Timing of Anterior Cruciate Ligament Repair: Now, Later, or Never?

Thomas L. Schwenk, MD

Authors and Disclosures

Posted: 09/22/2010; Journal Watch © Massachusetts Medical Society

Abstract and Introduction

Abstract

Functional outcomes were similar for immediate reconstruction and optional later reconstruction.

Introduction

Anterior cruciate ligament (ACL) tears can lead to joint instability and impaired knee function. Standard treatment is reconstruction, usually using patellar or hamstring tendon autograft; 200,000 such operations are performed annually in the U.S., despite no evidence of benefit beyond that of rehabilitation therapy.

In a Swedish trial of immediate versus delayed reconstruction, 121 athletically active adults (mean age, 26) with total acute ACL tears received standardized structured rehabilitation. Participants were randomized to reconstruction within 10 weeks of injury or to delayed reconstruction, with the option of surgery in the presence of continued serious instability and dysfunction.

At 2 years, roughly a third of patients in the delayed group had undergone ACL reconstruction, usually after 6 months of initial rehabilitation. On standardized testing, knee stability was significantly better in the early reconstruction group than in the delayed group; however, no between-group differences were noted in several functional and quality-of-life assessments specific to knee disability. Notably, most patients in both groups also underwent meniscal repair at some point during the study.

Comment

Elite athletes with ACL tears who perform intense cutting and pivoting maneuvers usually will need early ACL reconstruction, but nonelite athletes might do well without reconstruction. An editorialist makes an additional point: "Ultimately, the most important predictor of the long-term outcome may not be instability due to ACL deficiency but rather the presence of articular-cartilage or meniscal lesions, which may lead to premature arthritis."