ACL EBM Mixed Bag

1. ACL EBM Mixed Bag Josh Lewis MD 5/2008 Fairfax Family Practice Primary Care Sports Medicine Fellowship

2. Primary Questions: • Does ACL reconstruction prevent osteoarthritis? • Who are the appropriate candidates for ACL reconstruction?

3. Secondary Questions: • Is there anything better on the horizon?

4. Who is a candidate? Age: • 1987-Kannus and Jarvinen conservatively treated patients mean age 32 years, mean follow-up 8 years-poor results in non-operative treatment • 1994-Ciccotti et al reported 83% satisfaction in patients mean age 46 treated conservatively. Pt’s required to modify activity

5. What about the Foagies? • Prior to 2006 the oldest studied population averaged 44 yearsby Heier et al. • Barber et al demonstrated similar satisfaction in 44yo group(91%) to 27yo group (89%) mean f/u 21 months • Dara Torres(at right) set U.S. record in 50m Freestyle at age 40

6. Age and ACL Reconstruction Revisited-Orthopedics Jun 2006 • 23 patients of avg age 54yrs(49-64) • Evaluated at 24mo post-op by validated questionnaire, PE, X-ray, KT-1000 • 16 returned for testing, 3 agreed to phone f/u

7. 15 patients had “excellent” or “good” results 4 patients had “fair” or “poor” results The above 4 were noted to have moderate to severe osteoarthritis Mean Lysholm score 92 Visual analog scale 0.5, satisfaction rating 100%, KT-1000 testing 2mm ROM 0-135 Results

8. Author’s Conclusions: • “This study should expand the indications for ACL reconstruction to 49-64 years of age” • “We believe that ACL reconstruction with allograft…in patients with minimal arthrosis is a safe successful and satisfying operation for both the patient and the surgeon.”

9. Study Weaknesses • No control group • Too small a sample for statistical significance • No intention to treat analysis • No correlation of results to meniscal or chondral pathology at initial arthroscopy

10. What about those with OA • ¾ patients with the outcome “fair or poor” from the previous study by Stein et al had moderate to severe OA on plain films before surgery

11. Noyes and Barber-Westin previously reported on 40 patients who underwent ACL reconstruction with severe arthrosis at the time of surgery Only 55% were able to return to light athletics Pain and instability may have been improved Retrospective cohort study:

12. Positive results • Shelbourne/Brenner reported statistically significant, improved subjective survey scores in 52 patients with isolated medial compartment arthrosis with chronic ACL deficiency • At a mean of 10 years post-op, significant improvement was noted compared to preoperative evaluation

13. Summary • Most studies impaired by small sample group, lack of control • Data is lacking, however there may be select patients with OA and chronic ACL deficiency who would benefit from reconstruction.

14. What if we don’t? • A 2007 case-control study of 38/73 consecutive patients from 1998-2003 (Strehl et al) • Selected for low clinical sx(no giving way), low to medium sports activity levels, no additional significant structural damage, ability to comply • Conservatively treated patients followed from 1-8 yrs, avg 3.4. • Parameters followed included sports activity, subjective knee function, and subjective function compared to pre-injury

15. One third of patients had good or very good results Two thirds of patients required reconstruction for persistant symptoms Similar results have been borne out in multiple studies Failure of conservative treatment particularly frequent in the active Results

16. Does ACL reconstruction reduce development of OA? • The American Journal of Sports medicine recently reviewed 127 studies • A formal meta-analysis was impossible secondary to poor consistency between recorded variables

17. The relative risk of developing knee OA after ACL rupture is approximately 4.7 Multiple reports estimate a 50% incidence of OA 10-20 years after ACL rupture or meniscus tear Meniscus injuries are a known risk factor for the development of OA The incidence of meniscus injury with ACL rupture is approximately 50% This frequency increases with time in an ACL deficient knee Does ACL reconstruction reduce development of OA?

18. Lysholm scores were extracted from 54 published studies Mean scores trended around 90, between, “good” and “excellent” There was no apparent time dependant trend This is inconsistent with long term patient reporting Does ACL reconstruction reduce development of OA?

19. The more recent measure, Knee Injury and Osteoarthrotis Outcome score (KOOS) suggests different results In 8 publications, the trend is that scores peak 1-2 years after reconstruction KOOS scores deteriorate with time after that point. Does ACL reconstruction reduce development of OA?

20. In 2 corresponding cohort studies of 219 male and 103 female soccer players with ACL rupture about 75% reported significant symptoms in the affected knee 42% had radiographic evidence of OA compared to 4% in the uninjured knee Neither study demonstrated a difference between conservatively and surgically treated patients Does ACL reconstruction reduce development of OA?

21. What about the meniscus? • Similar story to ACL rupture • 50% incidence of progression to OA in 15-20 years • Higher incidence if tear is degenerative

22. There is significant evidence that the initial injury sets in motion a cascade of degenerative changes in chondral cartilage CII degradation appears to be an early event following ACL rupture and is unlikely to be a direct result of mechanical loading Compared to cadaver controls, cartilage s/p ACL rupture demonstrates: Increased cleavage and denaturation of Type II cartilage Increased proteoglycan content Mechanism of OA

23. ACL injury changes static and dynamic loading of the knee generating increased forces on joint cartilage Additional injuries tend to accumulate with time, particularly to the meniscus Reconstruction in young active individuals has been shown to provide some protection against additional procedures (dunn, lyman) Mechanism of OA

24. AJSM is in agreement with a recent Cochrane review that literature review does not provide evidence that ACL reconstruction reduces the rate of OA development or improves long term symptom outcome Additionally there is no indication of a decreased rate of OA in recent reports compared to older studies ACL reconstruction

25. ACL reconstruction • Reports do seem to suggest that ACL repair may protect against future meniscus injuries • Although this may be expected to lower the rate of OA development, this has yet to be shown

26. Risk Factors predicting poor outcome • Female Sex • Obese • Lateral Meniscectomy • Those with finger joint OA-genetic propensity

27. Current areas of Study

28. Current ACL reconstruction techniques are excellent at restoring anterior-posterior instability Multiple studies have demonstrated decreased efficiency at returning rotational kinematics to normal Rotational Kinematics

29. Dayal et al studied 230 patients with knee OA Knee laxity and AP semi-flexed radiographs obtained at start and 18 months Degree of laxity was not found to be predictive of progression of OA Other studies (Leitze et al, Jonsson et al) have found that the presence of a post operative pivot shift was predictive of poor outcome An abnormal Lachman absent a pivot shift had no correlation with outcome measures Rotational Kinematics

30. Multiple grafts and tibial tunnels used with the intent of better approximating the anteromedial (AP-stability), and posterolateral (rotational stability) bundles of the normal ACL While there is significant data suggesting improved rotational stability, no study to date has demonstrated improved clinical outcome. Double Bundle ACL Reconstruction

31. Double Bundle ACL Reconstruction • Risks include increased potential for intraoperative tibial fracture, and increased difficulty if revision becomes necessary.

32. ACL reconstruction is indicated for patients up to age 65, and possibly beyond ACL reconstruction has been shown to improve patient perception of stability ACL reconstruction has not been shown to decrease progression to OA or improve long term outcomes Double bundle reconstructions have not been shown to be clinically superior and require further study Take Home Points

33. References • Age and ACL Reconstruction Revisited. Stein et al, Orthopedics. June 2006. Volume 29 iss 6(533-537) • Isolated Anterior cruciate ligament reconstruction in the chronic ACL-deficient knee with degenerative medial arthrosis. Shelbourne KD, Brenner RW. The Journal of Knee Surgery. July 2007. 20(3):216-22 • Dunn WE, Lyman S, The effect of ACL reconstruction on the risk of knee injury. Am J of Sports Med. 2004;32:1906-1913 • Dayal et al, The Natural history of Anteroposterior laxity and its role in knee OA progression. Arthritis and Rheumatism. August 2005. 52(8) 2343-2349 • Leitz et al, Implications of the pivot shift in the ACL deficient knee. Clinical orthopedics and related research. July 2005. 436:229-236

34. References • Joonsson H et al, Positive pivot shift after ACL reconstruction predicts later OA…, Acta Orthopaedica Scandinavica. Oct 2004. 75(5):594-9 • Sempeles S, ACL reconstruction’s effectiveness questioned in restoring knee function. Bone and Joint. January 2005. 11(1)pp1, 3-4