The ACL SNNAP trial, led by University of Oxford researchers revealed over 18 months, going straight to reconstructive surgery has a better outcome than a programme with rehabilitation first – and subsequent surgery if needed – for anterior cruciate ligament (ACL) injury.
An estimated 30,000 surgical reconstructions are performed annually in the UK. However, despite being a common injury, existing management for ACL injury is based on insufficient evidence.
Speaking about the study on the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) website, David Beard, lead author and Professor of Musculoskeletal and Surgical Science at 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.
The clinical management study recruited 316 patients from 29 secondary care National Health Service orthopaedic units in the UK between 2017 and 2020.
They were randomly assigned 1:1 to either 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 (Eng) specialist surgical trials units supported by the Rosetree's Trust, and in collaboration with the Oxford Clinical Trials Research Unit (OCTRU).
The results showed both groups improved over time but patients with non-acute ACL injury undergoing immediate surgical reconstruction without any further intervention have 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 the devastating impact of ACL injury on activity and sport levels and, interestingly that in both groups, the return to pre-injury level of sport was very low at 18 months.
The research was funded by the National Institute for Health and Care Research and was published in The Lancet.
