Timing of Anterior Cruciate Ligament (ACL) reconstruction

Prodromidis, Apostolos (2018) Timing of Anterior Cruciate Ligament (ACL) reconstruction. Masters thesis, University of Central Lancashire.

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Background: Anterior Cruciate Ligament (ACL) ruptures are common but the ideal timing for ACL reconstruction following injury is unclear.
Objectives: To determine if there is a relationship between timing from ACL rupture to surgery and clinical, functional and patient-reported outcomes. To explore the feasibility of collecting clinicians’ views on ACL reconstruction timing.
Design and methods: A systematic review of five databases to identify studies investigating outcomes following different timing of reconstruction surgery and a pilot vignette study to identify variations in clinical decisions about timing of surgery in four different case scenarios.
Results: Systematic review: Ten studies were identified, only one was a randomised controlled trial. There appeared to be no difference in outcomes between early (< 3 months) and subacute (3 to 6 months) ACL reconstruction, but medial meniscal and chondral injuries were more common following delayed (> 6months) ACL reconstruction. The two studies on functional and/or patient reported outcomes had conflicting findings, with the trial suggesting no difference between early or delayed reconstruction. The studies had limited evidence about the relationship between timing of surgery and patient characteristics. Pilot Vignette study: The pilot vignette study had a response rate of 45% but a high question completion rate. There was clinical variation in timing between surgeons and across patient groups, but none recommended delayed surgery (>6 months).
Conclusions: Given the potential deleterious effects of meniscal and chondral injuries on knee function, delays of more than 6 months in patients deemed suitable for ACL surgery are not recommended, but there is some evidence that these delays are not common in practice. Further research on timing of ACL reconstruction should focus on shorter time-frames, functional and patient-reported outcomes, and the influence of patient characteristics, as available evidence is limited, inconsistent and of low quality. A vignette study seems feasible to provide insights on clinical decisions and guide current practice and future research.

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