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.

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.

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

Written by: Kyle Harris
Reviewed by:  Jeffrey Driban

Related Posts:

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