Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis

Lien-Iversen, Teodor; Morgan, Daniel; Jensen, Claus Hjorth; Risberg, May Arna; Engebretsen, Lars; Viberg, Bjarke

doi:10.1136/bjsports-2019-100765

Cited by 61 publications

(69 citation statements)

References 40 publications

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“…In a recent meta-analysis, the prevalence of radiographic knee OA was lower among people with nonsurgical treatment. 25 Recurrent instability episodes after ACL injury may be associated with increased odds of medial meniscal damage, 41 which is a risk factor for OA. 3 , 8 , 28 , 31 However, most studies reporting an increased risk of meniscal damage in nonsurgically treated patients are retrospective reviews of patient records of patients subsequently undergoing reconstruction and exclude patients who have been successfully managed with rehabilitation.…”

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confidence: 99%

“… 3 , 8 , 28 , 31 However, most studies reporting an increased risk of meniscal damage in nonsurgically treated patients are retrospective reviews of patient records of patients subsequently undergoing reconstruction and exclude patients who have been successfully managed with rehabilitation. 25 , 41 This highlights the need for further prospective research comparing rates of radiographic and symptomatic OA after surgical and nonsurgical management of ACL injury.…”

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confidence: 99%

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Radiographic and Symptomatic Knee Osteoarthritis 32 to 37 Years After Acute Anterior Cruciate Ligament Rupture

et al. 2020

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Background: The long-term prevalence of knee osteoarthritis (OA) after anterior cruciate ligament (ACL) injury is unknown, especially in patients without a history of ACL surgery. Purpose: To (1) describe the prevalence of radiographic OA, symptomatic OA, and knee replacement surgery 32 to 37 years after acute ACL injury and to (2) compare the prevalence of radiographic OA, symptomatic OA, and knee symptoms between patients allocated to early ACL surgery or no ACL surgery and patients who crossed over to ACL surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Participants aged 15 to 40 years at the time of ACL injury were allocated to surgical (augmented or nonaugmented ACL repair) or nonsurgical ACL treatment within 14 days of injury. At 32 to 37 years after the initial injury, 153 participants were followed up with plain weightbearing radiographs and completed 4 subscales from the Knee injury and Osteoarthritis Outcome Score (KOOS). Radiographic OA was defined as Kellgren and Lawrence grade 2 or higher. Symptomatic OA was defined as radiographic OA plus knee symptoms measured with the KOOS. Results: Participants allocated to ACL surgery (n = 64) underwent surgery at a mean ± SD of 5 ± 4 days (range, 0-11 days) after injury. Of the 89 participants allocated to no ACL surgery, 53 remained nonsurgically treated, 27 had ACL surgery within 2 years, and 9 had ACL surgery between 3 and 21 years after injury. In the total sample, 95 participants (62%) had radiographic tibiofemoral OA, including 11 (7%) who had knee replacement. The prevalence of radiographic tibiofemoral OA was lower in the group allocated to ACL surgery compared with the group who never had ACL surgery (50% vs 75%; P = .005). The prevalence of symptomatic OA (50% in the total sample) and patellofemoral radiographic OA (35% in the total sample) was similar between groups. Conclusion: Patients allocated to early ACL surgery, performed a mean 5 days after injury, had a lower prevalence of tibiofemoral radiographic OA at 32 to 37 years after injury compared with patients who never had ACL surgery. The prevalences of symptomatic OA, radiographic patellofemoral OA, and knee symptoms were similar irrespective of ACL treatment. Overall, the prevalence of OA after ACL injury was high. Registration: NCT03182647 (ClinicalTrials.gov identifier)

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Radiographic and Symptomatic Knee Osteoarthritis 32 to 37 Years After Acute Anterior Cruciate Ligament Rupture

et al. 2020

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“…In contrast to our study—and longer term after ACL injury or reconstruction—a recent systematic review found a higher risk of radiographic knee OA >10 years after ACLR (range, 24%-80%) than after rehabilitation alone (range, 11%-68%), but because of low quality of included studies, the results should be interpreted with caution. 31 Early cartilage degeneration assessed using MRI has also been shown to be more pronounced after ACLR than after rehabilitation alone in some studies, 54 while no differences have been found in others. 58 Our study, along with studies with longer-term follow-ups 2 , 31 , 40 and animal studies, 7 reinforces the conclusion that reconstruction does not protect the ACL-injured knee from OA.…”

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confidence: 99%

“… 31 Early cartilage degeneration assessed using MRI has also been shown to be more pronounced after ACLR than after rehabilitation alone in some studies, 54 while no differences have been found in others. 58 Our study, along with studies with longer-term follow-ups 2 , 31 , 40 and animal studies, 7 reinforces the conclusion that reconstruction does not protect the ACL-injured knee from OA. Hence, rehabilitation alone does not provide inferior long-term outcomes compared with ACLR and is a viable solution for some patients.…”

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confidence: 99%

Low Rates of Radiographic Knee Osteoarthritis 5 Years After ACL Reconstruction or Rehabilitation Alone: The Delaware-Oslo ACL Cohort Study

Pedersen

Grindem

Berg

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: Patients and clinicians often struggle to choose the optimal management strategy for posttraumatic knee osteoarthritis (OA) after an anterior cruciate ligament (ACL) injury. An evaluation of radiographic outcomes after a decision-making and treatment algorithm applicable in clinical practice can help to inform future recommendations and treatment choices. Purpose: To describe and compare 5-year radiographic outcomes and knee pain in individuals who had gone through our decision-making and treatment algorithm and chosen (1) early (<6 months) ACL reconstruction (ACLR) with pre- and postoperative rehabilitation, (2) delayed (>6 months) ACLR with pre- and postoperative rehabilitation, or (3) progressive rehabilitation alone. Study Design: Cohort study; Level of evidence, 2. Methods: We included 276 patients with unilateral ACL injury from a prospective cohort study. Patients chose management using a shared decision-making process and treatment algorithm, and 5-year postoperative radiographs of the index and contralateral knees were assessed using the Kellgren and Lawrence (K&L) classification and minimum joint space width measurements. We defined radiographic tibiofemoral OA as K&L grade ≥2 and knee pain as a Knee injury and Osteoarthritis Outcome Score for Pain ≤72. To further explore early radiographic changes, we included alternative cutoffs for radiographic knee OA using K&L grade ≥2/osteophyte (definite osteophyte without joint space narrowing) and K&L grade ≥1. Results: At 5 years, 64% had undergone early ACLR; 11%, delayed ACLR; and 25%, progressive rehabilitation alone. Radiographic examination was attended by 187 patients (68%). Six percent of the cohort had radiographic tibiofemoral OA (K&L grade ≥2) in the index knee; 4%, in the contralateral knee. Using the alternative cutoffs at K&L grade ≥2/osteophyte and K&L grade ≥1, the corresponding numbers were 20% and 33% in the index knee and 18% and 29% in the contralateral knee. Six percent had a painful index knee. There were no statistically significant differences in any radiographic outcomes or knee pain among the 3 management groups. Conclusion: There were no statistically significant differences in any 5-year radiographic outcomes or knee pain among the 3 management groups. Very few of the patients who participated in our decision-making and treatment algorithm had knee OA or knee pain at 5 years.

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“…62 The effectiveness of current interventions/surgical repair in reducing onset and progression of PTOA remains controversial. 31,36,38 Research into better defining those at risk or identifying OA-inducing versus non–OA-inducing ACL injuries is therefore critically needed.…”

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Long-term Effect of a Single Subcritical Knee Injury: Increasing the Risk of Anterior Cruciate Ligament Rupture and Osteoarthritis

et al. 2020

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Background: Rupture of the anterior cruciate ligament (ACL) is a well-known risk factor for the development of posttraumatic osteoarthritis (PTOA), but patients with the “same injury” can have vastly different trajectories for the onset and progression of disease. Minor subcritical injuries preceding the critical injury event may drive this disparity through preexisting tissue pathologies and sensory changes. Purpose: To investigate the role of subcritical injury on ACL rupture risk and PTOA through the evaluation of pain behaviors, joint mechanics, and tissue structural change in a mouse model of knee injury. Study Design: Controlled laboratory study. Methods: Ten-week-old male C57BL/6J mice were allocated to naïve control and subcritical knee injury groups. Injury was induced by a single mechanical compression to the right hindlimb, and mice were evaluated using joint histopathology, anteroposterior joint biomechanics, pain behaviors (mechanical allodynia and hindlimb weightbearing), and isolated ACL tensile testing to failure at 1, 2, 4, or 8 weeks after injury. Results: Subcritical knee injury produced focal osteochondral lesions in the patellofemoral and lateral tibiofemoral compartments with no resolution for the duration of the study (8 weeks). These lesions were characterized by focal loss of proteoglycan staining, cartilage structural change, chondrocyte pathology, microcracks, and osteocyte cell loss. Injury also resulted in the rapid onset of allodynia (at 1 week), which persisted over time and reduced ACL failure load ( P = .006; mean ± SD, 7.91 ± 2.01 N vs 9.37 ± 1.01 N in naïve controls at 8 weeks after injury), accompanied by evidence of ACL remodeling at the femoral enthesis. Conclusion: The present study in mice establishes a direct effect of a single subcritical knee injury on the development of specific joint tissue pathologies (osteochondral lesions and progressive weakening of the ACL) and allodynic sensitization. These findings demonstrate a predisposition for secondary critical injuries (eg, ACL rupture) and an increased risk of PTOA onset and progression (structurally and symptomatically). Clinical Relevance: Subcritical knee injuries are a common occurrence and, based on this study, can cause persistent sensory and structural change. These findings have important implications for the understanding of risk factors of ACL injury and subsequent PTOA, particularly with regard to prevention and management strategies following an often underreported event.

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Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis

Cited by 61 publications

References 40 publications

Radiographic and Symptomatic Knee Osteoarthritis 32 to 37 Years After Acute Anterior Cruciate Ligament Rupture

Radiographic and Symptomatic Knee Osteoarthritis 32 to 37 Years After Acute Anterior Cruciate Ligament Rupture

Low Rates of Radiographic Knee Osteoarthritis 5 Years After ACL Reconstruction or Rehabilitation Alone: The Delaware-Oslo ACL Cohort Study

Long-term Effect of a Single Subcritical Knee Injury: Increasing the Risk of Anterior Cruciate Ligament Rupture and Osteoarthritis

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