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Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

Beard, David J; Davies, Loretta; Cook, Jonathan A; Stokes, Jamie; Leal, Jose; Fletcher, Heidi; Abram, Simon; Chegwin, Katie; Greshon, Akiko; Jackson, William; Bottomley, Nicholas; Dodd, Matt; Bourke, Henry; Shirkey, Beverly A; Paez, Arsenio; Lamb, Sarah E; Barker, Karen; Phillips, Michael; Brown, Mark; Lythe, Vanessa; Mirza, Burhan; Carr, Andrew; Monk, Paul; Morgado Areia, Carlos; O'Leary, Sean; Haddad, Fares; Wilson, Chris; Price, Andrew; Emsley, Richard; Peat, George; Snow, Martyn; Campbell, Marion; Howell, Tessa; Johnson, Hilary; McDonnell, Stephen; Pinkney, Thomas; Williams, Mark; Campbell, Helen; Davies, Jackie; Li, Jiyang; Bagg, Christina; Haywood, Laura; Nicholson, Anne; Riches, Joanne; Symons, Sean; Vertue, Mark; Al Mouazzen, Louay; Bray, Rachel; Clark, Damian; Coulthard, James; Holland, Tim; Howells, Nick; Jones, Andrew; Kapur, Richard; Kiszely, Alastair; Krishnan, Harry; MacDonald-Taylor, Karen; Manara, Jon; Murray, James; Negrut, Corina; Pai, Vishai; Porteous, Andrew; Putnis...

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Authors

David J Beard

Loretta Davies

Jonathan A Cook

Jamie Stokes

Jose Leal

Heidi Fletcher

Simon Abram

Katie Chegwin

Akiko Greshon

William Jackson

Nicholas Bottomley

Matt Dodd

Henry Bourke

Beverly A Shirkey

Arsenio Paez

Sarah E Lamb

Karen Barker

Michael Phillips

Mark Brown

Vanessa Lythe

Burhan Mirza

Andrew Carr

Paul Monk

Carlos Morgado Areia

Sean O'Leary

Fares Haddad

Chris Wilson

Andrew Price

Richard Emsley

George Peat

Marion Campbell

Tessa Howell

Hilary Johnson

Stephen McDonnell

Thomas Pinkney

Mark Williams

Helen Campbell

Jackie Davies

Jiyang Li

Christina Bagg

Laura Haywood

Anne Nicholson

Joanne Riches

Sean Symons

Mark Vertue

Louay Al Mouazzen

Rachel Bray

Damian Clark

James Coulthard

Tim Holland

Nick Howells

Andrew Jones

Richard Kapur

Alastair Kiszely

Harry Krishnan

Karen MacDonald-Taylor

Jon Manara

James Murray

Corina Negrut

Vishai Pai

Andrew Porteous

Sven Putnis

James Robinson

Shav Rupasinghe

Veenesh Selvaratnam

James Smith

Nick Smith

Jarrad Stevens

Clare Taylor

Anthony Theodorides

Niraj Vetharajan

Helen Vint

Lucy Young

Susan Bullock

Rebecca Cook

Alexander Dodds

Amanda Freeman-Hicks

Paula Hillout

Thomas Cornell

Abbie Coutts

Suzy Dean

Nicki Devooght-Johnson

Emma Ferrell

Eve Fletcher

Chrissie Hall

Benjamin Kent

Sandra Kessly

Robin Kincaid

Mohamed Lazizi

Ahmed Mostafa

Toby Nisbett

Tim Powell

Peter Riddlestone

Andrew Roberton

Jessica Summers

Lucy Whitbread

Belinda Wroath

Emma Fenlon

Andrew Hall

Helen Jeffrey

Raghuram Thonse

Debra Dunne

Andy Metcalfe

Kerri McGowan

Simon Middleton

Feisal Shah

Tim Spalding

Charlie Marie Suddens

Tamar Sweed

Joanna Teuke

Peter Thompson

David Wright

Justine Amero

Emma Brown

Hugh Chissell

Andrea Croucher

Gareth Dickinson

Catherine Hawkes-Blackburn

Alice Peacocke

Graham Smith

Carol Snipe

Kim Dearnley

Reza Mayahi

Barry Andrews

Massimo Barcelona

Hazel Giles

Abdulkerim Gokturk

Paul Harnett

Katie Jeeves

Joyce Kadunyi

Sheena Mendoza

Ines Reichert

Marta Santamaria

Harshinder Virdee

Sanjeev Anand

Nayef Aslam-Pervez

Stephen Draycott

Faye Howarth

Irfan Jina

Niall Maher

Denise Ross

Lindsey Worstenholme

Abdul Baig

Arun Bhaskaran

Daniel Banks

Tracy Brear

Carla Christie

Laura Cowen

Jack Davis

Ross Dixey

Colin Esler

Amirah Essop-Adam

Christina Haines

Linzy Houchen-Wolloff

Husein Varachia

Richard Wood

Glaxy Gray

Jessica Nichols

Alice Panes

Susan Partridge

Lawrie Rogerson

Pankaj Sharma

David Triggs

Ian Venables

Danielle Wilcock

Sarah Buckley

Thelma Darian

Elizabeth Denis

Jo Duncan

Charlotte Hirst

James Newman

Fern Richardson

Jon Smith

Megan Adcode

Megan Cottingham

Eliza Foster

Andrew Kelly

Niamh McKay

Jane Rewbury

Alison Whitcher

James Williams

Esther Zebracki

Llinos Davies

Jayadeep Jayachandran

Alison Tardivel

Victoria Whitehead

Martha Batting

Amy Bond

Marc Deakin

Christopher Dodd

Alison Hudak

Samantha Hynes

Luke Jones

Gail Lang

David McKenna

Susan Morris

Clare Scott-Dempster

Adam Sykes

Iason Vichos

Simon Wood

Rupert Clifton

Stephanie Diaz

Craig Hendy

Nishil Modi

Brendan O'Mahony

Susan O'Sullivan

Nicola Parker

Mira Pecheva

Rowan Rumonovic

Emma McLoughlin

Jeremy Rushbrook

Anna Thornhill

Valerie Parkinson

Rafael Sales

Katja Van De Snepscheut-Jones

David Wilcock

Daniel Wright

Joanna Allison

Simon Baker

Kate Beesley

Gill Ferrari

Benedict Lankester

Alison Lewis

Joanne Lyons

Jamie O'Callaghan

Sarah Sutcliffe

Dianne Wood

Emily Bannister

Chloe Brown

Debbie Burden

Terence Campbell

Emma Craig

Rashmi Easow

Julie Foxton

Alexandra Hazlerigg

Chethan Jayabev

Rosie Murdoch

Georgie Parsons

Harry Brown

Paula Carvelli

Rugaia Montaser

Ali Pepper

Sinduja Sivarajan

Oliver Templeton-Ward

Eva Wilson

Julie Cronin

Sarah Diment

Victoria King

Katharine Shean

Leonidas Vachtsevanos

Katharine Wilcocks

Ben Wilson

Paul McNestry

Joanna Ollerenshaw

James Stoddard

Paul Sutton

Sanjay Anand

Judith Bell

Albert Chikate

Diane Daniel

Timothy Davies

Tom Finnigan

Antonio Frasquet-Garcia

Susan Hopkins

Sharon Kerrison

Angela McGowan

David Sands Johnson

Lara Smith

Philip Turner

Helen Wilkinson

Lynne Allsop

Deborah Anthony

Rebecca Boulton

Sarah Brown

Vikram Desai

Mandy Gill

Cheryl Heeley

Sushrut Kulkarni

Wayne Lovegrove

Dominic Nash

Terri Ann Sewell

Sarah Shelton

Katie Slack

James Cartwright

Lynda Connor

Andrew Davies

Caroline Davies

Glyn Gainard

Dave Graham-Woollard

Carl Murphy

Leanne Quinn

Caradog Thomas

Jenny Travers

Marie Williams

Amanda Bell

Sunny Deo

Katharine Francis

Tracy Jackson

Laura McCafferty

Basalingappa Navadgi

Karan Plank

Venkat Satish

Claire Thelwall

Rachel Knight

Rahul Patel

Bruce Paton

Ashutosh Acharya

Utuman Aland

Miltiades Areirobulos

Pascal de Feyter

Lisa Ditchfield

Hafiz Iqbaz

Daniel Massey

Gareth Stables

Sarah Appleby

Michael Brown

Sarah Cable

Alexander Damen

Joana Da Rocha

Louise Foster

Elizabeth Hamilton

Catriona Hatton

Cassie Honeywell

Kunal Kulkarni

Lucy Markham

Haadiya Mohammed

John O'Grady

Yogesh Joshi

Heather Mclintock

Tania Morgan

Jane Stockport

Victoria Whitehead

Pranshu Agrawal

Jo Armstrong

Shannon Briggs

Ben Coupe

Anne Evans

Rob Gilbert

Sandra Latham

Aslam Mohammed



Abstract

Background
Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.
Methods
We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.
Findings
Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.
Interpretation
Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management.

Journal Article Type Article
Acceptance Date Aug 18, 2022
Publication Date Aug 20, 2022
Journal The Lancet
Print ISSN 0140-6736
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 400
Article Number 10352
Pages 605 - 615
DOI https://doi.org/10.1016/S0140-6736%2822%2901424-6
Publisher URL https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01424-6/fulltext

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