Clinical Outcomes and Osteoarthritis at Very Long-term Follow-up After ACL Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background: Few studies on outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) have provided insight into the very long-term effects of this procedure. Purpose: To systematically review the outcomes, failure rate, incidence, and predictors of osteoarthritis (OA) for different ACLR techniques at a minimum 20-year follow-up. Study Design: Systematic review; Level of evidence, 4. Methods: A search of the PubMed, SCOPUS, and Cochrane databases was performed on June 2020 for studies of patients who underwent ACLR and had a minimum follow-up of 20 years. We extracted data on patient and surgical characteristics, patient-reported outcomes (Lysholm score, subjective International Knee Documentation Committee [IKDC] score, Knee injury and Osteoarthritis Outcome Score [KOOS], and Tegner score), clinical outcomes (IKDC grade, pivot shift, Lachman, and KT-1000 laxity), degree of OA (Kellgren-Lawrence, Ahlbäck, and IKDC OA grading), revisions, and failures. Relative risk (RR) of OA between the operated and contralateral knees was calculated as well as the pooled rate of revisions, failures, and conversion to total knee arthroplasty (TKA). Results: Included were 16 studies (N = 1771 patients; mean age, 24.8 years; mean follow-up, 22.7 years); 80% of the patients underwent single-bundle bone–patellar tendon–bone (BPTB) reconstruction. The average Lysholm (89.3), IKDC (78.6), and KOOS subscale scores were considered satisfactory. Overall, 33% of patients had “abnormal” or “severely abnormal” objective IKDC grade, 6.7% had KT-1000 laxity difference of ≥5 mm, 9.4% had Lachman ≥2+, and 6.4% had pivot shift ≥2+. Signs of OA were reported in 73.3% of patients, whereas severe OA was reported in 12.8%. The operated knee had a relative OA risk of 2.8 ( P < .001) versus the contralateral knee. Identified risk factors for long-term OA were male sex, older age at surgery, delayed ACLR, meniscal or cartilage injuries, BPTB autograft, lateral plasty, nonideal tunnel placement, residual laxity, higher postoperative activity, and postoperative range of motion deficits. Overall, 7.9% of patients underwent revision, and 13.4% of ACLRs were considered failures. TKA was performed in 1.1% of patients. Conclusion: Most patients had satisfactory subjective outcomes 20 years after ACLR; however, abnormal anteroposterior or rotatory laxity was found in nearly 10% of cases. The presence of radiographic OA was high (RR 2.8 vs uninjured knee), especially in patients with concomitant meniscal or cartilage injuries, older age, and delayed surgery; however, severe OA was present in only 12.8% of cases, and TKA was required in only 1.1%.

Patients that maintain their pre-injury level of physical activity 3–5 years after ACL reconstruction are, 18 months after surgery, characterised by higher levels of readiness to return to sport

“…In the light of the increased risk of developing symptomatic knee osteoarthritis after an ACL injury [ 17 , 25 ], it is of great importance that patients with an ACL injury remain physically active throughout life. In the present study, the included patients appeared to quit organised PA, such as football, handball, and floorball, in favour of strength training and cycling/indoor cycling, when comparing the reported type of PA from pre-injury up to 5 years after the ACL reconstruction.…”

ACL Reconstruction Patients Have Increased Risk of Knee Arthroplasty at 15 Years of Follow-up

“…After 15 years, the cumulative incidence of knee arthroplasty was 1.4% following cruciate ligament reconstruction and 0.2% in the matched control patients from the general population. Grassi et al 10 , in a systematic review involving 1,771 patients who had been followed for at least 20 years after ACL reconstruction, reported that TKA was performed in 1.1% of patients. Khan et al 8 , in a 20-year follow-up study involving 49,723 individuals who had undergone TKA and 104,353 controls, found that 153 (0.31%) of the patients in the TKA group had sustained an ACL injury, compared with 41 (0.04%) of the controls.…”

“…Abram et al 7 analyzed data on >110,000 ACL reconstructions in the U.K., utilizing the national health-care records for England from 1997 to 2017, and found that 0.97% of patients with ACL reconstruction had knee arthroplasty within 10 years. Two case-control studies have suggested that ACL injury may be associated with up to 7 times greater odds of knee arthroplasty compared with the general population 8 , 9 , and a recent review presented concomitant meniscal injury as a risk factor for radiographic OA after 20 years 10 .…”

Correlation of Lower Limb Muscle Activity with Knee Joint Kinematics and Kinetics during Badminton Landing Tasks

“…Studies have shown that lower extremity injuries account for 40–80% of badminton injuries, and the anterior cruciate ligament is the most serious injury to the lower extremity [ 1 , 2 ]. As we all know, once an injury occurs, it requires a long recovery period, high costs, and unsatisfactory treatment effects, which may lead to serious sequelae, causing many athletes to end their sports careers [ 3 ]. The most common injury to the ACL is a non-contact ACL injury (70%), which usually occurs during side cuts, twists, and landings during sports.…”