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Publications

Journal Article Ahead of print

PubMed: 42331698 DOI: 10.1016/j.jphys.2026.05.006

Smallest worthwhile effect of anterior cruciate ligament reconstruction compared with non-surgical management: a benefit-harm trade-off study.

J Physiother

Authors: Fahd Dibsh, Giovanni E Ferreira, Chris G Maher, Adam Culvenor, Evangelos Pappas, Harrison J Hansford, Simon Hall, Joshua R Zadro

Affiliations

  • Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia.
  • Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia.
  • La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia.
  • School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia.
  • School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.

Abstract

QUESTIONS

What is the estimated smallest worthwhile effect of anterior cruciate ligament (ACL) reconstruction followed by rehabilitation for improving knee function and return to sport compared with rehabilitation only? What are the associations between participant characteristics (age, gender, health insurance status, sports participation level, preference for surgery versus non-surgical management, previous ACL rupture) and these smallest worthwhile effect estimates?

DESIGN

Benefit-harm trade-off study conducted via an online survey.

PARTICIPANTS

A total of 92 people engaged in recreational or competitive sport.

DATA COLLECTION

Participants provided demographic information and answered two benefit-harm trade-off scenarios: a knee function scenario and a return to sport scenario. Participants indicated the minimum additional percentage improvement they would require for ACL reconstruction to be worthwhile compared with the anticipated percentage improvement with rehabilitation only. The expected benefits of rehabilitation only were based on published trial data. Associations between these smallest worthwhile effect estimates and participant characteristics were investigated using univariable regression models.

RESULTS

The median smallest worthwhile effect was 12% (IQR 8 to 16) for knee function and 41% (IQR 35 to 47) for return to sport. Smallest worthwhile effects were slightly higher for those participating in competitive sport. Age was associated with smallest worthwhile effect for the knee function scenario (0.3% increase per year older, 95% CI 0.1 to 0.4), although the size of this effect may not be clinically relevant. None of the tested predictors were associated with the smallest worthwhile effect for the return to sport scenario.

CONCLUSION

This study is the first to estimate the smallest worthwhile effect of ACL reconstruction. Participants require an additional 12% improvement in knee function or a 41% increase in the likelihood of returning to sport to justify undergoing ACL reconstruction. Therefore, the effects of surgery reported in many studies fall below what patients consider to be worthwhile.

REGISTRATION

OSF; https://osf.io/2kn97/.

MeSH

Anterior Cruciate Ligament Reconstruction, Rehabilitation, Return To Sport, Ligaments, Sports