Delay in ACL reconstruction is
associated with more severe and painful meniscal and chondral injuries.

Fok AWM, Yau WP. Knee
Surg Traumatol Arthrosc. 2012 May [Epub ahead of print].

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.

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?

Written by: Kyle

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