Top

European Journal of Orthopaedic Surgery & Traumatology

Published in:

Open Access 01-08-2019 | Original Article • KNEE - ARTHROPLASTY

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

Authors: D. Ferguson, A. Palmer, S. Khan, U. Oduoza, H. Atkinson

Published in: European Journal of Orthopaedic Surgery & Traumatology | Issue 6/2019

Abstract

Background

Anterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort.

Methods

A systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist.

Results

A statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias.

Conclusions

Although there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry may help to provide clearer guidance.

Available only for authorised users

Majewski M, Susanne H, Klaus S (2006) Epidemiology of athletic knee injuries: a 10-year study. Knee 13:184–188. https://doi.org/10.1016/j.knee.2006.01.005 CrossRefPubMed

Jameson SS, Dowen D, James P et al (2012) Complications following anterior cruciate ligament reconstruction in the English NHS. Knee 19:14–19. https://doi.org/10.1016/j.knee.2010.11.011 CrossRefPubMed

Janssen KW, Orchard JW, Driscoll TR, van Mechelen W (2012) High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 22:495–501. https://doi.org/10.1111/j.1600-0838.2010.01253.x CrossRefPubMed

Moses B, Orchard J, Orchard J (2012) Systematic review: annual incidence of ACL injury and surgery in various populations. Res Sports Med 20:157–179. https://doi.org/10.1080/15438627.2012.680633 CrossRefPubMed

Chambat P, Guier C, Sonnery-Cottet B et al (2013) The evolution of ACL reconstruction over the last fifty years. Int Orthop 37:181–186. https://doi.org/10.1007/s00264-012-1759-3 CrossRefPubMedPubMedCentral

Herbst E, Hoser C, Gföller P et al (2017) Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:569–577. https://doi.org/10.1007/s00167-016-4291-y CrossRefPubMed

Walden M, Hagglund M, Magnusson H, Ekstrand J (2016) ACL injuries in men’s professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65 of players still play at the top level 3 years after ACL rupture. Br J Sports Med 50:744–750CrossRefPubMed

Sherman OH, Banffy MB (2004) Anterior cruciate ligament reconstruction: which graft is best? Arthrosc J Arthrosc Relat Surg 20:974–980. https://doi.org/10.1016/j.arthro.2004.08.001 CrossRef

Biau DJ, Tournoux C, Katsahian S et al (2006) Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ 332:995–1001. https://doi.org/10.1136/bmj.38784.384109.2F CrossRefPubMedPubMedCentral

10.

Desai N, Björnsson H, Musahl V et al (2014) Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22:1009–1023. https://doi.org/10.1007/s00167-013-2811-6 CrossRefPubMed

11.

Prodromos CC, Fu FH, Howell SM et al (2008) Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest. J Am Acad Orthop Surg 16:376–384CrossRefPubMed

12.

Zaffagnini S, Grassi A, Serra M, Marcacci M (2015) Return to sport after ACL reconstruction: how, when and why? A narrative review of current evidence. Joints 3:25–30. https://doi.org/10.11138/jts/2015.3.1.025 CrossRefPubMedPubMedCentral

13.

Wright RW, Fetzer GB (2007) Bracing after ACL Reconstruction—a systematic review. Clin Orthop Relat Res 455:162–168. https://doi.org/10.1097/BLO.0b013e31802c9360 CrossRefPubMed

14.

Anderson MJ, Browning WM, Urband CE et al (2016) A systematic summary of systematic reviews on the topic of the anterior cruciate ligament. Orthop J Sports Med 4:232596711663407. https://doi.org/10.1177/2325967116634074 CrossRef

15.

Shelbourne KD, Patel DV (1995) Timing of surgery in anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthrosc 3:148–156. https://doi.org/10.1007/BF01565474 CrossRefPubMed

16.

Smith TO, Davies L, Hing CB (2010) Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 18:304–311. https://doi.org/10.1007/s00167-009-0965-z CrossRefPubMed

17.

Andernord D, Karlsson JJ, Musahl V et al (2013) Timing of surgery of the anterior cruciate ligament. Arthroscopy 29:1863–1871. https://doi.org/10.1016/j.arthro.2013.07.270 CrossRefPubMed

18.

Barry M, Thomas R, Rees A et al (1995) Effect of ACL reconstruction on meniscal and chondral lesions in the chronic anterior cruciate deficient knee. Knee 2:201–205. https://doi.org/10.1016/0968-0160(96)00008-7 CrossRef

19.

Granan L-P, Bahr R, Lie SA, Engebretsen L (2009) Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the Norwegian National Knee Ligament Registry. Am J Sports Med 37:955–961. https://doi.org/10.1177/0363546508330136 CrossRefPubMed

20.

Lohmander LS, Englund PM, Dahl LL, Roos EM (2007) The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med 35:1756–1769. https://doi.org/10.1177/0363546507307396 CrossRefPubMed

21.

Englund M, Lohmander LS (2004) Risk factors for symptomatic knee osteoarthritis fifteen to twenty-two years after meniscectomy. Arthritis Rheum 50:2811–2819. https://doi.org/10.1002/art.20489 CrossRefPubMed

22.

Mather RC 3rd, Hettrich CM, Dunn WR et al (2014) Cost-effectiveness analysis of early reconstruction versus rehabilitation and delayed reconstruction for anterior cruciate ligament tears. Am J Sports Med 42:1583–1591CrossRefPubMedPubMedCentral

23.

Eriksson K, von Essen C, Barenius B (2016) Acute ACL surgery decreases first year socio economic costs compared to delayed reconstruction. Orthop J Sports Med 4:2325967116S0002. https://doi.org/10.1177/2325967116S00026 CrossRef

24.

Frobell RB, Roos EM, Roos HP et al (2010) A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 363:331–342. https://doi.org/10.1056/NEJMoa0907797 CrossRefPubMed

25.

Frobell RB, Roos HP, Roos EM et al (2013) Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 346:f232. https://doi.org/10.1136/bmj.f232 CrossRefPubMedPubMedCentral

26.

Raviraj A, Anand A, Kodikal G et al (2010) A comparison of early and delayed arthroscopically-assisted reconstruction of the anterior cruciate ligament using hamstring autograft. J Bone Joint Surg Br 92:521–526. https://doi.org/10.1302/0301-620X.92B4.22973 CrossRefPubMed

27.

Li B, Bai L, Fu Y et al (2012) Effect of timing of surgery in partially injured ACLs. Orthopedics 35:408–412CrossRefPubMed

28.

Manandhar RR, Chandrashekhar K, Kumaraswamy V et al (2017) Functional outcome of an early anterior cruciate ligament reconstruction in comparison to delayed: are we waiting in vain? J Clin Orthop Trauma. https://doi.org/10.1016/j.jcot.2017.03.001 CrossRefPubMedPubMedCentral

29.

Hur C-I, Song E-K, Kim S-K et al (2017) Early anterior cruciate ligament reconstruction can save meniscus without any complications. Indian J Orthop 51:168–173CrossRefPubMedPubMedCentral

30.

Karuppiah SV, Majeed H, Sigamoney K et al (2016) Failure of meniscal repair association with late anterior cruciate ligament reconstruction. J Orthop 13:106–109CrossRefPubMed

31.

Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700. https://doi.org/10.1136/bmj.b2700 CrossRefPubMedPubMedCentral

32.

Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52:377–384. https://doi.org/10.1136/jech.52.6.377 CrossRefPubMedPubMedCentral

33.

Deeks JJ, Dinnes J, D’Amico R et al (2003) Evaluating non-randomised intervention studies. Health Technol Assess 7(iii–x):1–173

34.

Eriksson K, Barenius B (2016) Acute vs delayed ACL reconstruction. Early differences and preliminary two year results. Orthop J Sports Med 4:2325967116S0000. https://doi.org/10.1016/j.jcot.2017.03.001 CrossRef

35.

Irrgang JJ, Anderson AF, Boland AL et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29:600–613. https://doi.org/10.1177/0363546506288855 CrossRefPubMed

36.

Bottoni CR, Liddell TR, Trainor TJ et al (2008) Postoperative range of motion following anterior cruciate ligament reconstruction using autograft hamstrings. Am J Sports Med 36:656–662. https://doi.org/10.1177/0363546507312164 CrossRefPubMed

37.

Collins NJ, Misra D, Felson DT et al (2011) Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Ou. Arthritis Care Res (Hoboken) 63:S208–S228. https://doi.org/10.1002/acr.20632 CrossRef

38.

Irrgang J (2012) Summary of clinical outcome measures for sports-related knee injuries final report table of contents, pp 1–381. https://www.sportsmed.org/AOSSMIMIS/members/downloads/research/ClinicalOutcomeMeasuresKnee.pdf

39.

Briggs KK, Lysholm J, Tegner Y et al (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner Activity Scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37:890–897. https://doi.org/10.1177/0363546508330143 CrossRefPubMed

40.

Wera JC, Nyland J, Ghazi C et al (2014) International knee documentation committee knee survey use after anterior cruciate ligament reconstruction: a 2005–2012 systematic review and world region comparison. Arthroscopy 30:1505–1512. https://doi.org/10.1016/j.arthro.2014.05.043 CrossRefPubMed

41.

Hefti F, Müller W, Jakob RP, Stäubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234. https://doi.org/10.1007/BF01560215 CrossRefPubMed

42.

Hawker GA, Mian S, Kendzerska T, French M (2011) Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale. Arthritis Care Res (Hoboken) 63(Suppl 1):S240–S252. https://doi.org/10.1002/acr.20543 CrossRef

43.

Sgaglione NA, Del Pizzo W, Fox JM, Friedman MJ (1993) Arthroscopically assisted anterior cruciate ligament reconstruction with the PES anserine tendons. Comparison of results in acute and chronic ligament deficiency. Am J Sport Med 21:249–256. https://doi.org/10.1177/036354659302100215 CrossRef

44.

Wasilewski SA, Covall DJ, Cohen S (1993) Effect of surgical timing on recovery and associated injuries after anterior cruciate ligament reconstruction. Am J Sports Med 21:338–342. https://doi.org/10.1177/036354659302100302 CrossRefPubMed

45.

Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 18:292–299. https://doi.org/10.1177/036354659001800313 CrossRefPubMed

46.

Beynnon BD, Uh BS, Johnson RJ et al (2005) Rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 33:347–359. https://doi.org/10.1177/0363546504268406 CrossRefPubMed

47.

Wright RW, Preston E, Fleming BC et al (2008) A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg 21:217–224CrossRefPubMedPubMedCentral

48.

Wright RW, Preston E, Fleming BC et al (2008) A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg 21:225–234. https://doi.org/10.1016/j.humov.2008.02.015.Changes CrossRefPubMedPubMedCentral

49.

Kruse LM, Gray B, Wright RW (2012) Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 94:1737–1748CrossRefPubMedPubMedCentral

50.

Meighan AS, Keating JF, Will E (2003) Outcome after reconstruction of the anterior cruciate ligament in athletic patients. A comparison of early versus delayed surgery. J Bone Joint Surg Br 85:521–524. https://doi.org/10.1302/0301-620X.85B4.13743 CrossRefPubMed

51.

Hunter RE, Mastrangelo J, Freeman JR et al (1996) The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction. Arthroscopy 12:667–674CrossRefPubMed

52.

Petersen W, Laprell H (1999) Combined injuries of the medial collateral ligament and the anterior cruciate ligament. Early ACL reconstruction versus late ACL reconstruction. Arch Orthop Trauma Surg 119:258–262. https://doi.org/10.1007/s004020050405 CrossRefPubMed

53.

Marcacci M, Zaffagnini S, Iacono F et al (1995) Early versus late reconstruction for anterior cruciate ligament rupture. Results after five years of follow-up. Am J Sport Med 23:690–693. https://doi.org/10.1177/036354659502300610 CrossRef

54.

Drogset JO, Grøntvedt T (2002) Anterior cruciate ligament reconstruction with and without a ligament augmentation device: results at 8-year follow-up. Am J Sports Med 30:851–856. https://doi.org/10.1177/03635465020300061601 CrossRefPubMed

55.

Shelbourne KD, Gray T (2009) Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J Sports Med 37:471–480. https://doi.org/10.1177/0363546508326709 CrossRefPubMed

56.

Larkin J, Barber-Westin S (1998) The effect of injury chronicity and progressive rehabilitation on single-incision arthroscopic anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg 14:15–22. https://doi.org/10.1016/S0749-8063(98)70115-X CrossRef

57.

Eriksson K, Anderberg P, Hamberg P et al (2001) A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 83:348–354. https://doi.org/10.1302/0301-620X.83B3.11685 CrossRefPubMed

58.

Ahlen M, Liden M et al (2011) A comparison of the clinical outcome after anterior cruciate ligament reconstruction using a hamstring tendon autograft with special emphasis on the timing of the reconstruction. Knee Surg Sports Traumatol Arthrosc 19:488–494. https://doi.org/10.1007/s00167-010-1312-0 CrossRefPubMed

59.

Fithian DC, Paxton EW, Lou Stone M et al (2005) Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 33:335–346. https://doi.org/10.1177/0363546504269590 CrossRefPubMed

60.

Barenius B, Nordlander M, Ponzer S et al (2010) Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial. Am J Sports Med 38:1533–1541. https://doi.org/10.1177/0363546510369549 CrossRefPubMed

61.

Buckwalter JA, Saltzman C, Brown T (2004) The impact of osteoarthritis. Clin Orthop Relat Res 427:S6–S15. https://doi.org/10.1097/01.blo.0000143938.30681.9d CrossRef

62.

Chen A, Gupte C, Akhtar K et al (2012) The global economic cost of osteoarthritis: how the UK compares. Arthritis 2012:1–6. https://doi.org/10.1155/2012/698709 CrossRef

63.

Litwic A, Edwards MH, Dennison EM, Cooper C (2013) Epidemiology and burden of osteoarthritis. Br Med Bull 105:185–199. https://doi.org/10.1093/bmb/lds038 CrossRefPubMed

Title: Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis
Authors: D. Ferguson
A. Palmer
S. Khan
U. Oduoza
H. Atkinson
Publication date: 01-08-2019
Publisher: Springer Paris
Published in: European Journal of Orthopaedic Surgery & Traumatology / Issue 6/2019
Print ISSN: 1633-8065
Electronic ISSN: 1432-1068
DOI: https://doi.org/10.1007/s00590-019-02442-2

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2019

Outcomes of robotic-arm-assisted medial unicompartmental knee arthroplasty: minimum 3-year follow-up

Stem length in primary cementless total hip arthroplasty: Does it make a difference in bone remodeling?

Synovial hemangioma of the knee joint in pediatrics: our case series and review of literature

Is patient satisfaction related to patient reported sounds from ceramic on ceramic total hip arthroplasty? A study of 265 hips

A new minimally invasive U-shaped lumbopelvic stabilization technique

Analysis of parameters influencing intraarticular temperature during radiofrequency use in shoulder arthroscopy