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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5 comments:

Jeffrey Driban said...

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maggie lynch said...

This study is an important step in clinician's search for a way to decrease the prevalence of OA. Often, athletes and athletic trainers alike will jump right to the option of surgery after an ACL tear. While this may be the correct option for some, it is important to consider other options other than surgery as it will almost inevitably lead to osteoarthritis later in life. Other confounding injuries, like meniscus tears or cartilage defects, do need to be considered when selecting the appropriate course of action. I look forward to seeing where this research goes- thanks for sharing your findings!

Kyle said...

Maggie,

I could not agree with your comment more. There is currently a significant amount of research regarding many of the confounding factors your mentioned. The current issue is combining all of this data to a cohesive treatment plan. As you very astutely pointed out, each injury and patient really needs to be treated individually. Just like you, I am very anxious to continue following the latest and greatest research on this topic. Thanks for an excellent comment.

Kyle

Sarah H said...

I believe that this study reinforced my beliefs that "prehab" is an important step to take before considering and ACL reconstruction. As an athletic trainer, it is my obligation to keep my patient's best interests in mind. Although to them, immediate surgery may sound like the best thing and what the professional athletes do, this may not be the best option. Rehabilitation before surgery, focusing on increasing ROM, strength, and quadriceps activation will help the patient in the long-term by making it that much less that they have to gain after surgery.

When I consider exercise therapy before ACLR my main consideration are related to the individual. Not only pertaining to what cofounding factors they present with, such as cartilage damage or meniscal pathology, but what that individual's goals are and how we can accomplish those in the best way possible. Even if that is RTP, the typical 6-9 month timeline may not be what is best for that patient. If I am able to help them look beyond their "short-term" goals of RTP and look forward to what lies beyond their athletic career, I believe that should be done when considering ACLR timeline.

At this point, would you have an ideal timeline in mind for patients that do present with meniscal damage or increased knee symptoms/pain/or dysfunction? Thank you for your summary and I look forward to hearing more about this topic!

Kyle said...

Sarah,

Thank you for a very insightful comment and the question. I think that to answer your question, I would reflect back to you point that the individual's needs need to be considered when establishing a timeline for RTP. I think that the extent of the dysfunction or the meniscal damage needs to be considered to establish a good timeline. Further, I think we as clinicians need to be very open with our patients regarding the possibility that the timelines may need to be altered throughout the process due to factors outside of anyone's control. I think there are times that the timeline we as clinicians establish become an expectation and although our patient's look to us to know what to do, we cannot see the future. I think this honesty is important, as it seems like you do as well. Thanks again.

Kyle

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