Your meniscus is probably not affected by your ACL reconstruction

Meniscus procedures do not increase with delayed ACL reconstruction and rehabilitation: results from a randomized controlled trial.

van der Graaff SJA, Reijman M, van Es EM, Bierma-Zeinstra SMA, Verhaar JAN, Meuffels DE. The British Journal of Sports Medicine, 2023; 57:78-82.

Full text freely available

Take home message

People who initially receive rehabilitation with optional delayed anterior cruciate ligament (ACL) reconstruction are at a similar risk for meniscal surgery than those treated with early ACL reconstruction.

Background

Nonoperative treatment for ACL rupture is a viable option for many patients. However, some physicians have expressed concern that nonoperative treatment of ACL rupture or delayed ACL reconstruction may increase the risk of meniscal injury.

Study aim

van der Graaff and colleagues completed a secondary analysis of data from the COMPARE trial to evaluate whether treating ACL rupture with a delayed reconstruction option leads to more meniscal procedures than early ACL reconstruction.

Methods

The authors used data collected from the COMPARE study. The study included people who had suffered an acute ACL rupture in the previous two months. Eight-five participants randomly received early ACL reconstruction (within six weeks of study enrollment). Eighty-two participants were randomly assigned to receive nonoperative treatment with optional delayed ACL reconstruction. All participants in the non-operative group received at least three months of supervised physiotherapy. After 3 months of structured physiotherapy, participants could opt for ACL reconstruction. The authors recorded whether someone had undergone a meniscal procedure during ACL reconstruction or other surgery. In addition, all participants underwent a baseline MRI, which the research team assessed for signs of a meniscus tear.

Results

Half of the participants who started in the nonoperative group elected to undergo ACL reconstruction during the two-year follow-up period. At baseline, approximately 41% of participants had a meniscus tear, regardless of group. Approximately 30% of knees underwent a meniscal procedure during ACL reconstruction, regardless of whether it was early or delayed reconstruction. After reconstruction, 5% of knees required a new meniscal procedure, regardless of group. These subsequent surgeries were due to new trauma or knee complaints, but there was always a meniscus that the authors noted was damaged in the original ACL reconstruction. Approximately 10% of participants who never underwent ACL reconstruction underwent separate meniscal surgery.

Viewpoints

This study makes it clear that someone who attempts non-operative treatment is not at greater risk for a new meniscal injury than someone who receives early ACL reconstruction. These results are consistent with the results of the KANON study, which found similar rates of meniscal surgery over a five-year period after people were randomly assigned to early or optionally delayed ACL reconstruction.

Clinical implications

Clinicians should be aware that initially attempting non-operative treatment in someone with an ACL injury will not increase the risk of a meniscus tear requiring surgery. Educating patients about the pros and cons of delaying ACL reconstruction can help a patient better evaluate their options after an ACL rupture and allow them to choose the option that best suits their lifestyle.

Questions for discussion

How soon after an ACL injury do you discuss surgery as a possible outcome with your patients? Do you also discuss the options for patients to be treated non-operatively?

Written by Kyle Harris
Reviewed by Jeffrey Driban

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