Osteoarthritis Prevalence Following
Anterior Cruciate Ligament Reconstruction: A Systematic Review and
Numbers-Needed-to-Treat Analysis
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
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).
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.
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.
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?
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
by: Nicole Cattano
Reviewed
by: Jeffrey Driban
by: Jeffrey Driban
Related Posts:
Which is Better for ACL Surgery: Right Away, Later, or Never?
Other Resources:
Osteoarthritis Research Society International
Athletic Trainers’ Osteoarthritis Consortium
Other Resources:
Osteoarthritis Research Society International
Athletic Trainers’ Osteoarthritis Consortium
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
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!
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!