: Who Benefits from Early or Delayed ACL Reconstruction? (Sports Med Res)
Wednesday, June 14, 2017

Who Benefits from Early or Delayed ACL Reconstruction?

Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial.

Filbay SR, Roos EW, Frobell RB, Roemer, Ranstam J, Lohmander LS. Br J Sports Med. 2017. [Epub ahead of print].
http://bjsm.bmj.com/content/early/2017/05/17/bjsports-2016-097124

Take Home Message: Patients who are active and present with both an anterior cruciate ligament (ACL) rupture and meniscal injury or more severe knee pain/symptoms should consider starting exercise therapy before an ACL reconstruction. 

After an ACL injury, many patients fail to return to the same level of activity, develop early-onset osteoarthritis, or have a fear of reinjury – all of which could contribute to a decreased quality of life years after an injury. If clinicians knew which factors predicted long-term outcomes then they could develop best practices for selecting an optimal treatment strategy for certain patients. Therefore, Filbay and colleagues completed an exploratory analysis of data from the KANON randomized controlled trial to identify factors that may predict 5-year outcomes among 118 people with an acute ACL injury who were treated with 1) an early reconstruction (59 people), 1) supervised exercise therapy with a delayed ACL reconstruction (30 people), or 3) exercise therapy alone (29 people). The outcome of interest was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 5 years post injury.  The authors explored if injury-related (e.g., meniscal damage, osteochondral lesions), patient-reported (i.e., baseline KOOS scores and mental health score), or treatment-related (e.g., number of surgeries, graft rupture, number of rehab visits) factors were related to outcomes at 5 years. Among all 118 participants, the best predictor of a poor outcome was sustaining an ACL graft rupture or an ACL injury in the contralateral joint during the 5-year follow-up period. Furthermore, having at least one knee surgery (besides an ACL reconstruction/revision) during the follow-up period was related to poor outcomes at 5 years. For participants in the early reconstruction group, worse baseline KOOS scores were related to poorer outcomes. Furthermore, among people who had an early ACL reconstruction meniscal damage or an osteochondral lesion at baseline were more likely to have lower sport and recreation function or lower quality of life at 5 years, respectively. Conversely, baseline meniscal damage was related to less pain at follow-up among participants in the exercise therapy with a delayed reconstruction group. Among people who only received exercise therapy, there was a trend that suggested that the presence of a cartilage defect at baseline may predict poor outcomes.

These results should be interesting to clinicians because they suggest that patients who present with meniscal damage or more knee pain/symptoms/dysfunction at baseline may benefit from starting exercise therapy before an ACL reconstruction. This may seem contrary to clinicians’ inclinations as much of the literature on long-term joint health suggests that meniscal damage results in joint degeneration and that ACL reconstructions may be associated with delaying/preventing osteoarthritis among people with meniscal pathology. It’s important to keep in mind that this strategy still allows a patient to opt for an ACL reconstruction. This study is also interesting because the authors help explain why some patients may respond well to a treatment strategy while another does not. Clinicians should consider multiple factors when exploring the best treatment option for patients who have sustained an ACL injury and may wish to begin with an exercise therapy regiment. For example, a patient with a cartilage defect may be more likely to have a poor outcome after exercise therapy alone. Ultimately, more long-term follow-up studies should be completed to better understand how the clinical decisions made in the first 5 years post-injury will impact the joint over a longer period. It would also be interesting to see if these results are the same with 10-year outcomes. Based on these results, clinicians should be aware that some baseline factor may be related to 5-year outcomes. This information could be helpful when teaching patients about the possible long-term outcomes after an ACL injury.

Questions for Discussion: Do you feel this study will impact your current counseling and education approach to athletes who sustain and ACL rupture? When considering exercise therapy before ACL reconstruction, what factors do you look for in your patients?

Written by: Kyle Harris
Reviewed by:  Jeffrey Driban

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1 comments:

Jeffrey Driban said...

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