Editorial Title:

Treating ACL Injuries in Young Moderately Active Adults.

Article:

Currently, the clinical indication for anterior cruciate ligament (ACL) reconstruction takes into account both patient related and knee related factors.

In an effort to better identify these factors, Frobell and colleauges performed a randomized clinical trial comparing two treatment strategies for young moderately active patients with a torn ACL. Patients were randomized to ‘acute’ ACL reconstruction (within 10 weeks) or ‘optional delayed’ ACL reconstruction (rehabilitation with the option for delayed surgery).

In 2010, the authors published two year outcomes that reported no difference between the two treatment arms in the primary outcome (knee injury and osteoarthritis outcome score; KOOS) or secondary outcomes of SF-36 and Tegner Activity Scale (TAS).

However, supplementary data provided in an appendix reported 29 subsequent meniscus tears in the ‘optional delayed’ group, and by two years almost 40% of the patients in this group had already crossed over to ACL reconstruction surgery.

In a linked study, Frobell and colleauges report the five year outcomes for the trial. Similar to the two year results, the authors found no significant differences between the two treatment arms in primary (KOOS score) or secondary outcomes (TAS, meniscal surgery, radiogrpahic osteoarthritis).

The trial has shown – at both two year and five year endpoints – that some moderately active patients with a torn ACL but no collateral ligament or extensive meniscal damage can function well with an ACL deficient knee.

However, it is difficult to predict which patients will have symptoms of instability that require surgery. It is argued that surgical decision making should be individualised, taking into consideration the specifics of the particular injury, the individual needs of the patient, and the anticipated demands that the patient will palce on the knee.

Source: BMJ 2013;346:f963.

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