Objective To assess whether a clinically relevant difference exists in patients’ perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens. Design Open labelled, multicentre, parallel randomised controlled trial (COMPARE). Setting Six hospitals in the Netherlands, between May 2011 and April 2016. Participants Patients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months. Interventions 85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment). Main outcomes Patients’ perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months. Results Between May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups −9.3, −14.6 to −4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group. Conclusions In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction. Trial registration Netherlands Trial Register NL 2618.

In this retrospective pair-matched follow-up study, we found that after 20-year follow-up, there was no difference in knee osteoarthritis between operative versus nonoperative treatment when treatment was allocated on the basis of a patient's response to 3 months of nonoperative treatment. Although knee stability was better in the operative group, it did not result in better subjective and objective functional outcomes.

ObjectivesTo conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator).MethodsPatients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping.ResultsA total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective.ConclusionRoutine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

Intensity during cycling on an EAB, in all three measured conditions, is sufficiently high to contribute to the physical activity guidelines for moderate-intensity health-enhancing physical activity for adults (cutoff, 3 MET). Further study is needed to conclude whether these results still hold when using the EAB in regular daily life and in subjects with other fitness level.

The maximal power that muscles can generate is reduced at low muscle temperatures. However, in prolonged heavy exercise in the heat, a high core temperature may be the factor limiting performance. Precooling has been shown to delay the attainment of hyperthermia. It is still unclear if the whole body should be cooled or if the active muscles should be excluded from cooling in order to maintain muscle power. An experiment was performed to compare thermal strain and gross efficiency following whole body or partial body cooling. Eight well-trained participants performed 40 min of 60% VO2max cycling exercise in a 30 degrees C, 70% relative humidity climatic chamber after four different precooling sessions in a water perfused suit: N (no precooling), CC (45 min whole body precooling), WC (45 min lower body precooling), and CW (45 min upper body precooling). The uncooled body part was warmed in such a way that the core temperature did not differ from that in session N. Gross efficiency was used to compare performance between the sessions since it indicates how much oxygen is needed for a certain external load. The gross efficiency did not differ significantly between the sessions. Differences in heat loss and heat storage were observed during the first 20 min of exercise. The evaporative heat loss in session WC (305 +/- 67 W) and CW (284 +/- 68 W) differed from session N (398 +/- 77 W) and CC (209 +/- 58 W). More heat was stored in session CC (442 +/- 125 W) than in sessions WC (316 +/- 39 W), CW (307 +/- 63 W), and N (221 +/- 65 W). It was confirmed that precooling reduces heat strain during exercise in the heat. No differences in heat strain and gross efficiency were observed between precooling of the body part with the exercising muscles and precooling of the tissues elsewhere in the body.