Does ACL-reconstruction prevent early OA?

1. Does ACL-reconstruction prevent early OA? Ejnar Eriksson, M.D. Karolinska Institute, Stockholm, Sweden

2. Does ACL-reconstr. prevent OA? This is a highly debated subject! I wish I could give you a true and definitive answer. No consensus! So unfortunately, we still do not know the answer to this question. I will give you some information that might give you a little “food for thoughts”, though.

3. We all know that joint cartilage lacks blood supply and receives its nutrition from the joint fluid. The cartilage acts like a sponge – when compressed, fluid is squeezed out and when unloaded (during walking or running) it sucks up nutritious joint fluid. Joint cartilage

4. The easiest way to produce degenerative arthritis in a rabbit joint – is to immobilize the joint in a cast. Within some time you have severe arthrosis.

5. With that background, sports ought to be very good for our joints. During running we regularly load and unload our joints. This ought to improve the nutrition of the cartilage of our joints a lot.

6. Why then do we see 50-year old football players with horrible arthrosis after an ACL-injury like in this guy??

7. 25 years old ..or young football players like these two in their 20-ies with severe cartilage injuries/gonarthrosis after ACL-injuries? The explanation for their cartilage injuries is : 27 years old

8. ..that it is not the sport per se – the cartilage damage is caused by the injuries that the players have sustained!!

9. Does ACL-reconstr. prevent OA? An ACL-reconstruction would of course stabilize the knee and could prevent further dangerous pivot shifts. But if the cartilage damage is already there, an ACL reconstruction could only possibly stop further cartilage damage. The only way to find out more about this, is to search the literature…

10. Annual incidence of ACL injuries? • 3 /10 000 • In the population • 6 / 10 000 • In the active age group • 18 /10 000 • Soccer players • 27 /10 000 • Female soccer players • Nielsen & Yde -91 • Daniel & Fritchy -94 • Roos et al. -95

11. Does ACL-reconstr. prevent OA? • Medline 1960-2007: 3770 papers • Human studies, injury: 1203 • Prospective: 48 • Randomized: 16 • Controlled: 4 • Comparing surgery with no surgery : 1 Andersson, Odensten, Gillquist, 1991 (but they compared repair (+possible augmentation) with non-op treatment.

12. Does ACL-reconstr. prevent OA? Will reconstructive ACL-surgery increase or decrease the risk of OA after an ACL injury? Let’s look at the literature.

13. Does ACL-reconstr. prevent OA? • Lohmander & Roos 1994 • Neyret et al. Am J Sport Med, 1993 Review, 50% OA after 15 ys Soccer players, surg. treated 77% OA after 20 ys

14. Does ACL-reconstr. prevent OA? Non op treated, 12 ys, 37% JSN, 63% OA-changes • Segawa et al. Knee, 2001 • Myklebust et al. Am J Sports Med, 2003 • Lohmander et al 2004 • Neuman et al. 2005 42-46 % OA 8 years after ACL injuries in handball 42% and 48% OA, 12-14 ys 16 % after 15 ys, 0% if no meniscus injury in non-op.

15. Meunier et al: Scand J Med Sci Sports June 2007

16. Does ACL-reconstruction influence the development of arthrosis • ACL reconstruction: • Increases Daniel et al. 1994 • Patellar OA Lohmander et al. -04 • Decreases Hart et al. JBJS Br 2005 • Decreases Fink et al, ESSKA 2006 Kessler et al. ESSKA 2006

17. Effect of ACL-reconstruction on development of arthrosis Increase of arthrosis after ACL-reconstruction

18. Does ACL-reconstr. prevent OA? The group in Lund, Sweden with Harald Roos and Stefan Lohmander maintains that football players with ACL-injuries get arthrosis whether operated or not. This is a hot subject today. In Lund they are therefore right now making a propspective randomised study of ACL-reconstruction versus non-operative treatment of ACL.

19. Does ACL-reconstr. prevent OA?

20. Does ACL-reconstr. prevent OA? High incidence irrespective of treatment

21. Does ACL-reconstr. prevent OA? High incidence irrespective of treatment

22. Effect of ACL-reconstruction on development of arthrosis Positive effect of ACL-reconstruction

23. Does ACL-reconstr. prevent OA? Karl-Peter Benedetto and his group from Innsbruck saw less arthrosis after surgery than in non-op cases

24. We know from a series of excellent studies by Lohmander and his group in Lund, Sweden, that all injuries to a joint lead to release of harmful cytokines, that remain for quite a time and can cause cartilage damage.

25. Tesch et al showed in 2002 that activation of body adenosine A2a is the mechanism by which the body controls inflammatory joint-phenomena…

27. Will be published in KSSTA in July 2007

28. This is a very preliminary experimental study. If this holds true in larger controlled studies with longer follow-ups, maybe we could stop the cartilage damage caused by cytokines after injuries or surgery. I have actually written…

30. Does ACL-reconstr. prevent OA? Between 1968 and 1972, we operated 134 patellar tendon ACL-reconstructions at the Karolinska Hospital in Stockholm. In 1978, a young Robert J Johnson from Burlington, Vermont, USA came to Stockholm to follow up 84 of them after 5-10 years…

31. Does ACL-reconstr. prevent OA? These patients are now 35-40 years post surgery. We have therefore invited Bob Johnson to come back to Stockholm and re-examine the same cases.

32. Does ACL-reconstr. prevent OA? Heel-height KT-1000 One leg jump Isokinetics

33. Does ACL-reconstr. prevent OA? All the 86 we have studied so far have undergone X-ray and motion MRI. Unfortunately many of these patients had already had a meniscectomy before our ACL-reconstructions. 5-10 years after the ACL-reconstruction, Bob Johnson did not find any difference in arthrosis between the guys without menisci and the ones with intact menisci.

34. Does ACL-reconstr. prevent OA? 35 years later, the ones without menisci all have had a knee replacement or are waiting for one due to severe degenerative arthrosis. The ones with intact menisci and stable knees, are surprisingly good, though.

35. Does ACL-reconstr. prevent OA? These guys have been able to do pivoting sports ever since their surgery. They are now in their 60-ies and very satisfied with the operation. They do not have more arthrosis in the operated knee than in their healthy control knee.

36. Does ACL-reconstr. prevent OA? On motion MRI – one can see a normal-looking ACL that resists anterior drawer. Our study is not completed yet. But we already now can say that the “late” arthrosis evidently depends very much on absence of their menisci.

37. Does ACL-reconstr. prevent OA? The reason for performing an ACL-reconstruction thus seems to be to protect the menisci. Hogervorst found the same in his 2002 study like Meunier et al. in their 15 yr follow-up, 2007. But note this is for prevention of late osteoarthrosis.

38. Does ACL-reconstr. prevent OA? But your question to me was: Does ACL-reconstruction prevent EARLY osteo-arthrosis?? Let me therefore tell you the story of a young football player some 20 years ago. He came after an acute pivot-shift and ACL-injury…

39. These are his acute cartilage fractures . One can easily understand why such injuries lead to degenerative arthrosis in the future. In this case, it is questionable if an ACL-reconstruction could prevent early osteoarthrosis.

40. Does ACL-reconstr. prevent OA? I am sorry that I have not been able to give a clear-cut answer to your question. I hope, however, that I have given you some food for thoughts…

41. Invitations If you need an excuse for coming to beautiful Stockholm in September this year, we are arranging a fantastic conference then…

42. Invitations

43. Invitations 11th 13-18, 2008 If you like downhill skiing and Italian pasta – why not join me and the top faculty in beautiful Courmayeur in Italy Jan. 13-18, 2008. Our course always receives high points from the participants..

44. We eat lunch out on the slope…

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46. Thank you very much for your kind attention