Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment

Knee. 2014 Mar;21(2):462-70. doi: 10.1016/j.knee.2013.10.009. Epub 2013 Oct 23.


Aims: The purpose of this study was to determine the optimal clinical and cost-effective strategy for managing people following ACL rupture.

Methods: A systematic review of the published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, psycINFO and the Cochrane Library) and unpublished literature (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) was conducted on April 2013. All randomised and non-randomised controlled trials evaluating clinical or health economic outcomes of isolated ligament reconstruction versus non-surgical management following ACL rupture were included. Methodological quality was assessed using the PEDro appraisal tool. When appropriate, meta-analysis was conducted to pool data.

Results: From a total of 943 citations, sixteen studies met the eligibility criteria. These included 1397 participants, 825 who received ACL reconstruction versus 592 who were managed non-surgically. The methodological quality of the literature was poor. The findings indicated that whilst reconstructed ACL offers significantly greater objective tibiofemoral stability (p<0.001), there appears limited evidence to suggest a superiority between reconstruction versus non-surgical management in functional outcomes. There was a small difference between the management strategies in respect to the development of osteoarthritis during the initial 20 years following index management strategy (Odds Ratio 1.56; p=0.05).

Conclusions: The current literature is insufficient to base clinical decision-making with respect to treatment opinions for people following ACL rupture. Whilst based on a poor evidence, the current evidence would indicate that people following ACL rupture should receive non-operative interventions before surgical intervention is considered.

Keywords: Anterior cruciate ligament; Clinical decision-making; Cost-effectiveness; Physiotherapy; Surgical management.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries*
  • Anterior Cruciate Ligament Reconstruction*
  • Bone-Patellar Tendon-Bone Grafting
  • Cost-Benefit Analysis
  • Decision Making
  • Humans
  • Joint Instability / etiology
  • Knee Injuries / diagnosis
  • Knee Injuries / therapy*
  • Osteoarthritis, Knee / etiology
  • Patient Outcome Assessment
  • Physical Therapy Modalities
  • Range of Motion, Articular
  • Rupture / therapy
  • Tendons / transplantation