Inspiration

Early surgical reconstruction versus rehabilitation with electivedelayed reconstruction for patients with anterior cruciateligament rupture: COMPARE randomised controlled trial

Reijman M, Eggerding V, van Es E, van Arkel E, van den Brand I, van Linge J et al. Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial BMJ 2021; 372 :n375 doi:10.1136/bmj.n375

WHAT IS ALREADY KNOWN ON THIS TOPIC

Several non-randomised studies have suggested that for patients with rupture of the anterior cruciate ligament (ACL), clinical results for early reconstruction of the ACL compared with rehabilitation alone are similar Evidence from randomised controlled trials is lacking The preferred treatment for rupture of the ACL (surgery or rehabilitation) is unclear.

WHAT THIS STUDY ADDS

Patients who underwent early surgical reconstruction of the ACL, compared with those who had rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up This finding was significant but the clinical importance is unclear Interpretation of the results of the study should consider that 50% of patients randomised to the rehabilitation group did not need surgical reconstruction.

The aim

The aim of the trial was to assess whether a clinically relevant difference existed in patients’ perceptions of symptoms, knee function, and ability to participate in sporting activities between two commonly used treatment regimens: early reconstruction of the ACL versus rehabilitation and optional delayed ACL reconstruction. The primary outcome was measured with the International Knee Documentation Committee score over a period of two years after rupture of the ACL.

Early ACL reconstruction

Arthroscopic reconstruction of the ACL was scheduled within six weeks after randomisation. Surgeons chose their preferred technique and graft, and decided if more intra-articular surgery was necessary.

Rehabilitation with optional delayed ACL reconstruction

For non-operative treatment, patients were referred to a physical therapist for a supervised physical therapy programme for a minimum of three months, according to the recommendations of the Dutch ACL guideline.1 After a minimum of three months of rehabilitation, patients could opt for reconstruction of the ACL if instability persisted or if the desired activity level was not reached.

Questionnaire answer

Patients were seen at the outpatient clinic at baseline, and at 12 and 24 months. Patients completed a questionnaire at three, six, and nine months after randomisation. All questionnaires were completed digitally

Conclusions
In patients with acute rupture of the ACL, those who underwent surgical reconstruction alone,
compared with rehabilitation and optional surgical reconstruction, had improved perceptions of
symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction.

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