Sports Medicine Research: In the Lab & In the Field: ACL Reconstruction Provides Not So Good Long-Term Outcomes (Sports Med Res)


Wednesday, October 15, 2014

ACL Reconstruction Provides Not So Good Long-Term Outcomes

Osteoarthritis Prevalence Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Numbers-Needed-to-Treat Analysis

Luc B, Gribble PA, & Pietrosimone B. Journal of Athletic Training. 40(3) Published online first June 2014. doi: 10.4085/1062-6050-49.3.35

Take Home Message:  There is very little evidence that an anterior cruciate ligament (ACL) reconstruction can reduce the risk of knee osteoarthritis (OA).     

The primary goal of an ACL reconstruction is to restore stability and return a patient to a physically active life in the short term.  While many patients successfully return to physical activity, it remains less clear whether an ACL reconstruction can help prevent a patient from developing knee OA.  This systematic review aimed to determine if patients who underwent ACL reconstruction had lower knee OA prevalence than patients who tore their ACL but remained ACL deficient.  The authors assessed 38 studies, including 2837 total patients.  Analyses revealed that the 2500 patients who had an ACL reconstruction had a slightly higher OA prevalence (44%) than the 337 patients who remained ACL deficient (37%). Hence, patients with an ACL reconstruction are 1.29 times more likely to have knee OA later in life.  The overall prevalence rates for an isolated ACL injury revealed that ACL reconstructed patients had higher OA rates (42%) than ACL deficient patients (29%).  However, when there was a concomitant meniscal injury that required meniscectomy, ACL reconstruction patients had slightly lower OA prevalence (52%) than those who remained ACL deficient (59%) when there was a concomitant meniscal injury.  The authors found that a patient with an ACL reconstruction was more likely to have knee OA later in life if s/he had an open patellar tendon reconstruction (47%) or patellar tendon autograft (47%) compared with a patient who remained ACL deficient. In contrast, a patient who received a hamstrings autograft reconstruction (29%) may be less likely to have knee OA later in life.

This is another study that fails to provide support for the prophylactic value of ACL reconstruction to prevent knee OA.  Particularly if a patient suffers an isolated ACL injury s/he may have more of a decision to make now.  As clinicians, we need to understand the potential long-term effects of knee injuries in order to best educate our patients.  Surgery might not always be necessary.  This type of research may provide support to trying to conduct rehabilitation first to determine if conservative management and remaining ACL deficient will be sufficient to accomplish the short-term goals of the patient.  It is unclear if these results can be applied to today’s ACL surgical techniques because they are continually evolving (graft selection, single vs. double bundle) and we don’t have long term data on these newer techniques.  It would be interesting to be able to follow more ACL deficient patients longitudinally to determine whether they are true copers, become less physically active, or if they have repetitive giving-way episodes.  The meniscus seems to be a critical factor in OA risk, and giving-way episodes could threaten the integrity of the meniscus.  There were a small number of patients that were followed for over 19 years following injury, and those who remained ACL deficient had slightly higher OA prevalence rates than those that had reconstruction done; however, the sample size was small and this demonstrates an area that needs further investigation. It is going to be extremely important to follow more patients longitudinally longer to determine the long-term outcomes.  There may be a reason to have a slight shift in sports medicine thinking, just because an ACL is torn, does not necessarily mean that it needs to be fixed.  High OA prevalence rates post-knee injury mean that patients are likely to be living with a chronic disease that will negatively affect their lives.  These changes are occurring after they leave our care, but as sports medicine clinicians and researchers, we need to find mechanisms to best mitigate these long-term negative outcomes after a knee injury.

Questions for Discussion:  Have you ever advised or worked with any ACL patients who decided to remain ACL deficient?  If you personally suffered an ACL tear today, would you consider conservative management – why or why not?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Luc, B., Gribble, P., & Pietrosimone, B. (2014). Osteoarthritis Prevalence Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Numbers-Needed-to-Treat Analysis Journal of Athletic Training DOI: 10.4085/1062-6050-49.3.35


Stephan Bodkin said...

I agree that the main reason patients pursue ACL-reconstruction is to regain the stability within their knee to return to their previous level of activity. As studies suggest, the long-term health of the knee joint is not optimal as an early onset of cartilage degeneration is seen. As clinicians, I feel like our best effort to prevent this early onset of OA is to manage when these athletes are returning to play. I feel that many rehabilitation protocols are followed by where the athlete should be, and not where the athlete actually stands. I feel like many athletes return to play before they should be, resulting in the performance deterioration that these athletes express. I feel like more return to play decisions should be made from strength symmetry form the contralateral knee. Also, the rehab being performed to reach this symmetry should not be stopped at the time of return to play. I agree that following more ACL patients longitudinally could provide information that could help treatment decisions. Great article!

Jeffrey Driban said...

Hi Stephan:
Great points. Hopefully, future research can help us understand how return to play status influences the risk of OA. I agree we need to consider strength symmetry but also absolute strength. If the contralateral leg is no longer 100% of its strength compared to before the injury then it may not always be the ideal reference. I think you are absolutely correct that RTP should not be the end of the rehab but instead the beginning of a new phase of rehab exercises. Thanks for the comment!

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