Prevalence of osteoarthritis after conservative versus reconstructive treatment of anterior cruciate ligament rupture. D. Tsoukas V.Ch. Fotopoulos Orthopaedic Surgeon Orthopaedic Surgeon Director Orthopaedic Consultant & Sports Medicine Athens Medical Centre

Aim - Purpose The theory that prompt operative intervention reduces long-term osteoarthritis after ACL tear is not yet confirmed by the literature. The purpose of the present study is to evaluate the outcome of conservative versus ACL-reconstructive treatment with hamstrings.

Retrospective nonrandomized controlled clinical trial Methods Retrospective nonrandomized controlled clinical trial Homogeneous studied populations. 32 male patients with isolated ACL rupture and no concomitant injuries (meniscal tears or osteochondral lesions) were evaluated. Inclusion criteria - Tegner and Lysholm activity scale 5−7, - BMI <30, - a minimum of 5-year follow-up, - no previous surgery or injury of the knee.

Methods The patient’s selection for conservative or ACL-reconstructive treatment was made upon knee laxity measurements (pivot-shift test) and his will. Patients with an unstable knee (>5mm AP translation) that did not wish to undergo an operative treatment option were excluded from the study.

Methods 15 patients (mean age 33 years; range 25-39 years) were treated conservatively. 17 patients (mean age 31 years; range 20-36 years) had: - an early (<3 months after injury), - arthroscopic - ACL single-bundle reconstruction - with a four-stranded - semitendinosus-gracilis tendon autograft - using the anteromedial portal for the femoral tunnel.

Methods

Methods The follow-up assessment was established using the 2000 Revised IKDC Subjective Knee Evaluation Form. Quantitative laxity testing was performed with a KT-1000 arthrometer. The joint space narrowing assessment used the IKDC score with a 30 degrees posteroanterior weightbearing view.

Results Mean follow-up was 7 years (7±1.459 years; range 5-11 years).

Results According to IKDC scores, the operative group performed slightly better compared to the nonoperative group (86.76±6.517 vs. 77.48±13.79; P=0.0363). There was significant difference between the groups in KT-1000 arthrometer side to side tests (1.5±0.2 mm vs. 4.5±0.5 mm)

Results The observed degenerative joint changes were similar in the two groups (8/17 vs. 7/15 IKDC grade C or D). There was a deterioration of the physical activity levels after ACL rupture, though independent of the method of treatment –operative vs. conservative (Tegner and Lysholm activity scale 3-6). There was no correlation between radiologic findings and pain scores.

Results

Discussion Based on these results, it seems that ACL reconstruction with hamstrings does not reduce the incidence of further radiographic osteoarthritis. This finding is in accordance with numerous previous studies suggesting that ACL reconstruction did not prevent arthrosis. Is ACL rupture really the beginning of the end of the knee, as it was stated by Torg in 1976?

Discussion A change in cytokine and keratinsulphate profiles was observed after ACL rupture in injures knees. Arthritis could be induced by these biochemical alterations. Perhaps we should consider these alterations when we recommend the earliest ACL reconstruction possible. Could it be that we induce a “second hit” phenomenon inside the knee joint, the reason for the development of osteoarthritis?

Discussion The patients included in the present study had no concomitant injury (meniscal tear or osteochondral lesion). However, marrow signal changes detected only by MRI were frequently observed at time of ACL rupture. These are signs of subchondral lesions that could induce changes in the overlying cartilage over time. Many clinical and experimental studies suggest that bone bruises are a precursor of degenerative changes.

Conclusion Despite our efforts to eliminate the heterogeneity of the groups, this was not possible. The small sample size of the comparable groups pose the need for additional studies with larger cohorts. Although the functional scores showed a difference in favor of patients that followed the reconstructive treatment regimen, conservative treatment still remains an option. A correct neuromuscular rehabilitation program can result in improvement of knee stability in selected patients without the risk of an operation.

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