Treatment for Acute
Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial

Frobell RB,
Roos, HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS. BMJ. 2013, 346:
f232.  doi: 10.1136/bmj.f232 

cruciate ligament (ACL) tears occur frequently in athletics, and carry with it
the potential risk of osteoarthritis (OA). 
ACL injury is often treated with surgical reconstruction in an effort to
reduce the risk of secondary injuries and progression to OA.  Some people insist that an ACL reconstruction
is needed as quickly as possible; however, the timing of surgery or the lack of
surgery on longer-term outcomes has yet to be determined.  The purpose of this extended follow-up of a randomizedclinical trial (link to original article) was to
compare the outcomes of patients that had immediate ACL surgery versus those
that had optional delayed ACL surgery. 
One hundred twenty patients (ages 18 – 35 years) all underwent similar
rehabilitation, but were randomized to early (n = 61) or optional delayed (n =
59) ACL reconstruction surgery groups.  Of
those that were assigned to the optional delayed group, 51% (n = 30) opted for
ACL surgery.  At the 5 year follow-up,
there were no group differences in patient-reported outcomes (i.e., knee specific symptoms/function,
general health, Tegner activity scale), radiographic OA, or need for meniscal surgery.  Mechanical knee stability (i.e., Lachman and
pivot shift) was significantly better in knees assigned to early ACL
surgery.  Within ACL reconstructed knees,
more patellofemoral radiographic OA was found in knees that received the
patellar tendon in comparison to the hamstring tendon autograft procedures. Overall,
51% of participants underwent meniscal surgery during the 5-year follow-up and
24% of participants had radiographic knee OA.

This is the
first randomized clinical trial to explore this important question and it appears
that ACL surgery timing does not really seem to affect any major outcome at a 5
year follow-up.  It is interesting to see
that early ACL surgery does not necessarily provide better outcomes.  Furthermore, of those assigned to the
optional delayed surgery group, about 50% never needed surgery.  There were no differences between those
surgically repaired early, late, or with rehabilitation alone.  This may emphasize the importance of the
rehabilitation process, since all patients underwent similar rehabilitation
processes.  The study controlled for
meniscal status, but did not report any correlations between meniscal status
and outcomes, which would be interesting to see.  Based on this study it may be safe to delay
the ACL reconstruction to determine if the patient can tolerate conservative
management through rehabilitation and successfully return to play after an ACL
injury.  I am extremely interested in
following these same patients out to a later time point.  But ultimately, an ACL tear may not
necessitate surgery, and rehabilitation should be considered as a possible
option.  Has anyone had any success with
conservative management of ACL injuries?   

Written by:
Nicole Cattano
Reviewed by: Jeffrey


Original Paper with 2-year Follow-up:

Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (Clinical research ed.), 346 PMID: 23349407