By age 40-50, athletes who have anterior cruciate ligament (ACL) reconstruction in their teens or early twenties tend to develop osteoarthritis (OA) that may be severe enough to interfere with athletic and functional activities. In a study of 423 Shelbourne Knee Center patients, 28.6% had moderate to severe OA at >20 years after ACL reconstruction (1).
Certain objective factors increased the odds of developing OA in the long-term:
– Older age at surgery
– Medial meniscectomy
– Knee extension loss.
Shifting the Odds Away from OA
“Over 70% of our patients didn’t have an arthritic knee more than 20 years after ACL surgery,” says K. Donald Shelbourne, MD, orthopaedic surgeon and founder of Shelbourne Knee Center. The prevalence of arthritis was lower than expected, and lower than most other studies, which report OA rates of up to 54%. But 28.6% is still too high for Dr. Shelbourne. “We have learned what factors can lead to problems in the future and we’re continuously learning how to modify them in the patient’s favor,” he says.
Most of the 423 patients in this study obtained range of motion (ROM) equal to the opposite knee by the time of discharge from treatment:
- 83.5% for knee extension.
- 68.8% for knee flexion.
Even minor loss of knee extension and/or flexion at >20 years after surgery—a modifiable risk factor—increased the odds for developing moderate to severe OA about 2 to 4 times.
Quick and Complete ROM Restoration
Shelbourne Knee Center’s rehabilitation program focuses on quick and complete restoration of full knee extension and flexion as soon as possible after surgery. “A stiff knee joint never gets better. If you don’t have full range of motion six months after surgery, the odds are that you’ll still have a stiff knee 20 years later,” says Dr. Shelbourne. Using data from this and other studies, Shelbourne Knee Center continually fine-tunes its ACL rehabilitation program.
“We’re doing things that are statistically proven to be the best way to do things,” says Dr. Shelbourne.
Odds Ratios for Other Key Factors
The odds ratios for statistically significant factors for any OA at follow-up were:
- 2.98 for medial meniscectomy.
- 1.65 for lateral meniscectomy.
- 1.06 for age at follow-up.
- 1.62 for chronic injury type.
- 2.17 for articular cartilage damage.
The ACL Reconstruction Study
With 423 primary ACL reconstructions by Shelbourne Knee Center from 1982 to 1994, the ACL Reconstruction Study was the largest study ever conducted with data from >20 years after ACL reconstruction. In other studies, the highest number of patients studied at >20 years post surgery was 168.
Patient Demographics:
- Age at surgery, mean: 23.2 + 6.7
- Males: 67%
- Females: 33%
Methods:
- Prospective data:
- Demographics
- Meniscus and articular cartilage status.
- Ratings of bilateral standing posteroanterior weightbearing, lateral, and Merchant view radiographs.
- KT-1000 arthrometer measurements.
- ROM measurements.
- Radiographs:
- Graded for joint space narrowing, sclerosis, and osteophytes according to International Knee Documentation Committee criteria
The ACL reconstruction study continues to enroll patients and collect data, which the Shelbourne Knee Center team reviews quarterly.
Recent Patients Do Better
More recent ACL reconstruction patients (n = 2,012) at Shelbourne Knee Center had higher rates of ROM equal to the opposite knee by the time of discharge from treatment than earlier patients (2):
- Knee extension:
- 2012-2016: 98%.
- 1982-1994: 83.5%.
- Knee flexion:
- 2012-2016: 92%.
- 1982-1994: 68.8%.
“I know that our recent and current ACL reconstruction patients will have a better result at 20 years, including a decreased rate of OA, than patients did 30 years ago.”
For more information about ACL reconstruction and rehabilitation, please call 888-FIX-KNEE.
References
- Shelbourne KD, Benner RW, Gray T. Results of Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts: Objective Factors Associated With the Development of Osteoarthritis at 20 to 33 Years After Surgery. Am J Sports Med, 2017 Oct;45(12):2730-2738.
- Shelbourne KD, unpublished data, 2016.