No risk of arthrofibrosis after acute anterior cruciate ligament reconstruction
Eriksson K, von Essen C, Jonhagen S, Barenius B. Knee Surg Sport Traumatol Arthrosc. 2018 Oct;26(10):2875-2882. doi: 10.1007/s00167-017-4814-1
Acute ACL reconstruction shows superior clinical results and can be performed safely without an increased risk of developing arthrofibrosis
von Essen C, Eriksson K, Barenius B. Knee Surg Sport Traumatol Arthrosc. 2019 Sept Sep 26. doi: 10.1007/s00167-019-05722-w. [Epub ahead of print].
Early ACL reconstruction does not increase the risk for poor outcomes; such as post-operative knee stiffness or patient-reported outcomes.
Historically, a patient waited a few weeks to undergo an anterior cruciate ligament (ACL) reconstruction to allow for impairments to resolve and minimize post-operative stiffness. However, the recommendations to delay surgery are based on studies from over 20 years ago with older surgical techniques. Hence, we lack evidence regarding how the timing of surgery might impact outcomes. The authors of this clinical trial randomized 69 participants to undergo early or delayed ACL reconstruction to determine if the timing of surgery would affect patient-reported outcomes or range of motion up to 2 years after surgery. The authors included participants 18 to 40 years of age, with an isolated ACL injury, without a previous injury to either knee, and participation in high-demand pivoting activities. The acute ACL reconstruction group underwent surgery within 8 days of the injury. The delayed surgery group waited for 6 to 10 weeks until their impairments resolved. Before surgery, the authors collected range of motion, knee laxity, thigh circumference, and questionnaires about knee symptoms and function as well as activity level (IKDC, KOOS, Lysholm, and Tegner). The surgical technique included a hamstring graft and standardized procedure. Participants completed a standardized rehabilitation protocol, which included closed-chain strengthening, delayed running until at least 14 weeks, and return to sport only after 90% strength symmetry was achieved, but not before 6 months. The authors asked participants a weekly question – “how is your knee functioning?” – for the first 3 months via text messaging and received a response of 0 to 10. Range of motion was assessed at 3 months. At 6, 12, and 24-months after surgery the authors assessed all of the pre-operative measurements and strength.
The authors found no difference between the groups at any time for knee range of motion, knee extension strength, knee laxity, self-reported outcomes, and functional recovery. At 6-months, the acute group had better thigh circumference, single-leg hop test, and self-reported knee function. At 24-months, the acute group also had greater hamstring strength compared to the delayed group. The authors found no differences in return-to-sport at 6-months or return to pre-injury activity level at 24-months.
Based on this study, it may be safe for a patient to undergo an early or delayed ACL reconstruction. The authors anticipated worse self-reported outcomes and increased knee stiffness among patients who underwent an early ACL reconstruction; however, the groups appeared similar in most clinical and functional measures. Despite guidelines to delay an ACL reconstruction until impairments have been resolved, it is likely that current techniques do not contribute to increased risk for knee stiffness. In an acute injury, patients present with a variety of impairments that take time to resolve. If a patient delays surgery to allow for improved range of motion, swelling, and inflammation then the surgery introduces a new wave of trauma and inflammation. In some individuals, it may be beneficial to undergo surgery in the acute phase to mitigate a second wave of inflammation and trauma. Performing the surgery sooner may minimize the amount of time that the knee is exposed to inflammation and the chance of muscle atrophy. We will need to see more studies with other modern surgical approaches to see if these results apply broadly to other ACL surgical techniques. However, despite this limitation, it may be beneficial to discuss with patients the pros and cons of choosing an early ACL reconstruction instead of a delayed procedure.
Questions for Discussion
How does this impact recovery long-term? Does this mean that individuals who undergo early ACLR will be able to meet return-to-sport goals sooner because they are able to resolve impairments more quickly? And if they do, are they at an increased risk for a second injury?
Written by: Kathleen Cummer
Reviewed by: Jeffrey Driban
Which is Better for ACL Surgery: Right Away, Later, or Never?
It appears that this study shows how earlier ACL reconstructive surgery can improve long term recovery. The individuals that had earlier surgery had greater hamstring strength and leg circumference. In theory, according to the results from this study, an individual who has an earlier surgical intervention would be able to return to sport sooner than an athlete who waited for their symptoms, such as swelling, to subside. I do not believe they would be at an increased risk for a second injury compared to the other group because the same protocols would still apply to their return to play. Also, I would assume that if their strength is greater than the group who delayed surgery their risk of re-injury would be lower. This assumption is reliant on the athlete not becoming over zealous and over confident in their recovery too soon, which could lead to re-injury. This article stands in contradiction to the standard practice I have seen for athletes both in the athletic training environment and the physical therapy environment. I have seen athletes performing physical therapy for weeks pre-surgery for ACL tears. This was reasoned to be to limit muscle atrophy and loss of ROM post-surgery, but from reading this summary it seems those beliefs are false. I will definitely investigate both sides of this long time argument further to better understand an ACL pre-surgery protocol because of this insightful article.
Thank you for your comment. Yes, I agree the timing of surgery in this study is contradictory to what we have done historically for these patients, but a novel idea! Outcomes appear to be the same as traditional timing of surgery and may show great promise with more long term studies. I look forward to seeing more outcomes from this surgical change.
This study shows that ACL reconstructive surgery if done on people with acute injuries have better results in recovery. Those who had early on surgery show less signs of atrophy and more strength during range-of-motion. At my clinical rotations a soccer athlete went down on the field, the coaches and I weren’t at the game. The on-field AT suggested a referral to the doctors, and handed the athlete crutches. A couple of days later the athlete was referred and scheduled for operation. Now, it has been two week later his ROM has improved quickly due to treatments and rehab with the PT and AT, but also after reading this article it makes me suggest that because he was referred and operated on early his immfplmation and ROM was reduced and increased at a better rate. I d believe that those who resolve this impairment quickly has a better chance at return-to-play much faster than those who don’t. Now depending on the rehab and if the athlete is consistent with recovery there shouldn’t be any risk of a second injury, but also it can be unavoidable in certain contact sports or landings.
I’m curious how future studies will fair compared to this one. I am also curious if there is a difference in the rate of re-injury between the two groups. It is awesome to me that we do not necessarily have to wait for symptoms to decrease to send patients for surgery. I would love to see future studies and meta-analysis conducted to determine if there is a real clinical significance to these claims! If there is, then we as the medical professionals can further improve our patient outcomes!
In the clinical setting, I have seen patients wait to have an ACL reconstruction and others recieve surgery within 10 days of the injury. I found it pretty interesting that the author found no difference in knee range of motion, knee extension strength, knee laxity, self-reported outcomes, and functional recovery. I did like that the author found that the acute ACL reconstruction group had better thigh circumference, single-leg hop test, and self-reported knee function at 6 months post-surgery. This study may lead us in the right direction towards a protocol stating that patients do not have to wait and there may be a benefit to return to sport that we have not discovered yet.