ACL SURGICAL RECONSTRUCTION

Two low quality studies (Dunn 2004, Streich 2011) demonstrate a lower risk of adverse events (meniscus injury, secondary meniscectomy) after ACL reconstruction (ACLR). One high quality study (Tsoukas 2016) and six low quality studies (Meuffels 2009, Yperen 2018, Kovalak 2018, Dawson 2016, Wellsandt 2018, Streich 2011) report better function after ACL reconstruction via patient reported outcomes. Two low quality studies (Kessler 2008, Wellsandt 2018) report more frequent progression to osteoarthritis with ACL reconstruction compared to non-operative treatment while one low quality study (Lin 2017) favors ACL reconstruction. One low quality study (Wellsandt 2020) reports more knee joint loading in patients treated non-operatively, but no difference in the rate of radiographic arthritis. Two low quality studies (Ardern 2017, Wellsandt 2018) report less long-term pain after ACL reconstruction compared to non-surgical treatment. One low quality study suggests better quality of life after ACL reconstruction (Ardern 2017). There is no significant difference in return to activity based on three low quality studies (Kovalak 2018, Wellsandt 2018, Wellsandt 2020). Group consensus suggests that age and activity levels are important considerations when deciding between treatment options. For example, the study by Dunn (2004) was conducted in young military personnel and favored surgical reconstruction. Finally, while the available literature does not typically consider the impact of concomitant meniscus or chondral injuries when comparing outcomes of surgical versus non-surgical treatment of ACL tears, the workgroup suggests that concomitant injuries should be factored into treatment decisions. Previous AAOS clinical practice guidelines have recommended prompt treatment of ACL tears associated with a locked knee due to displaced meniscus tear in order to prevent a flexion contracture and further meniscal deficiency. However, this was based on group consensus due to limited evidence. 

Benefits/Harms of Implementation

ACL reconstruction is a common procedure. While reconstruction offers a number of benefits, evidence regarding long-term differences in outcomes between operative and non-operative treatment is lacking.

Outcome Importance

A number of outcomes are important in patients with an ACL injury. These include subjective and objective knee function, pain, return to activity, secondary injuries or surgeries, and progression to osteoarthritis. All of these are important and may have substantial medical, financial, and psychosocial effects. 

Cost Effectiveness/Resource Utilization

In the short-term, ACL reconstruction is more costly than non-operative treatment. Long-term cost-effectiveness comparisons are lacking.

Acceptability

ACL reconstruction is a common procedure, so acceptability likely will not be a concern.

Feasibility

ACL reconstruction is a common procedure, so feasibility likely will not be a concern.

Future Research 

Future research should strive for higher methodological quality. Additionally, stratified analyses (along the lines of age, activity level, patient goals, etc.) will help determine specifically which patients benefit from ACL reconstruction versus non-operative treatment.