Article review-
Filbay et al (2017)
Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial.
Filbay, S.R., Roos, E.M., Frobell, R.B., Roemer, F., Ranstam, J., and Lohmander, L.S. (BJSM May 2017)
Summary
5year follow up of a prospective RCT comparing 3 groups
1) Exercise therapy plus early ACLR (Surgery within 10 weeks)- 62 people
2) Exercise therapy with delayed ACLR (Median 867 days to surgery)- 30 people
3) Exercise therapy alone - 29 people
All participants (age 18-35, males 73%) had injured their ACL <4weeks ago; Excluded professional sports people and those less than moderately active.
Outcomes
1. Worse 5year KOOS outcomes were seen in all participants with
-ACL graft rupture (after early or delayed ACLR) or contralateral ACL rupture
-Having at least one non-ACL related knee surgery
-Worse baseline short form mental component score
2. At 5 year follow up, individuals undergoing early ACLR + exercise had a worse KOOS outcome than those undergoing exercise rehab only
3. Worse preoperative KOOS scores in the early ACLR group lead to more knee symptoms at 5 years. This was not the case for individuals treated with exercise therapy plus delayed reconstruction.
4. Early ACLR in people with baseline meniscal or osteochondral injury led to 12-14 point worse KOOS sport/rec score and QOL at 5year follow up compared to early ACLR in people without baseline meniscal/osteochondral injury.
5. Worse baseline KOOS scores are associated with worse knee symptoms, reduced sport/recreation function and decreased QOL at 5year follow-up in the early ACLR group.
6. In the delayed ACLR group, people with baseline meniscal damage demonstrated 14 point better KOOS (pain) score at 5year follow up compared with nil baseline meniscal damage.
Recommendations
1. In people with acute ACL injury and baseline meniscal/osteochondral injury: Better to undertake exercise therapy, with the option of delayed ACLR as required, rather than early ACLR. This may allow better resolution of joint trauma prior to undergoing second trauma (surgery) to the knee. It will also allow the person to gain better pre-operative muscle strength and neuromuscular control.
2. Surgical outcomes are best in patients with less severe pain/symptoms and better pre-op knee function. Patients with a less settled knee post-injury may benefit from postponing surgery and commencing exercise therapy first. This will allow a person to enter surgery with a better KOOS score, which is prognostic for better 5year outcome
Limitations
The group managed with exercise therapy only were the ones who had success with a conservative management program, the ones with ongoing symptomatic instability were analysed as treated in the exercise therapy + delayed ACLR group.