Article Text

Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis
  1. Tobias Saueressig1,
  2. Tobias Braun2,3,
  3. Nora Steglich2,
  4. Frank Diemer4,
  5. Jochen Zebisch1,
  6. Maximilian Herbst1,
  7. Wolfgang Zinser5,
  8. Patrick J Owen6,
  9. Daniel L Belavy2
  1. 1 Science and Research, Physio Meets Science GmbH, Leimen, Baden-Württemberg, Germany
  2. 2 Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit, Bochum, North Rhine-Westphalia, Germany
  3. 3 HSD Hochschule Döpfer (University of Applied Sciences), Cologne, North Rhine-Westphalia, Germany
  4. 4 DIGOTOR GbR, Brackenheim, Germany
  5. 5 Medical Practice, OrthoExpert, 8735 Fohnsdorf, Austria
  6. 6 Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
  1. Correspondence to Tobias Saueressig, Physio Meets Science GMBH, Leimen, Baden-Württemberg, Germany; t.saueressig{at}


Objective Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.

Design Living systematic review and meta-analysis.

Data sources Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.

Eligibility criteria Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.

Data synthesis Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.

Results Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.

Conclusions There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.

PROSPERO registration number CRD42021256537.

  • rupture
  • systematic review
  • rehabilitation
  • anterior cruciate ligament
  • randomized controlled trial

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  • Contributors Conceptualisation: TS, JZ, FD; data curation: TS, NS; formal analysis: TS; funding acquisition: NA. Investigation: TS, JZ, FD; methodology: TS, DB, TB, NS, MH; project administration: TS; resources: TS; software: TS; supervision: DB, PO, TB, WZ; validation: NA. Visualisation: TS; writing—original draft: TS, JZ, FD; writing—review and editing: all. Approved final manuscript: all.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. No funding was received to support this work.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.