Acute Anterior Cruciate Ligament Rupture: Repair or Reconstruction?
Hoogeslag RAG, Brouwer RW, Boer BC, de Vries AJ, and Huis in ‘t Veld H. Am J Sports Med. 2019. [Epub Ahead of Print].
Take Home Message: People who receive a dynamic augmented anterior cruciate ligament (ACL) repair have similar outcomes to those who receive an ACL reconstruction during the first 2 years after surgery.
Many clinicians have discussed the pros and cons of a surgical reconstruction or conservative care for an anterior cruciate ligament (ACL) rupture. In recent years, there has also been a renewed interest in re-assessing suture repair of a ruptured ACL. Therefore, Hoogeslag and colleagues completed a randomized trial to examine patient-reported, clinical, and radiological outcomes among young adults receiving a dynamic augmented ACL repair or ACL reconstruction.
The authors recruited people between 18 and 30 years of age, with a confirmed primary ACL rupture, with a Tegner Activity Scale score of 5 or more, and without concomitant injuries. A total of 48 participants randomly received either a dynamic augmented ACL repair or an ACL reconstruction. Following surgery, all participants received similarly structured rehabilitation. Participants completed evaluations at baseline, and then at 3-, 6-, 9-, 12-, and 24-months post-surgery. Outcomes were assessed with a physical examination, the International Knee Documentation Committee 2000 (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner score, and a visual analog scale to assess patient satisfaction. Overall, during the 2-year follow-up period, there was no difference between the augmented ACL repair group and the ACL reconstruction group. There was a trend that the repair group had fewer re-ruptures (repair: 9%, reconstruction: 19%) but more surgeries for reasons other than re-rupture (repair: 21%, reconstruction 14%; e.g., residual synovitis, extension deficit, cyclops lesions).
The study should interest clinicians as the authors demonstrate that people who receive a dynamic augmented ACL repair have similar outcomes to those who receive an ACL reconstruction during the first 2 years following surgery. These findings may be beneficial for patients because an augmented ACL repair is less traumatic than an ACL reconstruction and could lead to better outcomes. However, investigators need to assess outcomes beyond 2 years because 2 years may be insufficient to detect degenerative changes in the joint. Therefore, future research with longer follow-up periods would be preferable. One point of concern though was the possible trend of more second surgeries for reasons other than a re-rupture in the augmented ACL repair group. These adverse events are another variable that warrants further investigation. In the meantime, clinicians should be aware that in the short-term, augmented ACL repair does not differ greatly from ACL reconstruction and may be an option for some patients. Both an understanding of these findings and keeping abreast with future research in this area will allow clinicians to better educate and counsel their patients.
Questions for Discussion: What has your experience been with patients who have undergone augmented ACL repair? Have you seen any anecdotal evidence to either support or rebuke the findings of this study?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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