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DELAYED ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION RESULTS IN SECONDARY INTRA-ARTICULAR PATHOLOGYMichael
Joneleit Medical Student University of Goettingen (Germany) Australian
Institute of Musculo-Skeletal Research Address
for correspondence: ABSTRACTTo determine the incidence of intra-articular pathology resulting from delayed Anterior Cruciate Ligament (ACL) reconstruction, we reviewed 1960 patients who had undergone a primary ACL reconstruction. There were 1443 males and 517 females, with an average age of 28.3 years. The average age at injury was 25.4 years. 1136 patients (58%) had secondary intra-articular pathology. Of these, 621 (54.7%) had a medial meniscal tear, 594 (52.4%) had a lateral meniscal tear and 381 (33.5%) had chondral damage. The average time from injury to reconstruction was 2.9 years (34.8 months). Those with secondary intra-articular pathology presented for reconstruction later, average 3.9 years (46.8 months), compared to those without secondary pathology, average 1.5 years (18 months). The incidence of secondary intra-articular pathology increased with delay between original ACL injury and reconstruction. 41% of those waiting 12 months; 60% of those waiting 3 years; 79% of those waiting 5 years and 88% of those waiting 10 years had secondary intra-articular pathology. This study confirms the relationship between an unstable ACL deficient knee and the incidence of secondary intra-articular pathology. Furthermore our study reveals the increasing incidence of meniscal and chondral pathology the greater the delay from injury to ACL reconstruction. To prevent unnecessary secondary intra-articular pathology we recommend ACL reconstruction is performed with minimal delay. INTRODUCTIONThe aim of our study is to document the incidence of intra-articular pathology resulting from delayed Anterior Cruciate Ligament (ACL) reconstruction. We assessed meniscal and chondral damage found at the time of primary ACL reconstruction, and the relationship of intra-articular pathology to time since original ACL injury. Patients requiring reconstruction were those who presented to the senior author with symptomatic instability in an ACL deficient knee. Recurrent instability was deemed symptomatic if it interfered with either athletic pursuit or activities of daily living. METHODA prospective study of intra-articular pathology (meniscal and chondral damage) associated with anterior cruciate ligament deficiency in patients undergoing primary anterior cruciate ligament reconstruction. The indication for surgery was recurrent, symptomatic instability interfering with athletic pursuit or activities of daily living. At the time of surgery a data sheet for each patient was completed. The data sheet recorded patient demographics, time since anterior cruciate ligament injury and associated intra-articular pathology found at the time of reconstruction. RESULTSOver a 17-year period between 1982 and 1999, 2263 patients underwent ACL reconstruction using a bone-patellar tendon-bone autograft. 303 patients were excluded because of incomplete data sheets, leaving 1960 patients in the study. There were 1443 males and 517 females, with an average age of 28.3 years (range 9 to 71 years) and a median of 26.0. The average age at injury was 25.4 years (range 8 to 68). The average time from injury to reconstruction was 2.9 years or 34.8 months (range < 1 week to 51 years). 58% (1136) of patients had associated intra-articular pathology at the time of ACL reconstruction. Those with associated intra-articular pathology had their primary reconstruction at an average 3.9 years (46.8 months) after ACL injury whereas patients with no associated pathology were reconstructed at an average 1.5 years (18 months) from injury. Of the 1136 patients with intra-articular pathology 621 (54.7%) had medial meniscal damage, 594 (52.3%) had lateral meniscal damage and 381 (33.5%) had chondral damage. The incidence of secondary intra-articular pathology increased with delay between original ACL injury and reconstruction. 41% of those waiting 12 months or less, 60% of those waiting 1 to 5 years (13 to 60 months), 76% of those waiting 5 to 10 years (61-120 months) and 88% of those waiting 10 years or more (> 120 months) had secondary intra-articular pathology (Graph 1). However, a more detailed assessment of the data shows, that there is a steady state in the secondary changes between 5 and 10 years (60 –120 months), with a further increase after 10 years. (Graph 2). Age and sex had no influence on the incidence of secondary pathology.Chondral damage accounted for only 15.8% of secondary pathology of those waiting up to 5 years for ACL reconstruction. However at 5 to 10 years delay chondral damage accounted for 28.2% and after 10 years delay 53.3% of secondary pathology (Graph 3). |
Graph 1: Incidence of secondary intra-articular pathology in relation to time from injury to ACL-reconstruction.
Graph 2: Steady state of pathology reached after 5 years followed by a second increase after 10 years.
Graph 3: Increasing incidence of chondral damage with time following injury.
DISCUSSIONAnterior cruciate ligament injuries are common (Daniel, Ellison, Del Pizzo, Cross/Harris/Slater) and cause significant short term and long term disability. With each episode of ACL instability there is subluxation of the tibia on the femur, causing stretching of the enveloping capsular ligaments and abnormal shear forces on the menisci and on the articular cartilage. Delay in diagnosis and treatment gives rise to increased intra-articular damage as well as stretching of the secondary stabilising capsular structures (Cross). ACL deficiency is associated with an increased incidence of meniscal injury and arthrosis (Daniel, Shelton, Eriksson). Reported rates of associated meniscal injury range from 49% (Daniel) to 59% (Shelton). Evidence of osteoarthritis has been shown in 77% (Eriksson) to 96% (Johnson) of chronic ACL tear groups and lead to a large number of permanent disabilities (Eriksson). Some authors argue that there is no difference in the outcome of ACL injuries in operatively and non-operatively treated patients (Roos). However the conservative treatment of the anterior cruciate deficient knee leads to a reduced number of satisfied patients (Bonamo). In our study of 1960 patients we found that 58% had secondary intra-articular pathology at the time of primary ACL reconstruction. Furthermore the incidence of secondary pathology increased from 41% at 1 year to 88% after 10 years delay from injury to reconstruction. Of interest is the fact that the majority of secondary pathology (79%) occurs in the unstable knee within 5 years of injury. Thereafter there is a relative steady state with little increased pathology until after 10 years. At this point a second increase in incidence occurs, probably due to increasing degenerative damage within the knee joint. This is supported by our findings of an increasing percentage of chondral, relative to meniscal damage, from 15.8% at 5 years to 53.3% after 10 years. Delay between injury and ACL reconstruction has been noted to increase meniscal injury and degenerative articular damage (McDaniel, Jacobsen). Jomha et al ( ) revealed that knees with chronic ACL deficiency, even those with intact menisci before reconstruction, suffered early osteoarthiritic changes. Acute ACL reconstruction with meniscal preservation was shown to have the lowest incidence of degenerative change. A statistically significant increase in the incidence of menisectomy required at the time of ligament reconstruction in chronically injured knees has been reported (Jomha). Early ligament reconstruction is recommended before further intra-articular damage occurs (Jomha, Noyes, Cross/Slater). Bonamo () states that reconstruction should be considered earlier rather than repeatedly nibbling away at the menisci and articular surfaces while the grossly unstable knee deteriorates. Our study confirms the relationship between an unstable ACL deficient knee and the incidence of secondary intra-articular pathology. Furthermore our study reveals the increasing incidence of meniscal and chondral pathology the greater the delay from injury to ACL reconstruction. To prevent unnecessary secondary intra-articular pathology we recommend ACL reconstruction be performed with minimal delay. REFERENCESCross M.J., Harris J., Slater H.K: Recent developments in the Treatment and repair of Anterior cruciate ligament Injuries in the Athlete. Sports Medicine 10 (6): 349-354, 1990 Daniel DM, Stone ML, Dobson BE, et al: Fate of the ACL-injured patient. A prospective outcome study. 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