A comparative analysis of the efficacy of anterior cruciate ligament reconstruction with autologous ligament grafting at different time points

Efficacy and safety of early versus delayed reconstruction for anterior cruciate ligament injuries: A systematic review and meta-analysis

OBJECTIVE

To critically evaluate the efficacy and safety of early versus delayed anterior cruciate ligament reconstruction (ACLR) for anterior cruciate ligament (ACL) injuries based on the different cut-off values of the timing of operation.

METHODS

PubMed, Medline, Embase, Cochrane library, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang Digital Periodical database were searched from inception to November 2022 without language restrictions. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing early ACLR with delayed ACLR for ACL injuries were included.

RESULTS

Twenty-four studies (10 RCTs and 14 CSs) were included. According to the information from included studies, 3 weeks, 4 weeks, 6 weeks, 6 months, and 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR. When 4 weeks were considered as the cut-off value, early ACLR could significantly improve Lysholm score, IKDC score and VAS score at 6 and 12 months postoperatively and decrease the incidence of adverse events compared with delayed ACLR (P < 0.05). However, no statistically significant difference in positive rate of Lachman test and incidence of meniscus injuries and chondral lesions between the two groups when 3 weeks, 6 weeks, 6 months or 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR (P > 0.05).

CONCLUSION

The present study suggests that early ACLR, especially conducted within 3-4 weeks after ACL injuries, may be more effective for improving knee function and relieving pain compared with delayed ACLR. More high-quality RCTs are warranted.

Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis

BACKGROUND

Early surgery for acute ligamentous injuries has recently shown good clinical and functional outcomes.

PURPOSE

To assess the advantages of early vs delayed surgery in patients undergoing isolated anterior cruciate ligament (ACL) or multiligament-injured knee (MLIK) surgery.

STUDY DESIGN

Meta-analyses of Level 1, 2, and 3 studies; Level of evidence, 4.

METHODS

A systematic search was performed via PubMed, EMBASE, and Cochrane for studies reporting outcomes of timing of surgery after isolated ACL injury or in the MLIK setting using accelerated rehabilitation protocols. Two analyses were conducted to differentiate early and delayed treatment (3- and 6-week cutoffs). Collected outcomes included meniscal or chondral lesions, failure and reoperation rates, range of motion (ROM) deficits, other complications, muscle strength, instrumented laxity, and functional outcomes. Outcomes were reported in risk ratios (RR) or mean differences with 95% CIs.

RESULTS

For timing of isolated ACL surgery, 16 studies were included with 2093 patients. High-grade evidence indicated that there were no differences in meniscal or chondral lesions, failure and reoperation rates, stiffness, ROM deficits, complications, muscle strength, instrumented laxity, and functional outcomes between patients treated early and late (all P > .05). When including only studies that set no preoperative criteria for early surgery, the findings were similar. Regarding MLIK surgery, 14 studies were included with 1172 patients. Low evidence was noted for the following: patients treated early had significantly fewer meniscal injuries (RR, 0.7; P = .04) and chondral injuries (RR, 0.5; P < .001), while no differences were found in reoperation rates, complications, stiffness, ROM deficits, muscle strength, instrumented laxity, and functional outcomes between the groups. Other than higher Lysholm scores in the early group for the 3-week analysis (mean difference, 6.8; P = .01), there were no differences between cutoff analyses.

CONCLUSION

This systematic review with meta-analysis found no differences in clinical and functional outcomes between early and delayed surgery for isolated ACL injuries. For MLIK injuries, there were also no differences in surgical outcomes between early and delayed surgery.

Acute and subacute anterior cruciate ligament reconstructions are associated with a higher risk of revision and reoperation

PURPOSE

(1) Report concomitant cartilage and meniscal injury at the time of anterior cruciate ligament reconstruction (ACLR), (2) evaluate the risk of aseptic revision ACLR during follow-up, and (3) evaluate the risk of aseptic ipsilateral reoperation during follow-up.

METHODS

Using a United States integrated healthcare system's ACLR registry, patients who underwent primary isolated ACLR were identified (2010-2018). Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision, with a secondary outcome evaluating ipsilateral aseptic reoperation. Outcomes were evaluated by time from injury to ACLR: acute (< 3 weeks), subacute (3 weeks-3 months), delayed (3-9 months), and chronic (≥ 9 months).

RESULTS

The final sample included 270 acute (< 3 weeks), 5971 subacute (3 weeks-3 months), 5959 delayed (3-9 months), and 3595 chronic (≥ 9 months) ACLR. Medial meniscus [55.4% (1990/3595 chronic) vs 38.9% (105/270 acute)] and chondral injuries [40.0% (1437/3595 chronic) vs 24.8% (67/270 acute)] at the time of ACLR were more common in the chronic versus acute groups. The crude 6-year revision rate was 12.9% for acute ACLR, 7.0% for subacute, 5.1% for delayed, and 4.4% for chronic ACLR; reoperation rates a 6-year follow-up was 15.0% for acute ACLR, 9.6% for subacute, 6.4% for delayed, and 8.1% for chronic ACLR. After adjustment for covariates, acute and subacute ACLR had higher risks for aseptic revision (acute HR 1.70, 95% CI 1.07-2.72, p = 0.026; subacute HR 1.25, 95% CI 1.01-1.55, p = 0.040) and aseptic reoperation (acute HR 2.04, 95% CI 1.43-2.91, p < 0.001; subacute HR 1.31, 95% CI 1.11-1.54, p = 0.002) when compared to chronic ACLR.

CONCLUSIONS

In this cohort study, while more meniscal and chondral injuries were reported for ACLR performed ≥ 9 months after the date of injury, a lower risk of revision and reoperation was observed following chronic ACLR relative to patients undergoing surgery in acute or subacute fashions.

The efficacy of 5 rehabilitation treatments after anterior cruciate ligament reconstruction: A network meta-analysis

BACKGROUND

The efficacy of traditional rehabilitation, proprioceptive training, and neuromuscular training after anterior cruciate ligament (ACL) reconstruction is also controversial. In order to help medical staff better choose the rehabilitation treatment plan after ACL reconstruction, we conducted this network meta-analysis.

METHODS

Chinese and English databases such as Wanfang, Weipu, China Zhiwang, and PubMed, Cochrane Library, Embase were retrieved. We collected clinical controlled trial papers on traditional rehabilitation therapy, proprioceptive training and neuromuscular training after ACL reconstruction for meta-analysis.

RESULTS

In this meta-analysis, 12 studies were included, including 486 patients who received rehabilitation treatment after ACL reconstruction. Based on network meta-analysis, it was found that 4 groups of direct comparison and 6 groups of indirect comparison were formed for 5 rehabilitation treatment schemes after ACL reconstruction. The curative effect of traditional rehabilitation training combined with proprioception training is better than that of traditional rehabilitation training (mean difference value of traditional rehabilitation training combined with proprioception training vs traditional rehabilitation training was 8.00, 95% confidence interval: 2.61,13.39). The efficacy of proprioceptive training is better than that of traditional rehabilitation training (mean difference value of proprioceptive training vs traditional rehabilitation training is 11.01, 95% confidence interval: 0.62,21.39). There was no statistical significance between the other rehabilitation trainings. According to the surface under cumulative ranking curve, the therapeutic effects of the 5 rehabilitation treatment programs after ACL reconstruction were ranked as follows: proprioceptive training (72%) > traditional rehabilitation training combined with neuromuscular training (70.8%) > traditional rehabilitation training combined with proprioception training (57.1%) > neuromuscular training (45.5%) > traditional rehabilitation training (4.6%). No publication bias was found in the funnel plot.

CONCLUSION

Combined with the results of meta-analysis and surface under cumulative ranking efficacy sequence diagram, it can be seen that traditional rehabilitation training combined with proprioceptive training and traditional rehabilitation training combined with neuromuscular training have significant efficacy. Due to the limitations of this study, the conclusions of this network meta-analysis still need to be further confirmed by a large sample size and well-designed randomized controlled trials.