Early versus delayed anterior cruciate ligament reconstruction
Timing of surgery of the anterior cruciate ligamentArthroscopy. 2013 Nov;29(11):1863-71
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Data from 22 articles (10 RCTs) spanning 3,583 patients was systematically reviewed to determine whether delayed anterior cruciate ligament (ACL) reconstruction produced more meniscal and chondral pathologies, contributing to an increased risk of osteoarthritis, when compared to early reconstruction. The analysis of the appropriate literature revealed that substantial variability existed between included studies in terms of study design, methodology, surgical technique involved, and outcome measurements. In particular, the definition of delayed and early intervention was not similar between studies. Eight articles supported early reconstruction, while the majority of the evidence demonstrated no difference in outcome based on the timing of surgery.
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?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Anterior cruciate ligament (ACL) injury has been implicated in the development of osteoarthritis (OA), and the timing of reconstruction (whether early or delayed) plays a role in patient outcomes. Early reconstruction is associated with shorter rehabilitation periods, faster return to sports, and reduced risk of recurring knee injury and subsequent OA development. Delayed reconstruction is associated with optimal restoration of range of motion and strength, while minimizing the risk for arthrofibrosis. Thus, the optimal timing of ACL reconstruction remains controversial.
What was the principal research question?
Does delayed reconstruction of anterior cruciate ligament (ACL) injury result in more meniscal and chondral pathology, contributing to an increased risk of osteoarthritis, when compared to early reconstruction?
What were the important findings?
- Twenty-two articles spanning 3,583 patients were selected for final assessment: 10 randomized controlled trials (1,065 patients), 11 prospective comparative cohort studies (2,456 patients), and 1 prognostic study (62 patients).
- Eight articles demonstrated that early surgery was implicated in superior outcomes. Study design, methodology, surgical technique, and the primary research focus varied greatly between studies. Early surgery in these studies was defined as from 1 to 5 months, while delayed surgery ranged from 3 months to 24 years after surgery.
- Twelve studies revealed no significant differences in clinical outcome as affected by timing of surgery after ACL injury. Five of the 12 primarily focused on the injury-to-surgery interval, while 1 article compared early reconstruction with nonsurgical treatment. Early surgery was defined as from within 48 hours to within 6 months, while delayed surgery ranged from 3 weeks to more than 13 years after injury.
- Seven articles assessed the timing of ACL surgery as a primary objective. 1 of these articles demonstrated that early surgery was superior to delayed surgery as measured with the Tegner and Lysholm scores. The other 6 articles indicated no one intervention superior to the other.
- Three articles compared ACL surgery with conservative interventions and revealed that a growing number of patients (23% to 37%) in the conservatively treated group underwent delayed reconstruction due to unacceptable symptom instability. The number of meniscal injuries requiring surgery was significantly higher in patients undergoing delayed surgery.
- Eleven articles compared the risk for meniscal and chondral pathology between patients who underwent the two different timings of ACL reconstruction. 5 studies indicated an increased risk for subsequent intra-articular injuries when surgery was delay. The remaining 6 found no such correlation.
- Nine studies noted the incidence of radiographic OA and 4 of these studies had a follow-up of at least 10 years. Meunier et al. (longest follow-up) illustrated that delayed ACL reconstruction was associated with a higher rate of radiographic OA compared to early reconstruction (63% compared to 50%). Oiestad et al. indicated that delayed ACL reconstruction had significantly more radiographic signs of OA but there were no differences in symptomatic OA, and evaluation was confounded by the fact that the group with late reconstruction had combined ACL and meniscal and/or chondral injures.
- Two of the 3 midterm studies suggested a positive correlation between longer injury-to surgery interval and development of degenerative changes. 1 study found evidence to support the opposite. The 2 short-term studies similar degenerative changes between the two timings of surgery.
What should I remember most?
There was substantial variability between the 22 included studies in terms of study design, research methodology, surgical technique involved, and outcome measurements. In particular the definition of delayed and early intervention was not similar between studies. However, 8 articles supported early reconstruction while the majority of the evidence demonstrated no difference in outcome between the timings of surgery. 2 studies were inconclusive.
How will this affect the care of my patients?
The evidence presented in this systematic review indicated that there were little to no differences in outcomes concerning the timing of anterior cruciate ligament reconstruction. More high quality evidence with comparable methodology is required to effectively review the data pertaining to the timing of anterior cruciate ligament surgery.
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