Is surgical intervention superior to conservative (nonsurgical) intervention in the treatment of anterior cruciate ligament (ACL) injuries?
TYPE OF REVIEW
A Cochrane intervention review to assess the effects of surgical versus conservative interventions for treating ACL injuries.
RELEVANCE FOR NURSING
Rupture of the ACL is a common injury in young, physically active people. It often results in an unbalanced knee, which increases the risk of further knee damage. ACL injuries in active, athletic people are often treated surgically. Other forms of treatment include conservative (nonsurgical) interventions such as a progressive rehabilitation program featuring exercises aimed at improving strength and balance.
CHARACTERISTICS OF THE EVIDENCE
After conducting a review of the literature, looking for randomized controlled trials comparing the use of surgical and conservative interventions in participants with an ACL rupture, the authors identified one study reporting results for 121 young, active adults who had an ACL injury in the preceding four weeks. The study compared surgery (ACL reconstruction followed by structured rehabilitation) with conservative treatment (structured rehabilitation alone).
Results showed that there was no difference between surgery and conservative treatment in patient-reported knee scores at two and five years. Results failed to report the number of participants in each group who had any type of serious or nonserious complications. Serious events in the surgery group were predominantly surgery related, while those in the conservative-treatment group were predominantly knee instability. There were also incomplete data for participants with treatment failure, including subsequent surgery.
Complications included three cases of graft rupture in the surgery group and several cases of unstable knees in the conservative-treatment group. Twenty-three of the 59 participants in the conservative-treatment group (39%) had either reconstruction of the ACL or repair of a meniscus tear within two years, and 30 (51%) underwent surgery within five years. There was some evidence that similar numbers of participants in the two groups had surgical treatment of knee meniscal injuries at five years. There was very low-quality evidence that more participants in the surgery group had damage to the knee, which could mean that they were at greater risk for developing osteoarthritis. The quality of the evidence was limited by the fact that data came from only one study. The study was also at high risk of bias because the clinicians and participants were not blinded to treatment.
BEST PRACTICE RECOMMENDATIONS
The authors found no difference between surgery and conservative treatment in the patient-reported outcomes of knee function at two years and five years in young, active adults treated for acute ACL injury. However, many participants with an ACL rupture had unstable knees after structured rehabilitation and opted to have surgery later on. There is currently insufficient evidence to recommend either rehabilitation or surgery for treatment of ACL injuries.
Further randomized controlled trials comparing surgery with conservative treatment should not only assess and report outcomes of importance to patients with ACL rupture (such as subjective knee function, quality of life, effects on daily activities, and return to activity and sports), they should also consider factors such as crossover; standardization of interventions; and treatment preferences that create additional challenges in the design, conduct, and interpretation of these types of trials.
Monk AP, et al. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev