How Do Meniscal and Chondral Injuries Affect the Results of ACL Reconstruction?
How Do Meniscal and Chondral Injuries Affect the Results of ACL Reconstruction?
abstract & commentary
Synopsis: Articular cartilage damage and meniscal tears requiring partial or total meniscectomy adversely affect the objective and subjective results of ACL reconstruction at intermediate to long-term follow-up.
Source: Shelbourne KD, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med 2000;28(4):446-452.
This was a retrospective review of more than 1000 patients undergoing ACL reconstruction between 1982 and 1992. Shelbourne and colleagues attempted to compare the results of ACL reconstruction in patients with meniscal tears requiring meniscectomy and/or grade 3 or 4 chondrosis to patients who had ACL reconstruction without meniscal tears or significant chondrosis. Subjective follow-up, consisting of a modified Noyes questionnaire, was obtained at a mean of 8.6 years after surgery in 75% of the study group. Objective follow-up, which included KT-1000 and complete IKDC evaluation, was obtained in only 39% of the study group at a mean of 7.6 years after surgery.
Subjective scores were significantly lower for patients who had meniscectomies (at least 3 points lower) or chondral injuries (at least 4 points lower). Activity level in these groups was also lower. On objective evaluation, the percentage of normal and nearly normal scores was significantly higher in the non-meniscectomy group with normal articular cartilage. In addition, KT-1000 measurements were significantly higher (2.6 mm vs 2.0 mm) in patients undergoing medial meniscectomy.
Comment by Mark Miller, MD
Although Shelbourne et al make a point that they performed "routine prospective follow-up," this clearly is a retrospective study with all of the problems associated with that type of study. The incompleteness of follow-up, especially for objective testing, was particularly disappointing. Nevertheless, Shelbourne et al draw several conclusions that may have merit.
As expected, meniscectomy, which is known to frequently lead to arthritis, and chondral injury, which basically is arthritis, adversely affected the results of ACL reconstruction. The medial meniscus is a secondary stabilizer to anterior translation; therefore, it is not surprising that partial or total meniscectomy will result in greater laxity by KT-1000 testing even in ACL-reconstructed knees. It was interesting that there was no difference in results of acute vs. chronic ACL reconstructions. It was also interesting that ACL reconstruction appeared to have a protective effect against developing meniscal tears in this study. Finally, the paper at least partially challenges the findings of Daniel1 and colleagues, who, in their landmark natural history study, suggested that ACL reconstruction resulted in more arthritis than patients with ACL-deficient knees. The present study suggests that ACL reconstruction does not lead to a higher incidence of arthritis. Instead, it appears that the associated meniscal and chondral injuries, which signify a more severe initial injury, play a more important role in the development of arthritic changes.
Reference
- Daniel DM, et al. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 1994;22: 632-644.
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