Starting non-operative treatment in ACL injuries: no need to be afraid of more meniscal procedures

Keywords: anterior cruciate ligament injury, meniscal tear, physical therapy

Although recent evidence supports starting non-operative treatment in anterior cruciate ligament (ACL) injuries, orthopaedic surgeons are uncertain in doing so. Will starting non-operative treatment lead to an increase in meniscal tears? This idea is often used as an argument to choose for an early ACL reconstruction. Treating patients is based on scientific evidence, mainly acquired on a group level. This blog is based on a recent study that has given us more high-quality evidence to consider bespoke treatment for the ACL injured patient (1). 

Why is this study important?

About 40 to 60 percent of the patients with an ACL rupture have an associated meniscal tear. A meniscal injury increases the risk for osteoarthritis, can lead to additional complaints such as a locking knee and pain, and often requires surgical intervention. It is thought that persistent instability in the ACL deficient knee leads to more meniscal injuries. Surgeons choose to perform an early ACL reconstruction to reduce instability and hopefully reduce the risk of new meniscal injury. The existing evidence is too weak to conclude that early surgery in ACL ruptures indeed protects for additional meniscal injuries. The available evidence is not from randomised controlled trials (RCT) and is therefore not optimal to address this question. Therefore, we evaluated the risk of additional new meniscal tears in our RCT.

How did the study go about this?

We performed a secondary analysis on data from the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation (COMPARE) trial in which patients with an acute ACL rupture were randomised to early ACL reconstruction (surgery within 6 weeks after randomisation) or rehabilitation therapy with optional delayed ACL reconstruction (at least three months of physical therapy). In the COMPARE trial 167 patients were included and randomised, 85 in the early ACL reconstruction group and 82 in the rehabilitation therapy plus optional delayed ACL reconstruction group. Of the latter, 41 patients (50%) received a delayed ACL reconstruction during two-year follow-up. In the current paper we evaluated whether a meniscal procedure was performed during the two-year follow-up period (yes or no).

What did the study find?

During the two-year follow-up 25 patients in the early ACL reconstruction group (29%, 25/85 patients) had an additional meniscal procedure. In the rehabilitation plus optional delayed ACL reconstruction group 17 patients (21%, 17/82 patients) had a meniscal procedure in the ACL injured knee. Patients that had initial rehabilitation therapy had no more meniscal procedures compared to patients that had early ACL reconstruction (risk ratio 0.67, 95% confidence interval 0.40 to 1.12; p-value 0.12).

What are the key take-home points?

In this study the number of meniscal procedures in patients with an ACL rupture who were treated with rehabilitation therapy and optional delayed ACL reconstruction does not differ from patients who received early ACL reconstruction. Based on the results of this study on data of a high quality RCT, clinicians can safely start non-operative treatment in ACL injured patients without the risk of more meniscal procedures. However, there should still be a focus on preventing meniscal lesions and awareness of secondary risk of osteoarthritis.

Authors and affiliations: 

Sabine van der Graaff, MD, Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands

Max Reijman, PhD, Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands

Duncan Meuffels, MD, PhD, Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands

References:

  1. van der Graaff SJA, Reijman M, van Es EM, et alMeniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trialBritish Journal of Sports Medicine Published Online First: 22 September 2022. doi: 10.1136/bjsports-2021-105235

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