The Role of ACL Injury in the Development of Posttraumatic Knee Osteoarthritis

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Key Points

  • Acute ACL tears commonly occur in young, physically active individuals under age 30.

  • ACL injury increases osteoarthritis risk resulting in early onset OA during prime work and life years between ages 30 and 50.

  • Effective strategies to prevent ACL injury and to reduce OA risk after ACL tear are needed.

The anterior cruciate ligament (ACL) a relatively common injury in young, physically active individuals. ACL injuries are seen at high incidence in adolescents playing sports that involve pivoting,

Biomechanics and basic science of PTOA

The mechanism responsible for cartilage breakdown and progression to OA following ACL injury is multifactorial and not completely understood. The development of OA after ACL injury may be the result of the initial injury to the subchondral bone and hyaline cartilage. At the time of injury, the high force of the trauma disrupts the intra-articular structures.8 Occult osteochondral lesions, or bone bruises, as measured on magnetic resonance imaging (MRI), occur in 80%–90%9 of patients with an

Risk factors for PTOA

In an effort to reduce the incidence or progression of PTOA, the identification of risk factors associated with the development of this disabling process would be beneficial. Candidate risk factors for PTOA include the following:

  • Neuromuscular factors

  • Meniscus status

  • Body mass index (BMI)

  • Chondral damage

  • Age

  • Graft choice

  • Time interval between injury and surgical intervention.

Where do we go from here?

Surgical techniques have improved, including the advent of arthroscopic surgery and the abandonment of repair for the improved reconstructive procedures. Preservation of meniscal tissues is of the utmost importance, in which total meniscectomies are nearly nonexistent, and partial meniscectomies or meniscal repair have been the treatment of choice for concomitant meniscal injury. Early rehabilitation, both preoperatively and postoperatively, has improved outcomes. Despite these changes in

Addressing the biochemistry

From a biochemical standpoint, the ultimate method of preventing PTOA after ACL injury may be prevention of the inflammation that occurs acutely after injury. The majority of research in disease-modifying OA drugs focuses on the later stages of joint degeneration. However, in the case of PTOA, in which there is a clear precipitating event, a unique opportunity arises to intervene early in the acute posttraumatic period.61 Prevention of the cascade of destructive processes within the joint may

Rehabilitation

Whether a patient is treated nonoperatively or with ACL reconstruction, rehabilitation is an integral part of the treatment program. Rehabilitation techniques have evolved substantially over the past several decades, and the use of rehabilitation programs has become widely accepted. The goals of both nonoperative and postoperative rehabilitation include return of neuromuscular control, strength, power, and lower extremity functional symmetry.62 Depending on the patient (high-level athlete vs a

Prevention

Prevention of ACL injury is the number 1 approach to prevent PTOA. To reduce the risk of this injury, a large number of research studies are currently being conducted to identify ways to reduce the rate of ACL injuries and to improve rehabilitation after the injury.63 Currently, neuromuscular training is the most effective tool to reduce the incidence of ACL injuries.64 In a nonrandomized prospective study, female athletes enrolled in a neuromuscular and proprioceptive performance program saw

Summary

Anterior cruciate ligament tear accelerates joint degeneration and leads to osteoarthritis in a high proportion of patients. While successful in stabilizing ACL deficient knees, ACL reconstruction has not been shown to conclusively reduce OA risk. Altered biomechanics, age, meniscal status, cartilage and other joint tissue injury, as well as patient factors contribute to accelerated development of OA after ACL injury. The injury typically occurs in teenagers and young adults resulting in early

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References (65)

  • H. Segawa et al.

    Long-term results of non-operative treatment of anterior cruciate ligament injury

    Knee

    (2001)
  • L.S. Lohmander et al.

    High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury

    Arthritis Rheum

    (2004)
  • L.Y. Griffin et al.

    Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005

    Am J Sports Med

    (2006)
  • D.P. Piasecki et al.

    Intraarticular injuries associated with anterior cruciate ligament tear: findings at ligament reconstruction in high school and recreational athletes. An analysis of sex-based differences

    Am J Sports Med

    (2003)
  • L.S. Lohmander et al.

    The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis

    Am J Sports Med

    (2007)
  • K.D. Shelbourne et al.

    Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an isolated autogenous patellar tendon ACL reconstruction

    Knee Surg Sports Traumatol Arthrosc

    (1997)
  • R.C. Lawrence et al.

    Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II

    Arthritis Rheum

    (2008)
  • H. Roos et al.

    The prevalence of gonarthrosis and its relation to meniscectomy in former soccer players

    Am J Sports Med

    (1994)
  • M. Nishimori et al.

    Articular cartilage injury of the posterior lateral tibial plateau associated with acute anterior cruciate ligament injury

    Knee Surg Sports Traumatol Arthrosc

    (2008)
  • H.G. Potter et al.

    Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up

    Am J Sports Med

    (2012)
  • T.P. Andriacchi et al.

    A framework for the in vivo pathomechanics of osteoarthritis at the knee

    Ann Biomed Eng

    (2004)
  • R. Papannagari et al.

    In vivo kinematics of the knee after anterior cruciate ligament reconstruction: a clinical and functional evaluation

    Am J Sports Med

    (2006)
  • L.S. Lohmander et al.

    Changes in joint cartilage aggrecan after knee injury and in osteoarthritis

    Arthritis Rheum

    (1999)
  • J.M. Cuellar et al.

    Diagnostic utility of cytokine biomarkers in the evaluation of acute knee pain

    J Bone Joint Surg Am

    (2009)
  • M.L. Cameron et al.

    Synovial fluid cytokine concentrations as possible prognostic indicators in the ACL-deficient knee

    Knee Surg Sports Traumatol Arthrosc

    (1994)
  • K.A. Elsaid et al.

    Decreased lubricin concentrations and markers of joint inflammation in the synovial fluid of patients with anterior cruciate ligament injury

    Arthritis Rheum

    (2008)
  • H. Higuchi et al.

    Changes in biochemical parameters after anterior cruciate ligament injury

    Int Orthop

    (2006)
  • A. Meunier et al.

    Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: a randomized study with a 15-year follow-up

    Scand J Med Sci Sports

    (2007)
  • B. Lebel et al.

    Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft: a minimum 10-year follow-up

    Am J Sports Med

    (2008)
  • W.J. McDaniel et al.

    The untreated anterior cruciate ligament rupture

    Clin Orthop Relat Res

    (1983)
  • C.P. van der Hart et al.

    The occurrence of osteoarthritis at a minimum of ten years after reconstruction of the anterior cruciate ligament

    J Orthop Surg Res

    (2008)
  • R. Mihelic et al.

    Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17-20 years

    Int Orthop

    (2011)
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