AJSM - 2026-06-08 - Journal Article
Patient-Reported Knee Function and Return-to-Sport Rates After Nonsurgical and Surgical Treatment of an Acute Anterior Cruciate Ligament Injury: Results From the NACOX Prospective Cohort Study.
Croné A, Gauffin H, Hedevik H, Fältström A, Kvist J
Topics
Key Takeaway
At 24 months, non-ACLR and ACLR groups achieved equivalent IKDC-SKF scores and comparable RTS rates (72% vs 77%), but patients aged 26–40 years undergoing ACLR had a 3.15-fold higher risk of not returning to sport versus nonsurgical management.
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Summary
The NACOX multicenter cohort compared patient-reported knee function (IKDC-SKF) and RTS between non-ACLR and ACLR treatment groups over 24 months using shared decision-making allocation. Despite the ACLR group being younger (24.2 vs 27.6 years) with higher preinjury Tegner levels (8 vs 6.5), linear mixed-effects modeling found no between-group difference in IKDC-SKF scores at any timepoint. Overall RTS was 75% with no group difference, but non-ACLR patients returned faster (3.5 vs 8.1 months) and ACLR was associated with 3.15× higher risk of not returning to sport in the 26–40 age subgroup.
Key Limitation
Non-randomized treatment allocation with significant baseline differences in age and preinjury activity level between groups means residual confounding cannot be excluded despite multivariable adjustment.
Original Abstract
BACKGROUND
The best treatment for acute anterior cruciate ligament (ACL) injuries (surgical or nonsurgical) remains uncertain, particularly regarding return to sport (RTS) and knee function.
PURPOSE
To compare patient-reported knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]) and RTS between non-ACL reconstruction (ACLR) and ACLR treatment strategies 24 months after ACL injury or reconstruction and identify predictors of these outcomes.
STUDY DESIGN
Cohort study; Level of evidence, 2.
METHODS
From the NACOX multicenter cohort, 272 patients (mean age, 25.5 years; 95% CI, 24.6-26.3 years; 52% females) with acute ACL injuries were followed for 24 months after ACL injury or ACLR. Treatment (non-ACLR vs ACLR) was determined via shared decision-making in routine practice. IKDC-SKF scores were collected at 3, 6, 12, and 24 months and analyzed using a linear mixed-effects model adjusted for age, sex, preinjury activity level, and new serious knee injury. RTS was defined as return to preinjury Tegner level or higher. Risk factors for not returning to sport were evaluated using log-binomial regression.
RESULTS
The ACLR group had higher preinjury Tegner levels (8 vs 6.5; P < .001) and was younger (24.2 vs 27.6 years; P < .001). No differences in IKDC-SKF scores were observed between non-ACLR and ACLR groups. IKDC-SKF scores improved over time for both groups ( P < .001) but were negatively affected by new serious knee injury ( P < .001), older age ( P = .003), and female sex ( P = .004). Overall, 75% of patients achieved RTS within 24 months (mean, 6.3 months; 95% CI, 5.6-7.0 months), with no difference between groups (72% non-ACLR vs 77% ACLR; P = .286). Patients without ACLR returned to sport earlier (3.5 months [95% CI, 2.8-4.2 months] vs 8.1 months [95% CI, 7.2-9.0 months]; P < .001). In patients aged 26 to 40 years, ACLR was associated with a 3.15-fold higher risk of not returning to sport at 24 months compared to the non-ACLR group ( P = .015).
CONCLUSION
In this cohort of patients with ACL injury, both nonsurgical management and ACLR, determined through shared decision-making, resulted in comparable patient-reported knee function and RTS rates at 24 months, although the ACLR group was younger and had higher activity level. Non-ACLR treatment may therefore be a viable option for selected patients, particularly those who are older or have lower activity demands, to achieve satisfactory RTS outcomes. Older age (26-40 years) was associated with a higher risk of not returning to sport after ACLR, highlighting the importance of individualized treatment decisions.