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

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slide1
Does ACL-reconstruction

prevent

early OA?

Ejnar Eriksson, M.D.

Karolinska Institute,

Stockholm, Sweden

slide2
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.

slide3
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

slide4
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.

slide5
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.

slide6
Why then do we see

50-year old football

players with horrible

arthrosis after an

ACL-injury like

in this guy??

slide7
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

slide8
..that it is not the sport per se – the cartilage damage is caused by the injuries that the players have sustained!!
slide9
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…

slide10
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
slide11
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.

slide12
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.

slide13
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

slide14
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.

slide16
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

slide17
Effect of ACL-reconstruction on

development of arthrosis

Increase of arthrosis after ACL-reconstruction

slide18
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.

slide20
Does ACL-reconstr. prevent OA?

High incidence irrespective of treatment

slide21
Does ACL-reconstr. prevent OA?

High incidence irrespective of treatment

slide22
Effect of ACL-reconstruction on

development of arthrosis

Positive effect of ACL-reconstruction

slide23
Does ACL-reconstr. prevent OA?

Karl-Peter Benedetto and his group from Innsbruck

saw less arthrosis after surgery than in non-op cases

slide24
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.

slide25
Tesch et al showed in 2002 that activation of

body adenosine A2a is the mechanism by which the

body controls inflammatory joint-phenomena…

slide28
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…

slide30
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…

slide31
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.

slide32
Does ACL-reconstr. prevent OA?

Heel-height

KT-1000

One leg jump

Isokinetics

slide33
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.

slide34
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.

slide35
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.

slide36
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.

slide37
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.

slide38
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…

slide39
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.

slide40
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…

slide41
Invitations

If you need an excuse for coming to beautiful

Stockholm in September this year, we are

arranging a fantastic conference then…

slide43
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..

slide46
Thank you

very much

for

your kind attention

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