Why, When, and in Which Patients Nonoperative Treatment of Anterior Cruciate Ligament Injury Fails: An Exploratory Analysis of the COMPARE Trial
Graaff, Sabine J.A. van der, Duncan E. Meuffels, Sita M.A. Bierma-Zeinstra, Eline M. van Es, Jan A.N. Verhaar, Vincent Eggerding, and Max Reijman. The American Journal of Sports Medicine, (January 2022). https://doi.org/10.1177/03635465211068532.
After trying nonoperative treatments for an anterior cruciate ligament (ACL) injury, people who report knee instability concerns or worsening knee pain or function are more likely to receive an ACL reconstruction than their peers.
Nonoperative treatment of an ACL rupture is a viable option for many patients. However, clinicians lack information about who may eventually opt to discontinue nonoperative care for an ACL reconstruction.
Van der Graaff and colleagues completed a case-control study to investigate why, when, and which patients required surgery following nonoperative treatment for an ACL injury.
The authors used data collected from the COMPARE trial, including the IKDC form, Lysholm questionnaire, and Numeric Rating Scale scores for pain. The trial included people who sustained an acute ACL rupture. Eight-two participants randomly received nonoperative treatment with an optional delayed ACL reconstruction. All participants in the nonoperative group received at least 3 months of supervised physical therapy. After 3 months of structured physical therapy, participants could opt for an ACL reconstruction. The authors recorded the reason for surgery and a participant’s preference for surgery.
Half of the participants who began in the nonoperative group chose to have an ACL reconstruction during the 2-year follow-up period. People who decided to have an ACL reconstruction were younger, had a lower body mass index, and a higher level of physical activity pre-injury. Over 40% of people opted for an ACL reconstruction between 3 to 6 months after inclusion. Over 90% of participants reported knee instability concerns as the primary reason for an ACL reconstruction. Interestingly, 12 out of 41 participants who opted for reconstruction surgery stated a strong preference for surgery. Participants who opted for surgery tended to report more knee symptoms before their surgery than those who never opted for an ACL reconstruction.
Overall, this study clarifies who is more likely to opt for an ACL reconstruction after trying nonoperative treatments for 3 months. First, younger and more physically active patients may be more likely to decide on surgery. These findings highlight the importance of involving these patients in deciding whether to do an ACL reconstruction now or try nonoperative treatments. Second, almost everyone who opted for surgery reported experiencing knee instability, and on average, these participants tended to report worsening pain and function. Unfortunately, we don’t know how many people who never opted for surgery thought they had knee instability concerns. Regardless, the results suggest it may be helpful to monitor these patient-reported outcomes to inform treatment decisions. Finally, it’s interesting to note that only 12 out 41 participants had a strong preference for surgery, which may suggest that most of these participants felt like they lacked a choice because of their lingering knee symptoms.
Clinicians should be aware that younger and more active patients may be more likely to decide on an ACL reconstruction even after nonoperative treatments. Furthermore, if patients completing nonoperative treatments after an ACL injury report knee instability concerns or worsening knee pain or function, it may be beneficial to discuss the pros and cons of an ACL reconstruction.
Questions for Discussion
How soon after ACL injury do you discuss surgery as a potential outcome with your patients? Do you also discuss the potential for patients to be treated nonoperatively?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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