Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: A living systematic review and meta-analysis

We are conducting a living systematic review and meta-analysis that compares primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries (ACL). Here we share the status, and in future, results of our high-quality systematic review and meta-analysis.

A living systematic review is one that is regularly updated. Regular systematic reviews, where the search of the literature is done at a certain time point in time, lose their value as new primary studies are published. 25 percent of the published systematic reviews are obsolete within 2 years and 50 percent within 5 years. That is why we have committed to updating our review every year after publication. This enables us to provide up-to-date results to inform patients and health-care providers without delay.

What are ACL injuries?

The ACL is a ligament in the knee and is important for knee joint stability. Injury to the ACL is one of the most common and serious knee injuries, with an annual incidence of 0.03% in the general population and 0.15% to 3.67% in professional athletes with significant individual and socioeconomic impact. For people with an ACL tear, questions arise for them such as "Will I be able to return to my usual sport or job?", "What does this mean for my future performance?", "What longer-term health impairments will I possibly face after a few years?".

A key question people with an ACL tear ask themselves is "What is the best treatment for me?"

How are ACL injuries best treated?

Surgery is commonly performed as a primary treatment for ACL tear, yet this type of surgery was developed without questioning its necessity or benefit over other management approaches. There has been controversial debate for many years as to whether treatment should first be conservative (i.e. non-surgical) before surgery is performed if needed, or whether treatment should be primarily surgical. Surgery is costly and carries risks such as infection, donor site morbidity, arthrofibrosis and that could easily be prevented if surgical management is not required.

There is a paucity of high-quality evidence based on randomised, controlled trials. Accordingly, the evidence in previous reviews, could not provide clear advice whether one approach (e.g. primary conservative management first) vs. the other (e.g. primary reconstruction surgery first) is better.

Aim of the review

The aim of this work is to examine the question of a whether primarily surgical or a primarily rehabilitative (conservative, non-surgical) treatment strategy after an ACL rupture leads to better patient outcomes, such as self-reported knee function, rate of knee osteoarthritis or meniscal damage. Since the evidence base is still developing, potentially not definitive for all outcomes, and some trials (e.g. the Oxford/NDORMS ACL SNNAP trial) are still ongoing, we will conduct this as a "living systematic review".

Status of the review

The study was published in the British Journal of Sports Medicine in August 2022 (LINK) with the database search up to date in June 2022. Current data and statistical code are available in an online repository (LINK). The current clinical recommendation based on these finding is that management of ACL tears should be primarily rehabilitative.

The review plan was submitted to PROSPERO on 22/05/2021 and approved on 21/06/2021.

Collaborators

Tobias Saueressig, PT, Dipl.-Vw., Physio Meets Science GmbH, Leimen, Germany.

Dr Patrick J Owen, PhD; Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Geelong VIC 3220, Australia.

Frank Diemer, PT, M Sc., DIGOTOR GbR, Austraße 30, 74336 Brackenheim, Germany.

Jochen Zebisch, Sports Scientist M.A., Clinical Exercise Physiologist, Leimen, Physio Meets Science GmbH, Germany.

Max Herbst, PT, M Sc., Physio Meets Science GmbH, Leimen, Germany.

Nora Steglich, PT, M Sc., Hochschule für Gesundheit (University of Applied Sciences), Department of Applied Health Sciences, Division of Physiotherapy, Bochum, Germany.

Dr Tobias Braun, Hochschule für Gesundheit (University of Applied Sciences), Department of Applied Health Sciences, Division of Physiotherapy, Bochum, Germany.

Dr. Wolfgang Zinser, OrthoExpert, Fohnsdorf, Austria.

Prof Daniel L Belavy, PhD; Hochschule für Gesundheit (University of Applied Sciences), Department of Applied Health Sciences, Division of Physiotherapy, Germany.

Funding

None

Further Information

Further information about the project can be obtained from Prof. Dr. Daniel Belavy (HS Gesundheit) and Tobias Saueressig (Physio Meets Science).