Sports Medicine Research: In the Lab & In the Field: We’ll Ask the Question Again? Surgery or Nonoperative Treatment? (Sports Med Res)
Wednesday, July 27, 2016

We’ll Ask the Question Again? Surgery or Nonoperative Treatment?

Is anterior cruciate ligament reconstruction effective in preventing secondary meniscal tears and osteoarthritis?

Sanders TL, Kremers HM, Bryan AJ, Fruth KM, Larson DR, Pareek A, Levy BA, Stuart MJ, Dahm DL, Krych AJ. Am J Sports Med. 2016 Jul;44(7):1699-707.

Take Home Message: Patients who sustained an anterior cruciate ligament (ACL) rupture were more likely to develop secondary meniscal injury and arthritis when compared to a matched cohort. Specifically, those that were treated nonoperatively or with delayed surgery may be more likely to develop secondary meniscal injury, develop arthritis, and be in need of a total knee replacement when compared with those patients treated with early surgery.

After an anterior cruciate ligament (ACL) rupture, physically active patients often receive an ACL reconstruction if they wish to return to some level of activity. However, there is conflicting evidence about the long-term benefits of an ACL reconstruction. Therefore, Sanders and colleagues completed a retrospective study to 1) evaluate the protective benefits of ACL reconstruction (ACLR) with regards to meniscal tears and physician-diagnosed arthritis, 2) determine if there is an optimal time frame for undergoing treatment, and 3) identify predictive factors of long-term disability. The records of 964 patients with new-onset ACL tears between 1990 and 2000 were identified using the Rochester Epidemiology Project. Patients were included if they had no damage to other ligamentous structures in the knee. Patients who had concomitant meniscal injuries were included. Included patients were matched with 964 other patients who had no ACL injury. The authors found that of the 964 patients with an ACL rupture, 576 (60%) presented with meniscal damage at the time of an ACL diagnosis, 330 of which were treated with meniscectomy. The average time for follow-up were ~14 and ~15 years for ACL rupture and matched patients, respectively. Early (≤ 1-year post injury) ACLR was performed on 509 patients, while 91 underwent delayed reconstruction (≥ 1 year post-injury). A total of 364 patients opted for conservative care only. Overall, secondary meniscal tears were observed in 136 (37%) nonoperatively treated patients and 49 (8%) ACL reconstruction patients. With regards to arthritis, 115 nonoperatively treated patients and 51 ACLR patients developed arthritis, which caused the patient to seek the treatment of a physician and were confirmed radiographically. Ultimately, patients treated nonoperatively or with a delayed ACL reconstruction were at an increased risk of secondary meniscal tear, arthritis, and undergoing a total knee replacement compared with a patient who had an early ACL reconstruction. All patients with an ACL rupture were at a higher risk of arthritis compared to the matched patients.

Overall, this study presented some interesting data with regards to the long-term health of the knee joint following an ACL rupture. As can be expected, all patients with ACL rupture had high rates of meniscal tears and arthritis compared to a matched cohort. Further, patients who opted for nonoperative management or a delayed ACL reconstruction were at greater risk for poor outcomes than patients treated with an early ACLR. The current study may suggest that nonoperative treatment may fail to protect the joint over ~15 years after injury. However, before we can assess these findings some deficiencies need to be addressed. Firstly, prospective studies should be performed to better analyze the impact of treatments. While there are some inherent difficulties with this, record analysis does not address many subtle differences in treatment (e.g., types of rehab or surgery) and follow-up. A challenge in studying the long-term outcomes after an ACL injury is that our treatment strategies for ACL injury have changed dramatically over the past 25 years. Secondly, more details regarding the radiographic assessment of arthritis should be included. This will allow better understanding of the progression of disease and allow patient-to-patient comparison. Lastly, the data surrounding meniscal injury and arthritis is vast. In the current study, understanding the role the ACL rupture plays with regards to arthritis is difficult as 60% of the included patients had a meniscal tear at the time of injury. While this may be representative of patients with ACL ruptures, it makes interpreting the results difficult. It will be helpful to understand who will go onto develop arthritis and why. Ultimately though, the current study suggests that surgical treatment may better preserve the long-term health of the joint. This study is also a good reminder that we need to educate our patients about the long-term outcomes after an ACL injury so that we have an informed patient.

Questions for Discussion: What role do you play in making treatment decisions with your patients who sustain and ACL rupture? Do you focus on return to play or long-term health of the knee joint during these discussions?

Written by: Kyle Harris
Reviewed by:  Jeffrey Driban

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Sanders, T., Kremers, H., Bryan, A., Fruth, K., Larson, D., Pareek, A., Levy, B., Stuart, M., Dahm, D., & Krych, A. (2016). Is Anterior Cruciate Ligament Reconstruction Effective in Preventing Secondary Meniscal Tears and Osteoarthritis? The American Journal of Sports Medicine, 44 (7), 1699-1707 DOI: 10.1177/0363546516634325

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