Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes

Am J Sports Med. 2018 Apr;46(5):1129-1136. doi: 10.1177/0363546517751683. Epub 2018 Feb 13.


Background: An anterior cruciate ligament (ACL) rupture has major consequences at midterm follow-up, with an increasing chance of developing an old knee in a young patient. The long-term (≥20 years) effects of the operative and nonoperative treatment of ACL ruptures are still unclear.

Purpose: To compare the long-term treatment outcomes of operative versus nonoperative treatment of ACL ruptures in high-level athletes.

Study design: Cohort study; Level of evidence, 2.

Methods: Fifty patients with an ACL rupture were eligible for participation, and they were treated either nonoperatively (n = 25) in 1992, consisting of structured rehabilitation and lifestyle adjustments, or operatively (n = 25) between 1994 and 1996 with an arthroscopic transtibial bone-patellar tendon-bone technique. The patients in the nonoperative group were drawn from those who responded well to 3 months of nonoperative treatment, whereas the patients in the operative group were drawn from those who had persistent instability after 3 months of nonoperative treatment. Both groups were pair-matched and assessed at 10- and 20-year follow-up regarding radiological knee osteoarthritis, functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner, Knee injury and Osteoarthritis Outcome Score), meniscal status, and knee stability (KT-1000 arthrometer, pivot-shift test, Lachman test, 1-legged hop test).

Results: All 50 patients (100%) were included in the current study for follow-up. After 20 years, we found knee osteoarthritis in 80% of the operative group compared with 68% of the nonoperative group ( P = .508). There was no difference between groups regarding functional outcomes and meniscectomy performed. The median IKDC subjective score was 81.6 (interquartile range [IQR], 59.8-89.1) for the operative group and 78.2 (IQR, 61.5-92.0) for the nonoperative group ( P = .679). Regarding the IKDC objective score, 21 patients (84%) in the operative group had a normal or near normal score (A and B) compared with 5 patients (20%) in the nonoperative group ( P < .001). The pivot-shift test finding was negative in 17 patients (68%) versus 3 patients (13%) for the operative and nonoperative groups, respectively ( P < .001), and the Lachman test finding was negative in 12 patients (48%) versus 1 patient (4%), respectively ( P = .002).

Conclusion: 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.

Keywords: anterior cruciate ligament; nonoperative; operative; osteoarthritis; rupture; treatment.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Anterior Cruciate Ligament Injuries / diagnosis
  • Anterior Cruciate Ligament Injuries / therapy*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Athletes*
  • Conservative Treatment / methods*
  • Female
  • Follow-Up Studies
  • Forecasting*
  • Humans
  • Male
  • Orthopedic Procedures / methods*
  • Physical Therapy Modalities*
  • Radiography
  • Retrospective Studies
  • Treatment Outcome