Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomized controlled trial

Reijman M, Eggerding V, van Es E, van Arkel E, van den Brand I, van Linge J, Zijl J, Waarsing E, Bierma-Zeinstra S, & Meuffels D. BMJ. 2021 372:n375. Online ahead of print March 9, 2021. doi: 10.1136/bmj.n375.
Full Text Freely Available

ACL reconstruction for all is not cost-effective after ACL rupture

Eggerding V, Meuffels DE, van Es E, van Arkel E, van den Brand I, van Linge J, Zijl J, Bierma-Zeinstra S, & Koopmanschap. BMJ. 2021; 0:1-5. Online ahead of print February 14, 2021. doi: :10.1136/bjsports-2020-102564.
Full Text Freely Available

Take-Home Message

Half of patients may not need an anterior cruciate ligament (ACL) reconstruction; however, we need strategies to identify these people. Patients who undergo early ACL reconstruction may report slightly better outcomes at certain time points. However, an early ACL reconstruction is not cost-effective, and people who succeed with conservative care may have the best outcomes.

Background

Often, a patient will seek out surgery to restore function and limit long-term disability after an ACL injury. However, investigators found that someone receiving an early ACL reconstruction has similar outcomes up to 5 years after an injury than someone treated with rehabilitation and optional delayed ACL reconstruction. Confirming these findings with a new clinical trial may help encourage clinicians to change their clinical practice.

Study Goal

The investigators of the COMPARE randomized controlled trial compared outcomes and cost-effectiveness between early ACL reconstruction or conservative rehabilitation plus optional reconstruction.

Methods

The investigators randomly assigned patients in the Netherlands who ruptured their ACL to either early ACL reconstruction or rehabilitation with optional reconstruction pending instability issues. The early ACL reconstruction group had surgery within 6 weeks. In contrast, the conservative care group received rehabilitation for at least 3 months. The investigators assessed participants every 3 months for a year and then followed up again at 2 years. Participants completed various patient-reported outcomes (e.g., International Knee Documentation Committee Scores [IKDC], Knee Injury Osteoarhtirits Outcomes Scores, Lysholm Score, Instability, Pain, Satisfaction). The investigators calculated cost-effectiveness based on medical (e.g., imaging, surgery, rehabilitation, outpatient visits) and non-medical costs (e.g., productivity costs related to paid work, travel costs to and from care). These costs were put into perspective based on gains in quality of life (quality-adjusted life year).

Results

Half of the people initially receiving rehabilitation underwent an ACL reconstruction within 2 years because they experienced giving way and rotational instability. Participants in both groups improved in IKDC scores. The conservative group had better outcomes with IKDC at 3 months. However, the early ACL reconstruction group had better outcomes with IKDC at 9, 12, and 24 months. The early ACL reconstruction group also had better sport and quality-of-life scores at the 2-year follow-up.

The authors also reported that the early ACL reconstruction group had higher medical and non-medical costs. They also noted that the early ACL reconstruction might not be cost-effective because the improvement in quality-adjusted life years was small relative to conservative care. The researchers also looked at those who had delayed surgery and no surgery at all. They found that people who completed rehabilitation alone had the highest quality of life and lowest costs. In contrast, participants that failed the conservative route and opted for surgery had the worst quality of life and highest costs.

Viewpoints

The authors found that half of people may not need an ACL reconstruction. However, this study highlights the need for screening strategies to identify who may need an early ACL reconstruction and who may succeed with rehabilitation only. The high costs associated with surgical treatment were reported to not be cost-effective for the minor improvements in quality of life seen after a reconstruction. The authors acknowledged that while they observed statistically significant differences in patient-reported outcomes at specific time points, these slight differences may not be clinically meaningful. These findings expand on the original trial results because the new trial included participants that, on average, were 5 years older (31 vs. 26 years) and less competitive (more recreational sports than competitive sports participation) than people in the KANON trial.

Clinical Implications

Patient profiling and an individualized approach to treatment selection may provide the best outcomes after an ACL injury. Clinicians should discuss the pros and cons of early ACL reconstruction vs. rehabilitation with an optional delayed ACL reconstruction.

Questions for Discussion

Are there any criteria you look for to determine if someone is a good candidate for conservative care after an ACL tear? What are your thoughts about whether patients in the United States may ever opt for no surgery?

Early ACL Reconstruction May Help Protect the Meniscus After an ACL Rupture
Who Benefits from Early or Delayed ACL Reconstruction
ACL Reconstruction: Is Timing Everything?

Written by: Nicole M. Cattano
Reviewed by: Jeffrey Driban

Shannon Brown on May 25, 2021 at 2:08 am

It seems that with conservative care, IKDC scores were better at 3 months in comparison to the early ACL reconstruction group. This makes sense seeing that the early ACL reconstruction group is only 3 months post-op and they likely have less function and more symptoms. Therefore, a good candidate for conservative care may be an athlete looking to continue out their season. Other candidates that may be good for conservative care are those whose sport involves single line, straight line activities that don’t cause a lot of torque, twisting, and transverse plane motions. Further, those who are skeletally immature may benefit from conservative care since their growth plates are not fully closed and surgical management of an ACL may disrupt or impair growth of the tibia or femur. Lastly, patients who lack the financial means to pay for surgical management or those who are looking to be more cost-effective may opt-out of ACL surgery.
ACL surgery is a long, daunting process. It is painful, frustrating, and even mentally taxing. However, many patients that do not get surgical management complain of instability and giving way. The study stated that 50% of patients that received conservative care opted for delayed ACL reconstruction, which shows that patients were not satisfied with the results of conservative care. As someone who has undergone not one but two ACL reconstructions, I would advocate for surgical intervention. For my second ACL tear, I did not get surgery for nearly a year and a half. During this time I had great instability and fear when walking over slippery or uneven surfaces. Further, my delayed surgery resulted in both my meniscus being torn. I think that it is something noteworthy to mention: ACL reconstruction can help preserve the meniscus. However, I do believe it is ultimately up to the patient to decide whether they want to undergo surgery. Not everyone needs it, and if this is the case why spend the extra money and time to go through a long, painful process.

1 Comment

Shannon Brown on May 25, 2021 at 2:08 am

It seems that with conservative care, IKDC scores were better at 3 months in comparison to the early ACL reconstruction group. This makes sense seeing that the early ACL reconstruction group is only 3 months post-op and they likely have less function and more symptoms. Therefore, a good candidate for conservative care may be an athlete looking to continue out their season. Other candidates that may be good for conservative care are those whose sport involves single line, straight line activities that don’t cause a lot of torque, twisting, and transverse plane motions. Further, those who are skeletally immature may benefit from conservative care since their growth plates are not fully closed and surgical management of an ACL may disrupt or impair growth of the tibia or femur. Lastly, patients who lack the financial means to pay for surgical management or those who are looking to be more cost-effective may opt-out of ACL surgery.
ACL surgery is a long, daunting process. It is painful, frustrating, and even mentally taxing. However, many patients that do not get surgical management complain of instability and giving way. The study stated that 50% of patients that received conservative care opted for delayed ACL reconstruction, which shows that patients were not satisfied with the results of conservative care. As someone who has undergone not one but two ACL reconstructions, I would advocate for surgical intervention. For my second ACL tear, I did not get surgery for nearly a year and a half. During this time I had great instability and fear when walking over slippery or uneven surfaces. Further, my delayed surgery resulted in both my meniscus being torn. I think that it is something noteworthy to mention: ACL reconstruction can help preserve the meniscus. However, I do believe it is ultimately up to the patient to decide whether they want to undergo surgery. Not everyone needs it, and if this is the case why spend the extra money and time to go through a long, painful process.

Costs and Timing of Anterior Cruciate Ligament Reconstruction