LUND, Sweden— Surgical repair of tears to the anterior cruciate ligament (ACL) and menisci might stave off osteoarthritis (OA) in patients, but the research evidence is far from conclusive, according to a review article published online in The American Journal of Sports Medicine.¹

"The lack of evidence for this surgical therapy to prevent OA development might be explained by an insufficient quality of the published studies, by the surgical reconstruction not yet being good enough, or by the OA process being initiated and driven by other events," concludes lead author and CIAOMed editorial board member Stefan Lohmander, MD, orthopaedist at Lund University, in Sweden.

Young patients with old knees

The majority of patients with ACL tears are younger than 30, with a good proportion younger than 20. "They are the young patients with old knees," Dr. Lohmander and colleagues write. As a result, ACL injuries are a significant cause of early onset OA and its associated consequences. However, there some discrepancies in the literature about how many patients with ACL or meniscal tears actually develop OA.

Several reasons account for this variation. For example, acute events at the time of the injury or later events including surgery, rehabilitation, return to activity, chronic instability, or later-associated injuries may have an effect on progression to OA. Moreover, characteristics of the patients such as their activity level, strength, weight, personality, and education can tip the scale toward OA. Another reason for the variations is differing methods and criteria used to diagnose and evaluate OA.

"A better understanding of these variables may improve future prevention and treatment strategies," the researchers write.

Is surgery the solution?

Whether surgical repair can prevent subsequent OA in the damaged joint is an open question. It may be that the studies have low methodological quality rather than the surgery itself being ineffective. "A consistent finding in a review of the literature is the often poor reporting of critical study variables, precluding data pooling or a meta-analysis," the reviewers write. They add, "In evaluating medical treatment, we now expect large randomized clinical trials complemented by postmarketing monitoring. We should strive toward a comparable level of quality of evidence in surgical treatment of knee injuries."

While randomized clinical trials may not be feasible, natural history and other observational cohort studies must be carefully designed and reported to determine whether OA can be prevented following surgical treatment. Nonetheless, clinicians remain largely convinced that repairing the torn ACL and/or meniscus is a good idea.

"There is no question that nowadays if someone blows an ACL, they should have it repaired," Lewis G. Maharam, MD, a sports medicine specialist in New York City, told CIAOMed. "It's way better after reconstruction, and this can only improve the outcome later in life."

That said, Dr. Maharam agrees that more research is needed. "[Instinct tells me that] doing the reconstruction should prevent OA because it betters the biomechanics of the whole knee process," he said.

Reference

1. Lohmander LS, Englund PM, Dahl LL, et al. The long term consequences of anterior cruciate ligament and meniscus injuries. Am J Sports Med. 2007 Aug 29; doi: 10.1177/0363546507307396 [Epub ahead of print].