economic benefit of early knee reconstruction over optional delayed
reconstruction for ACL tears: registry enriched randomized controlled trial

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

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

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.

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?

Nicole Cattano
by: Jeffrey Driban


Kiadaliri, A., Englund, M., Lohmander, L., Steen Carlsson, K., & Frobell, R. (2016). No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data British Journal of Sports Medicine DOI: 10.1136/bjsports-2015-095308