Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial

Abstract

Objective: To assess whether a clinically relevant difference exists in patients' perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens.

Design: Open labelled, multicentre, parallel randomised controlled trial (COMPARE).

Setting: Six hospitals in the Netherlands, between May 2011 and April 2016.

Participants: Patients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months.

Interventions: 85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment).

Main outcomes: Patients' perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months.

Results: Between May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups -9.3, -14.6 to -4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group.

Conclusions: In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with 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 (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.

Trial registration: Netherlands Trial Register NL 2618.

Fig 1

Flowchart of the study participants. *Randomisation by blocks of various sizes by surgeon and age group (<30 and ≥30). ACL=anterior cruciate ligament

Fig 2

International Knee Documentation Committee Score over a follow-up period of 24 months in the early anterior cruciate ligament (ACL) reconstruction group and the rehabilitation and optional delayed ACL reconstruction group. Values are mean (95% confidence intervals). Data were adjusted for sex, body mass index, age, and surgeon. A significant difference was found in the course of the International Knee Documentation Committee score over the two year follow-up period (P<0.001 for interaction between follow-up and randomised allocation). A higher International Knee Documentation Committee score indicates more favourable patient ratings for symptoms, knee function, and ability to participate in sporting activities (optimum score 100)