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Author Spotlight: Implementing the Enhanced Recovery After Surgery Concept in Rehabilitation Following Anterior Cruciate Ligament Reconstruction

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Operative Versus Conservative Treatment of Anterior Cruciate Ligament Rupture

Matthias Krause¹, Fabian Freudenthaler, Karl-Heinz Frosch

¹Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf; Department of General Orthopedics and Center for Endoprosthetics, Schön Klinik Hamburg Eilbek; Department of Sports Orthopedics, University Hospital rechts der Isar, Technical University of Munich (TUM); Department of Orthopedics and Trauma Surgery, Martin-Luther-Hospital, Berlin; Department of Trauma and Reconstructive Surgery With Division of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Klinik St. Georg, Hamburg.

Deutsches Arzteblatt International

|February 16, 2019

Abstract

Background:

Anterior cruciate ligament (ACL) rupture is a serious injury in patients who are typically young and athletically active, with potential long-term complica- tions including functional limitation, posttraumatic osteoarthritis of the knee, and impaired quality of life. ACL reconstruction is now considered the gold standard of treatment for regaining stability and improving knee function. Conservative treatment is an alternative.

Methods:

To compare operative and conservative treatment, we reviewed pertinent publications retrieved by a systematic search in Ovid MEDLINE, the Cochrane Database of Systematic Reviews, and other databases. PROSPERO registration of the study protocol: CRD42017060462 on 31 March 2017.

Results:

13 publications concerning a total of 1246 patients were included in the analysis; only two were reports of randomized controlled trials (RCTs). In one of the RCTs, ACL reconstruction was found to yield better functional outcomes than con- servative management. The other RCT did not reveal any harm from initial conser- vative management, although the conservative-to-operative crossover rate in this trial was 51%. The functional outcomes were heterogeneous. In six observational studies, knee function was significantly better after surgery; in seven others, it was not. Five out of nine analyses in which knee-joint stability was restored after surgery showed superior functional outcomes after ACL reconstruction compared to conser- vative management. Three studies in which no satisfactory postoperative knee-joint stability was found did not show any functional difference between surgery and conservative management.

Conclusion:

On the basis of RCTs published to date, it cannot be definitively con- cluded whether surgery or conservative (expectant) management of ACL rupture yields a better functional outcome. There is a trend in observational studies toward better functional outcomes after ACL reconstruction. As an average across studies, conservative treatment fails in 17.5% (± 15.5%) of patients.

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