Conservative vs Surgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review

Abstract

Anterior cruciate ligament (ACL) injury is very common, especially in young athletic individuals who injure themselves during sports involving pivoting actions. Management options include conservative management, which involves progressive physical therapy, educating the patient on how to prevent instability, and the use of a hinged knee brace. Surgical management involves reconstruction of the torn ligament using an autograft or an allograft and ACL repair where the torn ligament is affixed back to the tibia or femur. The choice of management depends on the severity of the injury, other injuries in associated structures, the level of fitness, and the athletic goals of the patient. Many studies exist on the management choice of ACL injury, but no clear consensus prevails. This study will examine the effectiveness of conservative versus surgical management. A literature review will be performed to identify appropriate papers which compare and evaluate the two approaches. A literature search for randomized controlled trials (RCTs) and cohort studies comparing the conservative to surgical management of ACL injury was conducted on PubMed, Scopus, and Web of Science. Patient eligibility criteria included individuals older than 15 with an isolated, recent ACL injury diagnosis via an appropriate clinical test, MRI, or arthroscopy. Studies were eligible if they were using appropriate surgical or conservative methods, as mentioned previously, and measuring results via appropriate scores, tools, and methods that will be presented below. The follow-up timeline would be from presentation time until at least two years. Five papers were found to be eligible. Overall, these papers included 462 patients. Two studies measuring overall knee symptoms, function, and sports activities using the International Knee Documentation Committee Subjective Knee Form (IKDC) score found that the operated group had a significantly higher score. The other two studies measured overall knee function and health using the Tegner & Lysholm and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores. In both papers, no significant difference was found between the two groups. Regarding Tegner's activity score, only one paper had significant findings. A significantly longer period to return to sports activities was observed in the operative group. Stability was significantly higher in all papers in the operated group. Osteoarthritis was measured using different tools in each paper. Only one paper found a significantly higher risk in the operated group. Only one paper indicated significantly more complications in the operated group regarding side effects. Overall, very few differences were observed between the two treatment groups. The most significant differences observed were the higher stability and the longer recovery period in patients undergoing surgery. Large RCTs following patients for enough time are needed to prove if surgical treatment offers significant benefits over conservative treatment.

Keywords: acl rehabilitation; acl repair; anterior cruciate ligament (acl); anterior cruciate ligament injury; conservative vs surgical management; systematic literature review.

Figure 1. PRISMA 2020 flow diagram