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OrthopaedicAug 30, 2022

Reconstructive surgery is the 'best way forward' for longstanding ACL injuries: study in The Lancet

People with longstanding anterior cruciate ligament (ACL) injuries appear to fare better if they go straight to having reconstructive surgery, rather than following rehabilitation programmes run by physiotherapists first.

That is the conclusion of a team of researchers whose paper was published in The Lancet on 20 August, under the auspices of the University of Oxford-based ACL SNNAp trial. The trial, which is funded by the National Institute for Health and Care Research, could have significant implications for patient outcomes and potentially provide cost savings to healthcare providers.

David Beard, lead author and professor of musculoskeletal and surgical science at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) said: ‘Although there is good evidence from previous (Scandinavian and Dutch) studies that rehab can be effective for newly injured patients, waiting lists in the NHS for assessment (and treatment) often mean that many patients are seen much further down the line and with a longer-standing injury.'

Professor Beard added: ‘Despite my professional bias toward rehabilitation it became apparent (in my own clinic, and from others) that more longstanding ACL deficient patients did not improve or achieve sufficient knee stability with rehab alone. I was suspicious that these particular patients may be better served by undergoing reconstruction sooner, but a large rigorous trial was needed.’

Photo Credit: Shutterstock
Oleksandr Kobets falls down after sustaining an ACL injury in a 2019 international match

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Randomised controlled trial

The clinical management study recruited 316 patients from 29 secondary care NHS orthopaedic units in the UK from 2017 to 2020. They were randomly assigned (1:1) either to a surgical reconstruction group or to a group undergoing initial rehabilitation with subsequent surgery, as required.

Patients were followed up at 18 months and asked to report any pain, activity levels, secondary issues, satisfaction, and functionality of the knee. The study was run by SITU (the Surgical Intervention Trials Unit), one of the Royal College of Surgeons' (England) specialist surgical trials units supported by the Rosetree’s Trust, and in collaboration with the Oxford Clinical Trials Research Unit.

Lottie Davies, co-applicant and trial manager at NDORMS, said: ‘The trial had many challenges including the preference for specific treatment from both patients and clinicians and the problems in following up a young mobile population.' Dr Davies added: ‘Successfully completing the trial was the result of the much-valued effort and support of all involved without which these trials would not be possible.’

Better outcomes with quicker surgery

The results showed that both groups improved over time but patients with non-acute ACL injury undergoing immediate surgical reconstruction without any further intervention having substantially better outcomes at 18 months after randomisation than did those undergoing non-surgical management (and any subsequent necessary surgery).

The secondary outcome measures, including patient satisfaction, also favoured surgical reconstruction over non-surgical management. The study also showed how an ACL injury can have a devastating effect on people’s activity and sporting levels. Interestingly, the return to a pre-injury level of sport was very low at 18 months among those in both groups.

Benefit can still be achieved with rehabilitation, and can be offered, but it appears that undergoing expedited reconstructive surgery is the best way forward to stabilise the knee and achieve better function [Andrew Price]

Andrew Price, co-applicant and consultant knee surgeon stated: ‘This study has significant implications for how we treat ACL injuries, especially the more longstanding injured patients with ongoing knee instability.'

Professor Price did not rule out offering patients rehab options: ‘Benefit can still be achieved with rehabilitation, and can be offered, but it appears that undergoing expedited reconstructive surgery is the best way forward to stabilise the knee and achieve better function.'


Rupture of the ACL is a common knee injury that can have a variable impact. Some patients recover while others experience disabling effects of knee instability that can affect day-to-day activities, work and recreation. The injury mainly affects young, active individuals, with an estimated 30,000 surgical reconstructions performed annually in the UK.

Despite being ACL injuries being relatively common, the current management approach is based on insufficient evidence. With limited and conflicting evidence for the management and costs of ACL, there is no guide to help decision making in patients with long-standing injuries who are symptomatic. Treatment is either rehabilitation involving specialised physiotherapy exercises, or surgery that involves reconstructing the ligament.

To read the full version of the article, titled Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament (ACL) injury (ACL SNNAP): a pragmatic randomised controlled trial, titled, visit: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01424-6/fulltext

For more information about the ACL SNNAp trial, visit: https://www.ndorms.ox.ac.uk/research/clinical-trials/current-trials-and-studies

Author: Ian A McMillan
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