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Going straight to surgery better than undergoing rehabilitation first for anterior cruciate ligament injuries

Published: 30 August 2022

New NIHR-funded research shows initial surgery is more successful and cost effective than undergoing treatment with rehabilitation first, when treating longstanding anterior cruciate ligament injuries.

Results from the ACL SNNAP trial reveal going straight to reconstructive surgery has a better outcome than a programme with rehabilitation first for anterior cruciate ligament (ACL) injury over 18 months.

The multi-centre study, led by researchers at the University of Oxford, is published in The Lancet journal. The findings have significant implications for the long-term outcomes for patients as well as reducing costs for healthcare providers.

Rupture of the ACL is a common knee injury that can have different outcomes for patients. Some recover successfully while others have problems with knee instability that can affect everyday life. The injury mainly affects young and active individuals, with an estimated 30,000 surgical reconstructions performed annually in the UK.

Despite being a common injury, it is still not clear what the best treatment for ACL injury is. With limited evidence on the best treatment, there is no guide to help decision making for patients with long-standing injuries. Treatment is either rehabilitation involving specialised physiotherapy exercises or surgery involving reconstructing the ligament.

David Beard, lead author and Professor of Musculoskeletal and Surgical Science at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) said: “Although there is good evidence from previous (Scandinavian and Dutch) studies that rehab can be effective for newly injured patients, waiting lists in the NHS for assessment (and treatment) often mean that many patients are seen much further down the line and with a longer-standing injury.

“Despite my professional bias toward rehabilitation it became apparent (in my own clinic, and from others) that more longstanding ACL deficient patients did not improve or achieve sufficient knee stability with rehab alone. I was suspicious that these particular patients may be better served by undergoing reconstruction sooner, but a large rigorous trial was needed.”

The study recruited 316 patients from NHS orthopaedic units in the UK between 2017 and 2020. They were randomly assigned to either a surgical reconstruction group or to a group undergoing initial rehabilitation with subsequent surgery. Patients were followed up after 18 months and asked to report any pain, activity levels, secondary issues, satisfaction, and functionality of the knee. The study was run by SITU (the Surgical Intervention Trials Unit), one of the Royal College of Surgeons (Eng) specialist surgical trials units supported by the Rosetree’s Trust, and in collaboration with the Oxford Clinical Trials Research Unit (OCTRU).

The results showed that both groups improved over time. But patients with non-acute ACL injury undergoing immediate surgical reconstruction without any further intervention had substantially better outcomes after 18 months than those undergoing non-surgical management and any subsequent necessary surgery.

The results also showed that patients preferred surgical reconstruction over non-surgical management. The study showed the devastating impact of ACL injury on activity and sport levels and revealed that in both groups, the return to pre-injury level of sport was very low at 18 months.

Professor Andrew Price, co-applicant and Consultant Knee Surgeon, said: “This study has significant implications for how we treat ACL injuries, especially the more longstanding injured patients with ongoing knee instability. Benefit can still be achieved with rehabilitation, and can be offered, but it appears that undergoing expedited reconstructive surgery is the best way forward to stabilise the knee and achieve better function.”

The study was funded by the NIHR’s Health Technology Assessment (HTA) Programme.

Read more about the ACL SNNAP trial.

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