Sports Medicine Research: In the Lab & In the Field: Delayed ACL Reconstructions may be Associated with More Severe Meniscal and Chondral Lesions (Sports Med Res)


Friday, May 25, 2012

Delayed ACL Reconstructions may be Associated with More Severe Meniscal and Chondral Lesions

Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries.

Fok AWM, Yau WP. Knee Surg Traumatol Arthrosc. 2012 May [Epub ahead of print].

Anterior cruciate ligament (ACL) ruptures often coincide with meniscal and cartilaginous injuries. These ruptures are generally treated with surgical reconstruction or non-surgical treatment. Patients who chose to delay surgical treatment may be at greater risk for increasing the severity of the associated injuries; however, this has not been demonstrated in the literature. Therefore, Fok and Yau completed a retrospective, comparative study investigating (1) if delaying ACL reconstruction is associated with the number of meniscal and articular cartilage lesions, and (2) if ACL-deficient patients experiences greater frequency and magnitude of pain. A total of 150 patients (21 female, 129 male; 13 to 48 years old) were identified 1 week prior to their scheduled ACL reconstruction surgery. Patients were included if they experienced (1) instability during pivoting movements; (2) signs of ACL deficiency with Lachman’s, anterior drawer, or pivot shift test; and (3) magnetic resonance imaging revealed an ACL rupture. Patients were excluded if there was radiographic osteoarthritis present, a concomitant ligamentous injury, or an ACL revision procedure performed. Patients completed a self-reported medical history (which was verified with the hospital medical notes) and an IKDC questionnaire. At the time of surgery a single orthopedic specialist graded the cartilage injuries using a standardized documentation system. Patients were broken down into 2 subgroups for analysis (patients with greater than or less than 12 months delay between injury and surgery). Overall, the authors found that patients who delayed surgery more than 12 months, had significantly more meniscal damage which required removal rather than repair. Furthermore, patients with cartilage lesions had longer delays between injury and surgery. The authors also reported that the presence of intra-articular injuries was associated with more painful symptoms. For example, there was a moderate correlation between the size of the cartilage lesion and the frequency of pain experienced.

While this study provides some interesting data concerning whether or not patients who delay ACL reconstruction may have more meniscal damage and chondral lesions compared to patients who do not delay, its results must be interpreted cautiously. Firstly, this data cannot be applied to every patient that opts for nonsurgical care. This study focused on patients who had a delayed ACL reconstruction, which may indicate that the patient was having difficulties without an ACL (e.g., more symptoms, more episodes of giving way). Therefore, patients that successfully recovered with nonsurgical care were not studied. This study provides important data but we also need to consider that we can determine what damage is due to the ACL injury compared to wear over time. With this in mind, perhaps a study design such as a randomized control trial would be the ideal way to follow-up on this study. Despite the potential limitations, the data presented in this study suggests that immediate repair of the ACL may be beneficial to the long-term health of the joint compared to a delayed repair among knees that fail conservative management. With that in mind, perhaps we need to become more proficient at recognizing which patients are at risk for not tolerating conservative treatment and encourage them to pursue an early reconstruction to minimize the damage done to the meniscus and therefore, the promote long-term health of the joint. What do you currently recommend when advising your athletes on whether or not to undergo ACL reconstruction? What is the basis of your argument either for or against early ACL reconstruction?

Written by: Kyle Harris
Fok AW, & Yau WP (2012). Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 22552616


Andrew Lynch said...

Interpreted with caution indeed. We have no knowledge that those who have early reconstruction don't suffer the same degeneration a year after resuming activities. We probably won't have that information until our imaging studies improve to levels that can reliably measure that degeneration. Maybe follow-up arthroscopy will become accepted sometime soon.

As for how to identify those who need early reconstruction, there are so many factors which must be considered that current research techniques are insufficient to properly identify them. The registries that are frequently found in Scandinavian countries do not typically follow non-operative cases, although patient tracking with this scope will likely lead to a better understanding of non-operative outcomes.

Jeffrey Driban said...

Hi Andrew: I couldn't agree with you more. In fact, Kyle presented a systematic review at last year's NATA meeting (should be available in the JAT supplement) that there's no difference in the prevalence of osteoarthritis among those who undergo ACL reconstruction and those who don't when you assess studies that do head to head comparisons.

There is an randomized controlled trial evaluating "structured rehabilitation plus early ACL reconstruction and structured rehabilitation with the option of later ACL reconstruction if needed". Their preliminary results were published in the New England Journal of Medicine ( Frobell et al concluded "In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction." I believe they will be following these patients with multiple imaging modalities for several years so the answers to some of these questions could be just around the corner.

Jeffrey Driban said...

As an additional note...
Here's a SMR post related to the clinical trial Frobell et al are doing:

Guest Post: Structural Changes Occur in Knees After ACL Tears

Nicole Cattano said...

I think that current standards of practice are still to reconstruct the ACL after injury in an athletic population. However, recent research truly makes you start to question this concept. The notion of "early" reconstruction vs. delayed may warrant some more investigation as Andrew mentioned. But I think it may be more interesting to look at time until return to play, or even reconstruction vs. non-surgical options. Great post Kyle.

Jeffrey Driban said...

Nicole, you raise a great point. Regardless of how we manage the ACL injury (surgery or conservative care) a question that remains is when is it safe and optimal to return the patient back to activity. Unfortunately, while the first question (surgery vs conservative care) is being explored (and it should be) it seems the second question is not getting enough attention.

Court5km said...

I had a "delayed" reconstruction of my acl only because it was unkown to me that I had an ACL tear until my lateral meniscus was torn and started causing pain on my the lateral area of my knee. (10 yrs after the suspected acl tear incident). When I finally got an MRI, the report showed an atrophied ACL tear with a posterior horn meniscus tear. As a patient, I believe that early surgery is a better option to prevent further damage.

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