Sports Medicine Research: In the Lab & In the Field: Cruciate Ligament Reconstruction: A Bad Sign for a Future Knee Arthroplasty (Sports Med Res)
Monday, January 27, 2014

Cruciate Ligament Reconstruction: A Bad Sign for a Future Knee Arthroplasty

The risk of knee arthroplasty following cruciate ligament reconstruction: A population-based matched cohort study

Leroux T, Ogilve-Harris D, Dwyer T, Chahal J, Gandhi R, Mahomed N, and Wasserstein D. J Bone Joint Surg Am. 2014; [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/24382718

Take Home Message: Patients who underwent cruciate ligament reconstruction were 7 times more likely to undergo prosthetic knee arthroplasty within 15 years of surgery. Other factors that increased the risk for knee arthroplasty included older patient age, female sex, higher comorbidity score, and a surgeon with a low annual surgical volume.

Despite extensive research on the relationship between cruciate ligament reconstruction and long-term knee health, much of the literature is riddled with methodological limitations including, but not limited to small sample sizes and disagreement on a radiographic threshold of osteoarthritis (OA). A better understanding of this relationship would allow clinicians to better inform patients of risk factors following cruciate ligament injury and eventually mitigate those risk factors to prevent OA and the eventual need for prosthetic knee arthroplasty. With this in mind, Leroux and colleagues completed a population-based matched cohort study to compare the rate of knee arthroplasty following cruciate ligament reconstruction with the rate of knee arthroplasty in the general population. The authors identified 34,786 patients who had undergone cruciate ligament reconstruction between July 1993 and March 2008 through a retrospective review of the Ontario Health Insurance Plan physician billing records. All of the patients were 16 to 60 years of age and had no prior knee arthroplasty or reconstruction. Each of the 30,301 case patients was matched to 5 control patients according to patient demographics (e.g., age, sex, comorbidity score). The authors assessed both cohorts for the occurrence of a knee arthroplasty from 1993 to 2012 to assess knee OA. At follow-up the individuals with a cruciate reconstruction and control cohort underwent 181 and 111 total knee arthroplasties, respectively. The cumulative incidence of knee arthroplasty was 7 times greater among those with a cruciate reconstruction than control patients. The overall event rate (per 1000 person-years) was higher for the patients with a cruciate reconstruction (0.68) than control (0.10) patients. Patient record analysis revealed that older age (> 49 years), female sex, higher comorbidity score, low annual surgeon volume of cruciate ligament reconstructions (<13 reconstructions), and a reconstruction in a university-affiliated hospital were associated with an increased risk of requiring a knee arthroplasty. Neither meniscal repair nor debridement at the time of reconstruction were associated with an increased risk of knee arthroplasty.

Overall, the current study presents clinicians with some interesting data surrounding a well-researched topic. Patients who undergo cruciate ligament reconstruction are significantly more likely to need a knee arthroplasty in the future. Furthermore, risk factors such as age, female sex, higher comorbidity score, and low annual surgeon volume of cruciate ligament reconstructions also influenced arthroplasty risk. Clinicians should be aware of this and press upon patients that finding an experienced surgeon can influence the long-term health of the joint. An especially interesting finding was that meniscal injury did not influence the risk of knee arthroplasty. This is not in agreement with much of the existing OA literature. Perhaps undergoing a knee arthroplasty, which is a more conservative outcome than radiographic determination of OA influenced the results because of the follow-up period was less than 15 years. Ultimately, the data presented in the current study is yet another building block for clinicians to better understand about the influence that cruciate ligament injury and reconstruction has on the long-term health of the knee joint. We can use this knowledge to educate our patients with a cruciate ligament rupture. 

Questions for Discussion: Do you believe that this information could be a useful tool to educate your patients with an ACL rupture? Do you feel athletes would be receptive to hearing about such long-term consequences as knee arthroplasty?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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Leroux T, Ogilvie-Harris D, Dwyer T, Chahal J, Gandhi R, Mahomed N, & Wasserstein D (2014). The risk of knee arthroplasty following cruciate ligament reconstruction: a population-based matched cohort study. The Journal of Bone and Joint Surgery. American Volume, 96 (1), 2-10 PMID: 24382718

4 comments:

Nicole Cattano said...

Kyle-Great post! I absolutely agree and think personally I would be open to hearing about the long-term consequences. Although I am older and have a different perspective. I'm not certain as to how open athletes may be to hear about this...I struggle with how to approach athletes about the long-term risks. They are very near-sighted and "just want to get back out there." Any advice?

Kyle said...

Nicole,

Great question! I wish the answer could be stated as simply and clearly as you question. This is an extremely difficult situation. I have dealt with this much at the JUCO level. Unfortunately not all strategies work on all athletes. When counseling athletes on long-term risks, I always try to identify something they are highly passionate about (family, being involved in their sport, their career) and try to impress upon them how long-term disability could affect that passion (inability to interact with children/cousins/etc., inability to coach/remain active in lower level competition, etc.). I also think its important to frame this conversation in terms trying to avoid this long-term disability. I have found that often athletes are willing to listen and work with you in you approach the situation compassionately. I like to use phrases like "I want you to be able to...in the future." I think this shows the athletes that you as the clinician are on their side and have their interesting in mind. For more short-sighted athletes I often ask the athlete to tell me what they will gain and what they will risk by returning to play at that time. Many times when these athletes are the one's to give you, the clinician, the pros and cons they often answer the question at hand for you. In the end getting clinicians need to appeal to the athlete, not as an athlete but as a person who will grow older and need to deal with any disability their participation causes.

Edward Grigoryan said...

Seeing as to how this study did not compare operative vs. non-operative patients with ACL injuries, couldn't ACL injury alone account for the greater likelihood of future knee arthroplasty? I find this to be a major confounder to this study.

Jeffrey Driban said...

Very true Edward. Several systematic reviews are in press with the Journal of Athletic Training that suggest individuals who undergo an ACL reconstruction are either at greater or equivalent risk for knee OA. I think one key finding from this study is the list of potential variables that may increase the risk (e.g., surgeon with less annual ACL reconstructions).

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