Delay in ACL reconstruction is
associated with more severe and painful meniscal and chondral injuries.
associated with more severe and painful meniscal and chondral injuries.
Fok AWM, Yau WP. Knee
Surg Traumatol Arthrosc. 2012 May [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/22552616
Surg Traumatol Arthrosc. 2012 May [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/22552616
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.
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?
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
Harris
Reviewed by: Jeffrey
Driban
Related Posts:
“To Reconstruct Or Not To Reconstruct?” That is the question. – ACL Tears in the Skeletally Immature
Articular Cartilage Damage and Long-term Changes After an ACL Tear
Risk Factors for Poor Long-Term Outcomes among Knees with ACL Reconstructions
Predictors of Knee Osteoarthritis After ACL Reconstruction
Driban
Related Posts:
“To Reconstruct Or Not To Reconstruct?” That is the question. – ACL Tears in the Skeletally Immature
Articular Cartilage Damage and Long-term Changes After an ACL Tear
Risk Factors for Poor Long-Term Outcomes among Knees with ACL Reconstructions
Predictors of Knee Osteoarthritis After ACL Reconstruction
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
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.
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 (https://www.ncbi.nlm.nih.gov/pubmed/20660401). 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.
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
https://sportsmedresearch.blogspot.com/2011/07/guest-post-structural-changes-occur-in.html
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.
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.
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.