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Does ACL-reconstruction Does ACL-reconstruction prevent prevent early OA?early OA?
Does ACL-reconstruction Does ACL-reconstruction prevent prevent early OA?early OA?
Ejnar Eriksson, M.D.Ejnar Eriksson, M.D.Karolinska Institute,Karolinska Institute,Stockholm, SwedenStockholm, Sweden
This is a highly debated subject!This is a highly debated subject!
I wish I could give you a true andI wish I could give you a true and
definitive answer. No consensus!definitive answer. No consensus!
So unfortunately, we still do notSo unfortunately, we still do not
know the answer to this question.know the answer to this question.
I I willwill give you some information that give you some information that
might give you a little “food formight give you a little “food for
thoughts”, though.thoughts”, though.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
We all know thatWe all know that
joint cartilage lacksjoint cartilage lacks
blood supply andblood supply and
receives its nutritionreceives its nutrition
from the joint fluid.from the joint fluid.
The cartilage actsThe cartilage acts
like a sponge – whenlike a sponge – when
compressed, fluid iscompressed, fluid is
squeezed out and squeezed out and
when unloaded when unloaded
(during walking or (during walking or
running) it sucks up running) it sucks up
nutritious joint fluid. nutritious joint fluid.
Joint cartilageJoint cartilageJoint cartilageJoint cartilage
The easiest way toThe easiest way to
produce degenerativeproduce degenerative
arthritis in a rabbitarthritis in a rabbit
joint – is to immobilizejoint – is to immobilize
the joint in a cast.the joint in a cast.
Within some Within some
time you havetime you have
severe arthrosis.severe arthrosis.
With that background,With that background,
sports ought to besports ought to be
very good for ourvery good for our
joints. During runningjoints. During running
we regularly loadwe regularly load
and unload our joints.and unload our joints.
This ought to improveThis ought to improve
the nutrition of the the nutrition of the
cartilage of ourcartilage of our
joints a lot.joints a lot.
Why then do we seeWhy then do we see
50-year old football50-year old football
players with horribleplayers with horrible
arthrosis after anarthrosis after an
ACL-injury likeACL-injury like
in this guy??in this guy??
..or young football players..or young football players
like these two in their like these two in their
20-ies with severe cartilage20-ies with severe cartilage
injuries/gonarthrosis afterinjuries/gonarthrosis after
ACL-injuries?ACL-injuries?
The explanation for theirThe explanation for their
cartilage injuries is :cartilage injuries is :
25 years old25 years old
27 years old27 years old
..that it is not ..that it is not the sport per sethe sport per se – the cartilage – the cartilage
damage is caused by the damage is caused by the injuries injuries that the players that the players
have sustained!!have sustained!!
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
An ACL-reconstruction would of course An ACL-reconstruction would of course
stabilize the knee and could prevent furtherstabilize the knee and could prevent further
dangerous pivot shifts. dangerous pivot shifts.
But if the cartilage damage is already there, But if the cartilage damage is already there,
an ACL reconstruction could only possibly an ACL reconstruction could only possibly
stop further cartilage damage.stop further cartilage damage.
The only way to find out more about this, isThe only way to find out more about this, is
to search the literature…to search the literature…
Annual incidence of ACL Annual incidence of ACL injuries?injuries?
Annual incidence of ACL Annual incidence of ACL injuries?injuries?
3 /10 0003 /10 000– In the In the
populationpopulation 6 / 10 0006 / 10 000
– In the active In the active age groupage group
18 /10 00018 /10 000– Soccer playersSoccer players
27 /10 000 27 /10 000 – Female soccer Female soccer
playersplayers
Nielsen & Yde -91Nielsen & Yde -91
Daniel & Fritchy -Daniel & Fritchy -9494
Roos et al. -95Roos et al. -95
Medline 1960-2007: 3770 papersMedline 1960-2007: 3770 papers Human studies, injury: 1203Human studies, injury: 1203 Prospective: 48Prospective: 48 Randomized: 16Randomized: 16 Controlled: 4Controlled: 4
Comparing surgery with no surgery : 1 Comparing surgery with no surgery : 1 Andersson, Odensten, Gillquist, 1991 (but they compared Andersson, Odensten, Gillquist, 1991 (but they compared
repair (+possible augmentation) with non-op treatment.repair (+possible augmentation) with non-op treatment.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?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.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Lohmander & Lohmander & Roos 1994Roos 1994
Neyret et al. Neyret et al. Am J Sport Am J Sport Med, 1993Med, 1993
Review, 50% OA after 15 ysReview, 50% OA after 15 ys
Soccer players, surg. treatedSoccer players, surg. treated77% OA after 20 ys77% OA after 20 ys
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Segawa et al. Knee, Segawa et al. Knee, 20012001
Myklebust et al. Am Myklebust et al. Am J Sports Med, 2003J Sports Med, 2003
Lohmander et al Lohmander et al
20042004 Neuman et al. 2005Neuman et al. 2005
42-46 % OA 8 years 42-46 % OA 8 years after after ACL injuries in handballACL injuries in handball
42% and 48% OA, 12-14 42% and 48% OA, 12-14 ysys
Non op treated, 12 ys, Non op treated, 12 ys, 37% JSN, 63% OA-changes37% JSN, 63% OA-changes
16 % after 15 ys, 0% if no 16 % after 15 ys, 0% if no meniscus injury in non-op.meniscus injury in non-op.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Meunier et al: Scand J Med Sci Sports June 2007Meunier et al: Scand J Med Sci Sports June 2007
ACL reconstruction:ACL reconstruction: – IncreasesIncreases Daniel et al. 1994Daniel et al. 1994– Patellar OAPatellar OA Lohmander et al. -Lohmander et al. -
0404– DecreasesDecreases Hart et al. JBJS Br Hart et al. JBJS Br
20052005
– DecreasesDecreases
Does ACL-reconstruction influence Does ACL-reconstruction influence the development of arthrosisthe development of arthrosisDoes ACL-reconstruction influence Does ACL-reconstruction influence the development of arthrosisthe development of arthrosis
Fink et al, ESSKA 2006Fink et al, ESSKA 2006Kessler et al. ESSKA 2006Kessler et al. ESSKA 2006
Increase of arthrosis after ACL-Increase of arthrosis after ACL-reconstructionreconstruction
Effect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosisEffect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosis
The group in Lund, Sweden with Harald The group in Lund, Sweden with Harald
Roos and Stefan Lohmander maintains Roos and Stefan Lohmander maintains
that football players with ACL-injuries that football players with ACL-injuries
get arthrosis whether operated or not.get arthrosis whether operated or not.
This is a hot subject today. In Lund This is a hot subject today. In Lund
they are therefore right now making a they are therefore right now making a
propspective randomised study of ACL-propspective randomised study of ACL-
reconstruction versus non-operative reconstruction versus non-operative
treatment of ACL. treatment of ACL.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
High incidence irrespective of treatmentHigh incidence irrespective of treatment
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
High incidence irrespective of treatmentHigh incidence irrespective of treatment
Effect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosisEffect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosis
Positive effect of ACL-Positive effect of ACL-reconstructionreconstruction
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Karl-Peter Benedetto and his group from InnsbruckKarl-Peter Benedetto and his group from Innsbruck
saw less arthrosis after surgery than in non-op casessaw less arthrosis after surgery than in non-op cases
We know from a series of excellentWe know from a series of excellentstudies by Lohmander and his groupstudies by Lohmander and his groupin Lund, Sweden, that all injuriesin Lund, Sweden, that all injuriesto a joint lead to release of harmfulto a joint lead to release of harmfulcytokines, that remain for quite acytokines, that remain for quite atime and can cause cartilage damage.time and can cause cartilage damage.
Tesch et al showed in 2002 that activation ofTesch et al showed in 2002 that activation ofbody adenosine A2a is the mechanism by which thebody adenosine A2a is the mechanism by which thebody controls inflammatory joint-phenomena…body controls inflammatory joint-phenomena…
Tesch et al showed in 2002 that activation ofTesch et al showed in 2002 that activation ofbody adenosine A2a is the mechanism by which thebody adenosine A2a is the mechanism by which thebody controls inflammatory joint-phenomena…body controls inflammatory joint-phenomena…
Will be published in KSSTA in July 2007Will be published in KSSTA in July 2007
This is a very preliminary experimental study.This is a very preliminary experimental study.If this holds true in larger controlled studiesIf this holds true in larger controlled studieswith longer follow-ups, maybe we could stopwith longer follow-ups, maybe we could stopthe cartilage damage caused by cytokines afterthe cartilage damage caused by cytokines afterinjuries or surgery. I have actually written…injuries or surgery. I have actually written…
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Between 1968 and 1972, we operated 134Between 1968 and 1972, we operated 134
patellar tendon ACL-reconstructions atpatellar tendon ACL-reconstructions at
the Karolinska Hospital in Stockholm.the Karolinska Hospital in Stockholm.
In 1978, a young Robert J Johnson fromIn 1978, a young Robert J Johnson from
Burlington, Vermont, USA came to StockholmBurlington, Vermont, USA came to Stockholm
to follow up 84 of them after 5-10 years…to follow up 84 of them after 5-10 years…
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
These patients are now 35-40 years post These patients are now 35-40 years post
surgery. We have therefore invited Bobsurgery. We have therefore invited Bob
Johnson to come back to Stockholm and Johnson to come back to Stockholm and
re-examine the same cases.re-examine the same cases.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
KT-1000KT-1000KT-1000KT-1000 Heel-heightHeel-heightHeel-heightHeel-height
IsokineticsIsokineticsIsokineticsIsokinetics One leg jumpOne leg jumpOne leg jumpOne leg jump
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
All the 86 we have studied so far haveAll the 86 we have studied so far have
undergone X-ray and motion MRI.undergone X-ray and motion MRI.
Unfortunately many of these patients Unfortunately many of these patients
had already had a meniscectomy before had already had a meniscectomy before
our ACL-reconstructions.our ACL-reconstructions.
5-10 years after the ACL-reconstruction, 5-10 years after the ACL-reconstruction,
Bob Johnson did not find any difference in Bob Johnson did not find any difference in
arthrosis between the guys without arthrosis between the guys without
menisci and the ones with intact menisci.menisci and the ones with intact menisci.
35 years later, the ones 35 years later, the ones
without menisci all have had without menisci all have had
a knee replacement or are a knee replacement or are
waiting for one due to waiting for one due to
severe degenerative severe degenerative
arthrosis.arthrosis.
The ones with intact menisci The ones with intact menisci
and stable knees, are and stable knees, are
surprisingly good, though.surprisingly good, though.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
These guys have been able These guys have been able
to do pivoting sports ever since to do pivoting sports ever since
their surgery. They are nowtheir surgery. They are now
in their 60-ies and very satisfiedin their 60-ies and very satisfied
with the operation.with the operation.
They do not have more arthrosis They do not have more arthrosis
in the operated knee than in their in the operated knee than in their
healthy control knee.healthy control knee.
On motion MRI – one can see a normal-On motion MRI – one can see a normal-
looking ACL that resists anterior looking ACL that resists anterior
drawer.drawer.
Our study is not completed yet. But we Our study is not completed yet. But we
already now can say that the “late” already now can say that the “late”
arthrosis evidently depends veryarthrosis evidently depends very
much on absence of their menisci.much on absence of their menisci.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
The reason for performing an ACL-The reason for performing an ACL-
reconstruction thus seems to be to reconstruction thus seems to be to
protect the menisci. Hogervorst protect the menisci. Hogervorst
found the samefound the same
in his 2002 study like Meunier et al. in his 2002 study like Meunier et al.
in their 15 yr follow-up, 2007.in their 15 yr follow-up, 2007.
But note this is for prevention of But note this is for prevention of latelate
osteoarthrosis.osteoarthrosis.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
But your question to me was: But your question to me was:
Does ACL-reconstruction prevent Does ACL-reconstruction prevent
EARLYEARLY osteo-arthrosis?? osteo-arthrosis??
Let me therefore tell you the story of aLet me therefore tell you the story of a
young football player some 20 years ago.young football player some 20 years ago.
He came after an acute pivot-shift andHe came after an acute pivot-shift and
ACL-injury…ACL-injury…
These are his acute cartilageThese are his acute cartilage
fractures .fractures .
One can easily understand One can easily understand
why such injuries lead towhy such injuries lead to
degenerative arthrosis indegenerative arthrosis in
the future. In this case,the future. In this case,
it is questionable if anit is questionable if an
ACL-reconstruction couldACL-reconstruction could
prevent prevent earlyearly osteoarthrosis. osteoarthrosis.
Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?
I am sorry that I have not been able toI am sorry that I have not been able to
give a clear-cut answer to your question.give a clear-cut answer to your question.
I hope, however, that I have given youI hope, however, that I have given you
some food for thoughts…some food for thoughts…
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