http://www.sportsmedres.org/2012/05/delayed-acl-reconstructions-may-be.html

Delayed ACL Reconstructions may be Associated with More Severe Meniscal and Chondral Lesions

Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries.

Fok AWM, Yau WP. Knee Surg Traumatol Arthrosc. 2012 May [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/22552616

Anterior cruciate ligament (ACL) ruptures often coincide with meniscal and cartilaginous injuries. These ruptures are generally treated with surgical reconstruction or non-surgical treatment. Patients who chose to delay surgical treatment may be at greater risk for increasing the severity of the associated injuries; however, this has not been demonstrated in the literature. Therefore, Fok and Yau completed a retrospective, comparative study investigating (1) if delaying ACL reconstruction is associated with the number of meniscal and articular cartilage lesions, and (2) if ACL-deficient patients experiences greater frequency and magnitude of pain. A total of 150 patients (21 female, 129 male; 13 to 48 years old) were identified 1 week prior to their scheduled ACL reconstruction surgery. Patients were included if they experienced (1) instability during pivoting movements; (2) signs of ACL deficiency with Lachman’s, anterior drawer, or pivot shift test; and (3) magnetic resonance imaging revealed an ACL rupture. Patients were excluded if there was radiographic osteoarthritis present, a concomitant ligamentous injury, or an ACL revision procedure performed. Patients completed a self-reported medical history (which was verified with the hospital medical notes) and an IKDC questionnaire. At the time of surgery a single orthopedic specialist graded the cartilage injuries using a standardized documentation system. Patients were broken down into 2 subgroups for analysis (patients with greater than or less than 12 months delay between injury and surgery). Overall, the authors found that patients who delayed surgery more than 12 months, had significantly more meniscal damage which required removal rather than repair. Furthermore, patients with cartilage lesions had longer delays between injury and surgery. The authors also reported that the presence of intra-articular injuries was associated with more painful symptoms. For example, there was a moderate correlation between the size of the cartilage lesion and the frequency of pain experienced.

While this study provides some interesting data concerning whether or not patients who delay ACL reconstruction may have more meniscal damage and chondral lesions compared to patients who do not delay, its results must be interpreted cautiously. Firstly, this data cannot be applied to every patient that opts for nonsurgical care. This study focused on patients who had a delayed ACL reconstruction, which may indicate that the patient was having difficulties without an ACL (e.g., more symptoms, more episodes of giving way). Therefore, patients that successfully recovered with nonsurgical care were not studied. This study provides important data but we also need to consider that we can determine what damage is due to the ACL injury compared to wear over time. With this in mind, perhaps a study design such as a randomized control trial would be the ideal way to follow-up on this study. Despite the potential limitations, the data presented in this study suggests that immediate repair of the ACL may be beneficial to the long-term health of the joint compared to a delayed repair among knees that fail conservative management. With that in mind, perhaps we need to become more proficient at recognizing which patients are at risk for not tolerating conservative treatment and encourage them to pursue an early reconstruction to minimize the damage done to the meniscus and therefore, the promote long-term health of the joint. What do you currently recommend when advising your athletes on whether or not to undergo ACL reconstruction? What is the basis of your argument either for or against early ACL reconstruction?

Written by: Kyle Harris

Fok AW, & Yau WP (2012). Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 22552616