Does anterior cruciate ligament reconstruction lead to degenerative disease?  Thirteen-year results after bone-patellar tendon-bone autograft

Murray JRD, Lindh AM, Hogan NA, Trezies AJ, Hutchinson JW, Parish E, Read JW, & Cross MV. American Journal of Sports Medicine. 2011 November 23.  [Epub ahead of print] doi: 10.1177/0363546511428580

Anterior cruciate ligament (ACL) rupture is common in the athletic population. Many studies have demonstrated favorable short-term patient-centered outcomes after an ACL reconstruction; however, the long-term consequences of ACL reconstructions remain unclear.  The purpose of this study was to identify the incidence of osteoarthritis (OA) in patients that have undergone ACL reconstruction utilizing the bone-patellar tendon-bone autograft technique as well as to identify factors associated with poor radiographic and patient-centered outcomes. A total of 114 patients were included in the study and followed up with, on average, 13-years post ACL reconstruction.  Patients were evaluated for knee stability (i.e., Lachman, pivot shift, KT-1000), function (i.e., range of motion, Lysholm, International Knee Documentation Committee [IKDC] questionnaire), and joint structural status (i.e., radiographs).  Most patients had relatively high patient satisfaction (average 9 out of 10), good knee stability (~83% KT-1000 contralateral difference ≤ 3 mm), returned to sporting activity at their previous level (55%) and low re-rupture (4%) rates. In this cohort, 33% of the patients (28 out of 84 knees) evaluated had poor radiographic outcomes (OA) compared to 24% of assessed contralateral uninjured knees (10 out of 42 knees).  Factors that were associated with poor radiologic outcome in the ACL reconstructed knee were injury to the cartilage or meniscus, meniscectomy performed with ACL reconstruction, a poor IKDC subjective score, and the radiographic status of the contralateral medial compartment.  Similar factors, including chondral injury, previous surgery, previous surgery, not returning to sport, and poor radiographic grades, were identified as being associated with poor subjective outcomes (i.e., IKDC and Lysholm).

This study demonstrates that a considerable number of knees with a history of an ACL reconstruction have a high incidence of knee OA.  This study also provides important information about which factors may predispose patients to poor outcomes (radiographic and patient-reported).  This is the second study that I have recently reviewed that has shown no association between stability and patient-reported outcomes.  This further emphasizes that patient-reported outcomes may not be entirely linked to restoration of biomechanics.  Concomitant injuries to the meniscus or cartilage appear to increase the likelihood of radiographic OA and poor patient-reported outcomes.  It is very interesting that for the subgroup analyses, the only significant difference found was that all cartilage injuries were found in the delayed surgical group. The authors attribute all cartilage injuries being found in the delayed surgical group to the prolonged altered biomechanics while waiting to undergo surgery > 2 months post injury.  It may be critical to monitor patients for concurrent chondral or meniscal injuries as well as other structural changes and if present a plan may be needed to repair the secondary pathology rather than taking a wait and see approach.  Has anyone had any experiences with athletes’ early development of cartilage defects?  What factors or previous injuries have you clinically seen associated with the development of cartilage injury? It would be interesting to see the incidence of chondral defects over time after an ACL injury or isolated meniscus tears.

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Murray JR, Lindh AM, Hogan NA, Trezies AJ, Hutchinson JW, Parish E, Read JW, & Cross MV (2011). Does Anterior Cruciate Ligament Reconstruction Lead to Degenerative Disease? Thirteen-Year Results After Bone-Patellar Tendon-Bone Autograft. The American Journal of Sports Medicine PMID: 22116668