Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up

Abstract

Purpose Degeneration of the cartilage after anterior cruciate ligament reconstruction (ACL-R) is known, and further deterioration can be expected in patients with tunnel malplacement or partial meniscal resection. It was hypothesized that there is a significant increase in cartilage degeneration after failed ACL-R. Material and methods Isolated ACL revision surgery was performed in 154 patients at an interval of 46 ± 33 months (5–175 months) between primary and revision surgery. Cartilage status at the medial, lateral femorotibial, and patellofemoral compartments were assessed arthroscopically during primary and revision ACL-R in accordance with the Outerbridge classification. Tunnel placement, roof angle, and tibial slope was measured using anteroposterior and lateral radiographic views. Results Cartilage degeneration increased significantly in the medial femorotibial compartment, followed by the lateral and patellofemoral compartments. There was a correlation between both cartilage degeneration in the patellofemoral compartment (PFC) (rs = 0.28, p = 0.0012) and medial tibial plateau (Rs = 0.24, p = 0.003) in relation to the position of tibial tunnel in the frontal plane. Worsening of the cartilage status in the medial femorotibial compartment, either femoral or tibial, was correlated with the tibial aperture site in the lateral view (Rs = 0.28, p < 0.001). Cartilage degeneration in the lateral compartment of the knee, on both femoral or tibial side, was inversely correlated with the femoral roof angle (Rs = −0.1985, p = 0.02). Meniscal tears, either at the medial or lateral site or at both, were found in 93 patients (60%) during primary ACL-R and increased to 132 patients (86%) during revision ACL-R. Discussion Accelerated cartilage degeneration and high prevalence of meniscal lesions are seen in failed ACL-R. Tunnel placement showed significant impact on cartilage degeneration and may partially explain the increased risk of an inferior outcome when revision surgery is required after failed primary ACL-R. Level of evidence: Level IV—retrospective cohort study.

Risk factors of cartilage lesion after anterior cruciate ligament reconstruction

“…The placement of this non-anatomical tunnel may lead to abnormal knee joint kinematics after ACLR ( Tashman et al, 2004 ), which may be a potential cause of cartilage degeneration ( Van Eck & Fu, 2011 ). Andrä et al (2021) , however, found that tibial tunnel localization had a greater effect on cartilage degeneration progression than femoral tunnel localization. Patients who underwent revision ACLR exhibited a higher risk of progression of OA compared to those who underwent initial reconstruction ( Grassi et al, 2016 ).…”

Risk Factors Associated with Cartilage Defects after Anterior Cruciate Ligament Rupture in Military Draftees

“…Soderman et al [ 3 ] reported that the incidence of OA of the medial tibiofemoral compartment in ruptured ACL grafts was greater than in intact ACL grafts. A significant increase in cartilage degeneration in the medial femorotibial compartment, followed by the lateral and patellofemoral compartments, was assessed arthroscopically in a study that included 154 patients after failed ACLR at 4 years of follow-up [ 26 ]. It was also shown that there was a greater risk of cartilage defects in the graft rupture group than in the intact graft group; even when compared with the conservative treatment group, more cartilage defects were still observed in the graft rupture group.…”

“…This is because once graft rupture occurs, the risk of cartilage defects in the graft rupture group was higher than that in the conservative group. In particular, in patients who had a high risk of graft complications that had increased Beighton scores and greater side-to-side differences in thigh circumference, increased lateral posterior tibial slope, anterolateral tibia subluxation, anteromedial tibia subluxation, and a positive family history of ACL tear [ 22 , 26 ], the necessity of surgery should be carefully considered. For technical errors such as tunnel malposition found during intraoperative or postoperative evaluation [ 21 , 22 , 26 ], postoperative rehabilitation and protection need to be strengthened, and we must be careful to avoid serious complications such as graft rupture, which will increase the probability of cartilage defects and postoperative OA.…”

“…The status of meniscal injury could differ among the conditions of post-ACLR. Meniscal lesions increased from 60% to 86% in all patients between primary and revision ACLR [ 26 ]. Another study also reported meniscal tears (medial or lateral) in 94.5% of primary and 83.3% of revision ACLRs and combined (medial and lateral) meniscal tears in 32.1% and 51.1% of primary and revision ACLRs, respectively [ 22 ].…”

“…Furthermore, graft failure after ACLR is a devastating event, and there are many factors affecting graft failure [ 21 , 22 ]. The sequelae of graft failure, especially OA, are still clinically challenging problems [ 3 , 23 , 24 , 25 , 26 ]. However, the cause of OA is multifactorial and long-term outcomes after ACL injury and post-ACLR are influenced by many associated factors, such as the status of the articular cartilage, meniscus, BMI, state of the quadriceps muscles, and knee joint laxity [ 5 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”