de Jonge Robert, Máté Miklós, Kovács Norbert, Imrei Marcell, Pap Károly, Agócs Gergely, Váncsa Szilárd, Hegyi Péter, Pánics Gergely
Budapesti Uzsoki Street Hospital, Budapest, Hungary.
Center for Translational Medicine, Semmelweis University, Budapest, Hungary.
Orthop J Sports Med. 2024 Apr 8;12(4):23259671241239665. doi: 10.1177/23259671241239665. eCollection 2024 Apr.
An anterior cruciate ligament (ACL) tear is a risk factor for early osteoarthritis (OA) onset. Generally, ACL reconstruction (ACLR) is associated with better outcomes. However, there is a lack of evidence regarding the effect of operative versus nonoperative treatment for preventing premature knee OA in isolated ACL tears while achieving good functional outcomes.
PURPOSE/HYPOTHESIS: The purpose of the study was to compare the outcomes of ACLR to primarily nonoperative management of isolated ACL tears. It was hypothesized that the outcomes between treatment types would be similar.
Systematic review; Level of evidence, 3.
This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (registration No. CRD42021285901) and was conducted according to the Cochrane Handbook guidelines. We systematically searched for randomized and nonrandomized studies that compared ACLR with nonoperative treatments in isolated ACL tears in 3 databases until October 25, 2021. The risk of bias and quality of evidence of the included studies was assessed in accordance with the Cochrane guidelines. The primary outcome was radiologic signs of OA, and the secondary outcomes were functional parameters. Using the common effects model, we calculated pooled mean differences (MDs) and odds ratios (ORs) with 95% CIs.
Five studies-2 randomized controlled trials (RCTs) and 3 retrospective non-RCTs-were included. There was a moderate risk of bias in 2 studies and a serious risk of bias in 1 study. The quality of evidence was rated low because of the higher risk of bias and inconsistency. Nonoperatively treated knees showed a trend toward lower odds of developing radiological signs of OA (OR, 1.84 [95% CI, 0.90 to 3.75]); however, surgically reconstructed knees had significantly better stability (MD, -2.44 [95% CI, -3.21 to -1.66 ]) and a trend toward better but clinically not meaningful Lysholm scores (MD, 2.88 [95% CI, -1.09 to 6.85]). The qualitative synthesis showed that surgical reconstruction was protective against subsequent injuries but not superior when returning to previous activity levels or various functional tests.
Findings indicated that there is no certain evidence that ACLR for an isolated ACL tear is superior to nonoperative treatment. Clinicians should consider nonoperative treatments with a well-designed rehabilitative program as a primary option. However, these findings must be interpreted with caution because of low study quality and high risk of bias.
前交叉韧带（ACL）撕裂是早期骨关节炎（OA）发病的一个危险因素。一般来说，ACL重建术（ACLR）的效果更好。然而，对于单纯ACL撕裂在预防过早发生膝关节OA同时获得良好功能结局方面，手术治疗与非手术治疗的效果缺乏证据。
目的/假设：本研究的目的是比较ACLR与单纯ACL撕裂主要采用非手术治疗的效果。假设是不同治疗方式的效果相似。
系统评价；证据等级，3级。
本系统评价在国际前瞻性系统评价注册库（PROSPERO）上注册（注册号CRD42021285901），并按照Cochrane手册指南进行。我们在3个数据库中系统检索了比较ACLR与单纯ACL撕裂非手术治疗的随机和非随机研究，截至2021年10月25日。根据Cochrane指南评估纳入研究的偏倚风险和证据质量。主要结局是OA的放射学征象，次要结局是功能参数。使用固定效应模型，我们计算了合并均数差（MDs）和比值比（ORs）及95%可信区间。
纳入了5项研究——2项随机对照试验（RCT）和3项回顾性非RCT。2项研究存在中度偏倚风险，1项研究存在严重偏倚风险。由于偏倚风险较高且存在不一致性，证据质量被评为低质量。非手术治疗的膝关节出现OA放射学征象的几率有降低趋势（OR，1.84 [95%可信区间，0.90至3.75]）；然而，手术重建的膝关节稳定性明显更好（MD，-2.44 [95%可信区间，-3.21至-1.66]），并且Lysholm评分有改善趋势但在临床上无显著意义（MD，2.88 [95%可信区间，-1.09至6.85]）。定性综合分析表明，手术重建可预防后续损伤，但在恢复到先前活动水平或进行各种功能测试时并不优于非手术治疗。
研究结果表明，没有确凿证据表明单纯ACL撕裂行ACLR优于非手术治疗。临床医生应将精心设计康复计划的非手术治疗作为首选。然而，由于研究质量低和偏倚风险高，这些结果必须谨慎解读。
