ACL SNNAP

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial.

Beard DJ, Davies L, Cook JA, et al. Lancet (London, England) 2022 · PMID 35988569 · doi:10.1016/s0140-6736(22)01424-6

Question

For patients with a non-acute ACL injury and ongoing symptoms of instability, is surgical reconstruction better than rehabilitation with the option of later reconstruction?

Design

Pragmatic, NIHR-funded multicentre RCT in NHS hospitals in the UK, with 18-month follow-up.

Patients

Adults with a non-acute ACL-deficient knee and symptoms of instability.

Intervention

Surgical ACL reconstruction

Comparison

Non-surgical rehabilitation, with optional reconstruction later if instability persisted

Primary outcome

KOOS4 at 18 months

Key result

Reconstruction gave a statistically significantly better KOOS4 at 18 months than rehabilitation. Around two-fifths of the rehabilitation group went on to have reconstruction within 18 months, so most avoided surgery in that period.

Limitations

Unblinded with substantial crossover from rehabilitation to surgery; the between-group difference was modest relative to commonly quoted minimal important differences.

Impact on practice

Supports offering reconstruction to UK patients with symptomatic non-acute ACL deficiency, while rehabilitation remains a reasonable first option that many patients find sufficient.