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Early Versus Delayed Reconstruction of the Anterior Cruciate LigamentA Decision Analysis Approach
Joseph Bernstein, MD1
1 Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104. E-mail address: orthodoc@post.harvard.edu
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Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 May 04;93(9):e48 1-5. doi: 10.2106/JBJS.J.01225
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A recent randomized controlled trial compared early anterior cruciate ligament reconstruction with a program of initial rehabilitation, with delayed anterior cruciate ligament reconstruction if needed. The authors reported that the improvement in Knee Injury and Osteoarthritis Outcome Scores was nearly identical in both groups and concluded that in young, active adults with acute ACL (anterior cruciate ligament) tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. Yet, in making that assessment, the authors did not account for the fact that there were more meniscal injuries in the group with delayed anterior cruciate ligament surgery. Establishing the true superiority of one strategy requires consideration of meniscal injury, as well as a further determination if the apparent protective effect regarding meniscal tears found in the cohort of patients with early anterior cruciate ligament reconstruction is offset by the costs of additional reconstructive surgery. That analysis of offsetting utility, omitted in the randomized controlled trial noted above, is provided in the present study.


A decision analysis model considering the options and probabilities described in the randomized controlled trial was constructed: the functional outcome of all groups was assumed to be equal, the likelihood of a patient eventually needing surgery despite initially choosing a program of rehabilitation was 37%, and the likelihood of needing a meniscectomy was 23% for the early surgery group and 35% for the rehabilitation and deferred anterior cruciate ligament reconstruction group.


The early surgery option is the preferable therapeutic approach as long as the costs of a potential meniscal tear are at least 5.25 times the costs of reconstructive surgery.


Early surgery for anterior cruciate ligament tears may be the preferred approach for some patients, on the basis of the utility values they assign to the possible treatment outcomes. The reported randomized controlled trial did not establish a dominant strategy. Indeed, early surgery may be the more effective approach overall.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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