Increased Risk of Osteoarthritis
After Anterior Cruciate Ligament Reconstruction: A 14-Year Follow-up Study of a
Randomized Controlled Trial
After Anterior Cruciate Ligament Reconstruction: A 14-Year Follow-up Study of a
Randomized Controlled Trial
Barenius
B, Ponzer S, Shalabi A, Bujak R, Norlen L, & Eriksson K. Am J
Sports Med. 2014 Published Online
First March 18, 2014: doi: 10.1177/0363546514526139
B, Ponzer S, Shalabi A, Bujak R, Norlen L, & Eriksson K. Am J
Sports Med. 2014 Published Online
First March 18, 2014: doi: 10.1177/0363546514526139
Take Home Message: Knees with a history of an anterior cruciate
ligament injury are more likely to have osteoarthritis compared with a healthy
contralateral knee but graft selection has no effect on long-term outcomes, such
as osteoarthritis or knee functional outcomes.
ligament injury are more likely to have osteoarthritis compared with a healthy
contralateral knee but graft selection has no effect on long-term outcomes, such
as osteoarthritis or knee functional outcomes.
An
individual with a history of an acute knee injury, including anterior cruciate
ligament (ACL) injury, is three to 6 six times more likely to have knee osteoarthritis
(OA) than someone without a history of injury.
Unfortunately, we lack a consensus on whether ACL reconstruction timing
and graft selection affects the risk for knee OA. Therefore, the authors completed an extended follow
up of a randomized clinical trial that compared quadrupled semitendinosus
tendon and bone-patellar tendon-bone grafts. They aimed to determine if graft
selection influenced the prevalence of OA 14 years after surgery. The authors assessed 135 (82%) participants
from the original trial. Three radiologists assessed the presence of OA in both
knees with weight-bearing radiographs and knee function was assessed via the Knee Injury and Osteoarthritis Outcome Score (KOOS). Roughly 50-70% of knees with an ACL
reconstruction had radiographic OA compared with 10-25% of healthy
contralateral knees. The authors found no difference in the prevalence of OA
between the two graft choices. Concomitant meniscectomy at the time of ACL reconstruction
increased the odds of having OA compared with individuals who had a meniscal
repair or no meniscal injury. The
authors also observed that time between injury and reconstruction did not
influence the chances of presenting with OA.
As expected, KOOS scores were lower among patients that had radiographic
evidence of OA (especially in the medial compartment) in comparison with those
that did not have any evidence of OA.
individual with a history of an acute knee injury, including anterior cruciate
ligament (ACL) injury, is three to 6 six times more likely to have knee osteoarthritis
(OA) than someone without a history of injury.
Unfortunately, we lack a consensus on whether ACL reconstruction timing
and graft selection affects the risk for knee OA. Therefore, the authors completed an extended follow
up of a randomized clinical trial that compared quadrupled semitendinosus
tendon and bone-patellar tendon-bone grafts. They aimed to determine if graft
selection influenced the prevalence of OA 14 years after surgery. The authors assessed 135 (82%) participants
from the original trial. Three radiologists assessed the presence of OA in both
knees with weight-bearing radiographs and knee function was assessed via the Knee Injury and Osteoarthritis Outcome Score (KOOS). Roughly 50-70% of knees with an ACL
reconstruction had radiographic OA compared with 10-25% of healthy
contralateral knees. The authors found no difference in the prevalence of OA
between the two graft choices. Concomitant meniscectomy at the time of ACL reconstruction
increased the odds of having OA compared with individuals who had a meniscal
repair or no meniscal injury. The
authors also observed that time between injury and reconstruction did not
influence the chances of presenting with OA.
As expected, KOOS scores were lower among patients that had radiographic
evidence of OA (especially in the medial compartment) in comparison with those
that did not have any evidence of OA.
This
study supports the notion that ACL graft selection does not affect long-term
outcomes (e.g., OA prevalence, function).
The high prevalence of OA among knees with an ACL reconstruction also
supports previous clinical trials that found that an ACL reconstruction may not
protect a knee from OA as discussed in previous posts. This is particularly concerning since the
average age of participants at follow-up was only 39 to 42 years. Interestingly,
this study further supports the notion that concomitant meniscal resection at
the time of ACL reconstruction places an individual at a higher risk for OA. It
is important to note, that the authors excluded participants who had additional
surgery on the involved knee or the contralateral (healthy) knee for
follow-up. It would be interesting to
see if the authors found any trends among those who needed surgery on either
knee within the follow up period. It
would seem reasonable that the prevalence rates reported in this study may be
lower than what we may see in the clinical setting because the authors excluded
these patients. Overall, this study further highlights that a large number of
individuals with an ACL injury may have OA early in life and that meniscal
status could be a key risk factor. In a medical community focused on
prevention, we need to strive to prevent not just injuries but also chronic
pain conditions like OA that could affect our patients for over half their
lives.
study supports the notion that ACL graft selection does not affect long-term
outcomes (e.g., OA prevalence, function).
The high prevalence of OA among knees with an ACL reconstruction also
supports previous clinical trials that found that an ACL reconstruction may not
protect a knee from OA as discussed in previous posts. This is particularly concerning since the
average age of participants at follow-up was only 39 to 42 years. Interestingly,
this study further supports the notion that concomitant meniscal resection at
the time of ACL reconstruction places an individual at a higher risk for OA. It
is important to note, that the authors excluded participants who had additional
surgery on the involved knee or the contralateral (healthy) knee for
follow-up. It would be interesting to
see if the authors found any trends among those who needed surgery on either
knee within the follow up period. It
would seem reasonable that the prevalence rates reported in this study may be
lower than what we may see in the clinical setting because the authors excluded
these patients. Overall, this study further highlights that a large number of
individuals with an ACL injury may have OA early in life and that meniscal
status could be a key risk factor. In a medical community focused on
prevention, we need to strive to prevent not just injuries but also chronic
pain conditions like OA that could affect our patients for over half their
lives.
Questions for Discussion: Do
you think that ACL injury is the primary culprit of OA development or is it
underlying concomitant injury? Are there
any other clinical findings that you see that may lead people to be more
susceptible to OA development after knee injury?
you think that ACL injury is the primary culprit of OA development or is it
underlying concomitant injury? Are there
any other clinical findings that you see that may lead people to be more
susceptible to OA development after knee injury?
Written
by: Nicole Cattano
by: Nicole Cattano
Reviewed
by: Jeffrey Driban
by: Jeffrey Driban
Related Posts:
Barenius, B., Ponzer, S., Shalabi, A., Bujak, R., Norlen, L., & Eriksson, K. (2014). Increased Risk of Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A 14-Year Follow-up Study of a Randomized Controlled Trial The American Journal of Sports Medicine DOI: 10.1177/0363546514526139
Biomechanical changes in the joint caused by the ACL reconstruction and the presence of muscle inhibition post-surgery predispose the patient to OA. How many of the patients included in this study returned to higher level sports following ACL-R and how many were recreationally active or sedentary? How does sport involvement following ACL-R contribute to the progression of OA and does it speed up the initial onset of OA?
Liz-Thank you for your comment. You are absolutely correct that some biomechanical changes occur secondary to the presence of muscle inhibition. However, there are residual biomechanical changes seen post-surgery due to joint contact forces and an inability of the surgery to completely restore native biomechanical properties. It remains unclear as to whether this is possible or what role these changes may play in propagating long-term changes.
This research study included participants ranging in age from 29 to 57 years of age with a mean age of 40. So very few of them were likely high level athletes. The Tegner activity scores showed an average scores ranging from moderately heavy labor to recreational sporting activities at each of the follow-up points.
Interestingly there have been several studies that have looked at surgical vs. non-surgical management of ACL and how OA is happening at comparable rates. It appears that the injury itself is the catalyst for the event and not necessarily what happens after the ACL injury.
In a group that has had ACL-R, it would be interesting to compare those who returned to sporting activity and those that did not return to sports. But it would be tough to control for so many other factors such as weight, general activity level, strength, etc. which may influence OA onset and progression.
I cannot say that I know of many people that choose to have ACL-R and not attempt to return to physical activity. Do you know of any???
everyone i know that had ACL-R returned to sports. I just wondered if there was a difference on OA onset in those who returned to high school or collegiate sports vs. those who chose to just become recreationally active and not continue to pursue high school or collegiate sports.