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The optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness
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OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2013;1(5):84 Arthroscopy. 2013 Mar;29(3):556-65. doi: 10.1016/j.arthro.2012.09.005. Epub 2013 Jan 12Exclusive Author Interview
Dr. Chris Servant discusses the optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness.
Eight studies (4 randomized control trials and 4 cohort studies) were included in this analysis which investigated the impact of early versus late surgery on stiffness outcomes of anterior cruciate ligament (ACL) reconstruction. Adverse outcomes of arthrofibrosis, stiffness, or range of motion deficits were reported for a minimum of one year postoperatively in the included studies. The results of the analysis indicated that surgery characterized as either early or delayed did not increase the risk of adverse stiffness outcomes.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
はい = 1
不確実＝0.5
無関係 = 0
いいえ = 0
報告基準評価では、著者が出版物内で試験の方法論的特徴や試験特性を報告する際の透明性を評価します。評価は以下の5つのカテゴリーに分類されます。
4/4
Introduction
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Accessing Data
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Analysing Data
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Results
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Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
Fragility Indexは、重要な所見の解釈を助けるツールで、結果の強さの尺度を提供します。Fragility Indexは、その所見が有意でなくなるために、二項対立の結果に追加する必要がある連続した事象の数を表します。数値が小さいほど弱い所見を表し、数値が大きいほど強い所見を表します。
なぜ今この研究が必要なのですか？
There has been recent interest in the timing of anterior cruciate ligament (ACL) reconstruction following ACL injury, with some advocating that delayed surgery can lead to reduced prevalence of arthrofibrosis and improved postoperative stiffness. Although there has been evidence to support this claim, research has also been undertaken which has found no difference between the early and delayed surgery. Due to these conflicting findings, a synthesis of existing literature was undertaken to determine if there was a significant relationship between the timing of surgery and postoperative stiffness experienced by patients.
主な研究課題は何ですか？
Did delaying ACL reconstruction significantly reduce the incidence of postoperative motion loss and knee stiffness compared to early surgery, measured after a minimum of 12 months postoperatively?
重要な知見は？
- Search strategy concluded with finding four RCTs (3 Level I evidence and 1 Level II evidence) and four cohort studies (all Level II evidence).
- The three Level I studies were analyzed for risk of adverse outcomes (reduced range of motion, arthrofibrosis, stiffness, extension deficit) associated with variable cutoff points for early surgery (2, 3, and 10 weeks), and indicated there were no significant differences in outcome in any of the studies (2 weeks: RR 1.38 (95%CI 0.10-20.16); 3 weeks: RR 0.34 (95%CI 0.04-3.14); 10 weeks: RR 3.81 (95%CI 0.44-33.08).
- Analysis of 7 included studies (1 excluded because it did not report poolable outcomes) indicated there was no significant increase in risk of adverse outcome associated with early or delayed surgery when stratified by different cutoff points for early surgery (1, 2, 3, 10, 12, and 20 weeks).
- A sensitivity analysis considering individual outcomes of arthrofibrosis incidence, extension deficit >3°, and flexion deficit >3° and stratified for different criteria of early surgery observed no clear overall trend.
最も覚えておくべきことは？
There was no increased risk of adverse outcome, with respect to arthrofibrosis, stiffness and ROM deficit, observed associated with early surgery compared to delayed surgery following ACL injury.
それが私の患者ケアにどのように影響するか？
The results of this analysis suggest that there is no increased risk of arthrofibrosis or range of motion deficit between early and delayed ACL reconstruction, provided a modern surgical technique and an accelerated postoperative rehabilitation protocol is implemented. The overall strength of this evidence is debatable, however, considering the nonuniformity in classification of "early" surgery (1 to 20 weeks), as well as the inclusion of a considerable amount of Level II evidence (primarily cohort studies). Future research should be guided by establishing definitive criteria for early versus late surgery and outcomes should be investigated in randomized controlled trials before any conclusive statements can be made.
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