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

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Improving informed choice about acupuncture and placebo interventions

Introduction: Patients need to be able to make informed choices about potential participation in medical treatments and trials for back pain. Yet research has shown that some patients hold misconceptions about treatments, and are not always provided with comprehensive information. This study asks: can providing comprehensive and empirically informed (‘enhanced’) information online about acupuncture and placebos improve informed choice about these interventions, compared with receiving ‘standard’ online information?Methods: First ‘enhanced’ online information pages about acupuncture and placebos were developed. 352 participants who had consulted with back pain in the last three years then took part in the study online to test these pages. Participants viewed either: (1) ‘enhanced’ acupuncture or ‘standard’ acupuncture content, and: (2) ‘enhanced’ placebo or ‘standard’ placebo content. Participants then completed self-rated measures of informed choice about these treatments.Preliminary results: Data for this study has not yet been analysed. A factorial 2 (acupuncture X placebo) by 2 (‘enhanced’ X ‘standard’ website) design will test for differences in informed choice across conditions.Conclusions: Research has shown that patients are not always given comprehensive information about medical treatments or trials. In developing ‘enhanced’ online information, we hope to improve informed choice about acupuncture and placebos, and, in doing so, highlight ways of enhancing information provision for patients making treatment decisions

COS Ambassadors

A collection of materials and resources for COS ambassadors