Key Points
- ‘Rehabilitation first’ approach has shown positive outcomes in some patients and may help save unnecessary costs that is associated with ACL-R surgeries
- Certain subgroups of patients such as patients with concomitant meniscal and cartilage injuries may benefit from early ACL-R
- In addition, patients who are returning to pivoting and cutting sports may experience better outcomes with early ACL-R
- Any decision made should be informed and shared between the patient and clinician
CLINICAL IMPLICATIONS
- It is important for clinicians and patients to be educated on the pros and cons of each approach
- Shared decisions should be made and should be well informed with the most recent evidence
- With any decision made, it expectations should be well managed
- Treatment plans should be individualised and unique to each patient
Over the past two decades, there has been an increase in the number of anterior cruciate ligament reconstruction (ACL-R) procedures. Injury burden has also increased over the years due to increases in sports participation in youth and the desire to stay active in the elderly. A large percentage of ACL injuries are treated surgically with an ACL-R. However, some patients choose to be treated conservatively through rehabilitation first, with the option of reconstruction in case of instability.
Rehabilitation first approach vs early ACL-R
What does research tell us?
Studies have shown that rehabilitation before ACL-R (prehab), compared to no rehabilitation, has reported to significantly improve outcomes and increase return to play rates. On top of that, 40% of patients function well with a torn ACL.
Why ‘rehabilitation first’?
Since surgery is not performed, this treatment approach mitigates the risk of complications that may arise from surgery such as infection, joint stiffness, pain and persistent instability. Additionally, this approach also helps to identify patients who may not need surgery.
In cases where instability persists, the option of an ACL-R after conservative rehabilitation has shown to provide good outcomes too. Moreover, patients undergoing ACL-R within 3 months of injury had a higher risk of ACL revision, suggesting early ACL-R to be cost ineffective.
When is the ‘rehabilitation first’ approach not optimal?
The risk of meniscus and chondral injuries due to persistent instability should be considered. Such injuries have shown to negatively influence the outcomes of ACL-R, in cases where ACL-R surgery is performed after prehabilitation.
While this approach may eliminate unnecessary costs associated with surgeries, it is important for us to be aware that there is a possibility of failure, where instability persists. Some patients still undergo ACL-R surgery after conservative rehabilitation. Such cases result in the most expensive and longest route of recovery.
Moreover, many patients may not have access to high level rehabilitation and follow-up.
OTHERWISE…
Why does early surgery make more sense?
Early surgery for ACL tears with concomitant meniscus injuries such as bucket handle, radial, and meniscus root tears is recommended. This is in order to restore normal joint loading and stability.
Early ACL-R surgery is also indicated for patients who plan to return to cutting and pivoting sports too. It has also been shown that patients who fail conservative rehabilitation treatment and undergo consequential ACL-R have the lowest quality of life and highest cost.
Conclusion
Decisions made should be shared, involving both clinician and patient. The decision made should be an informed decision, backed by research and expectations should be appropriately managed.
While early ACL-R may be ideal in patients with concomitant meniscus and cartilage injuries, it is considerably costly. On the other hand, the ‘rehabilitation first’ approach can help save cost and potentially avoid unnecessary surgery. However, if this approach fails, it ends up being the most expensive and long route to recover.
Therefore, it is important to weigh the pros and cons of each option, before making a decision. More research is needed to determine the optimal patient suitability of each intervention. Each treatment plan should be individualised and specific to each patient.
References:
Moatshe, G., Kweon, C. Y., Gee, A. O., & Engebretsen, L. (2021). Anterior cruciate ligament reconstruction is not for all—a need for improved patient selection.
