Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Abstract

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury. Level of evidence V.

Treatment decision-making process after an anterior cruciate ligament injury: patients’, orthopaedic surgeons’ and physiotherapists’ perspectives

“…In contrast, orthopaedic surgeons and physiotherapists do state that they rate the importance of each other’s assessments highly [ 6 ]. Since it is proposed that a structured rehabilitation should be initiated in most situations before the treatment decision is made [ 5 ], it is likely that the physiotherapist will have had repeated contact with the patient before the treatment decision takes place. The physiotherapist will therefore have had the opportunity to discuss the preferred treatment and expectations with the patient.…”

“…After an anterior cruciate ligament (ACL) injury, a decision for surgical reconstruction of the ACL (ACLR) or non-surgical (non-ACLR) treatment has to be taken. It is recommended that ACLR should be considered when the patient suffers from functional instability, has high activity demands and/or has a concomitant injury that should be treated with initial surgery [ 1 – 5 ]. It seems, from previous research, that high activity demands are the most important factor for the treatment decision [ 6 – 8 ], but to authors knowledge, neither the decision-making process nor the collaboration between patient and caregiver have been clearly described.…”

“…The decision about non-surgical or surgical treatment after ACL injury is complex, with low evidence for the best treatment [ 5 , 9 , 10 ]. For non-surgical treatment, rehabilitation lasts approximately four to five months, and the patient should probably be recommended not to return to contact and pivoting sports [ 11 ].…”

Efficacy of Repair for ACL Injury: A Meta‑analysis of Randomized Controlled Trials

“…Anterior cruciate ligament (ACL) injury is one of the most common types of knee joint injury. According to statistics, 85 out of every 100,000 people aged 16–39 suffer from ACL injury 1 . Mayo et al successfully performed one-stage open ACL repair surgery for the first time since 1895 and reported the good results of the surgery 2 .…”

Posterior cruciate ligament injuries: what do we really know?

“…The far more controversial question, however, is: what is the ideal timing for PCL reconstruction (early vs. delayed)? While evidence supports early reconstruction in patients with ACL injuries, research continues to find answers to this controversial question in patients with PCL and multiple ligament knee injuries [ 4 , 7 , 14 ]. One such research project is the STaR Trial (Surgical Timing and Rehabilitation of multiple ligament knee injuries).…”