International

International Orthopaedics (SICOT) (1991) 15:367-371

Orthopaedics © Springer Verlag 1991

Osteoarthritis of the knee after ACL reconstruction A. Ferretti, F. Conteduca, A. De Carli, M. Fontana, and P. P. Mariani Department of Orthopaedic Surgery, University of Rome, La Sapienza, 1-00185 Rome, Italy

Summary. One hundred and fourteen knees with deficiency of the anterior cruciate ligament (ACL) which had undergone reconstruction o f the ligament using semitendinosus and gracilis were reviewed at a mean of 61 months after operation. Radiological and clinical evaluation was undertaken. A significant correlation was f o u n d between the number o f meniscectomies performed in acute cases and those undertaken on the chronic knee. There was also significant correlation between meniscectomy and the Fairbank grading of degenerative changes seen on the radiographs. There was no correlation between the clinical results, residual laxity and the development of osteoarthritis. In A CL deficient knees with irreparable meniscal tears, or in which meniscectomy had been undertaken, the development o f osteoarthritis seemed independent of the degree o f stability, but in such knees with no meniscal tear or meniscal repair, reconstruction appeared to save the menisci and preserve the joint. R+sum~. Les auteurs ont revu, avec un recul de 61 mois, 114 genoux opbrbs pour reconstruction du ligament croisd antdrieur (LCA) au moyen du demitendineux et du droit interne. Une bvaluation clinique et radiologique a btd effectube. L'analyse des radiographies en charge a montrb une corrblation significative entre l'existence de signes de dbgradation articulaire et les mbniscectomies effectu~es dans le m6me temps que la reconstruction ligamentaire. Une bonne corrblation a btb bgalement retrouvbe entre le niveau sportif post-opdratoire et la prbsence de ces signes. Aucune corrblation n'a dtb trouvde entre l'bvolution de l'arthrose et le rbsultat Reprint requests to: A. Ferretti, Piazzale Aldo Moro 5, 1-00185

Rome, Italy

clinique, en ce qui concerne la stabilitb. En conclusion, dans les cas comportant une lbsion irrbparable des mbnisques et une mdniscectomie, la reconstruction du LCA ne semble pas capable de prbvenir le dbveloppement de l'arthrose post-traumatique.

Introduction

Although rupture of the anterior cruciate ligament (ACL) has been called "the beginning of the end of the knee" (1), the role of knee instability in the development of osteoarthritis is uncertain. The radiographic appearance of the knees of patients with chronic insufficiency of the ACL usually shows only minor arthritic changes [16]. Previous ligament damage has rarely occurred in patients requiring tibial osteotomy or arthroplasty for severe osteoarthritis of the knee [7]. The development of early radiographic changes of osteoarthritis, similar to those described by Fairbank after meniscectomy, has been reported in athletes with untreated ACL insufficency [11]. Other important factors which may influence degeneration in unstable knees include the extent of anatomical injury, the level of activity, pre-existing axial deformity, and associated meniscal tears or chondral damage [8]. There have been few reports describing articular changes in knees after ligament reconstruction, and it is still uncertain if these procedures really reduce the incidence of post-traumatic osteoarthritis of the knee. This paper discusses the radiographic changes observed in 114 knees after ACL reconstruction using the pes anserinus tendons.

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A. Ferretti et al.: Osteoarthritis of the knee after ACL reconstruction

1. Scoring system for evaluation of knees after ACL reconstruction used in C O T U R (Orthopaedic Clinic of Rome University)

Table

Cotur scoring system Subjective results

Objective results

Satisfaction 15 very satisfied 10 satisfied 5 disappointed 0 unhappy Pain 10 never 5 rare during sport 0 rare - 5 frequent during sport - 1 0 frequent Giving-way 20 never 5 rare during sport 0 rare during day-life -10 frequent during sport -20 frequent during day-life Swelling 10 never 5 rare after sport 0 rare - 5 frequent after sport -10 frequent

Range of motion 15 full range loss of extension 0 1- 9 degrees -20 10-19 degrees -30 more than 20 degrees loss of flexion 5 135-121 degrees -20 120-111 degrees -30 less than 110 degrees Jerk test 20 negative 10 positive 1 + -10 positive 2 + -20 positive 3 + Lachman test 10 negative 5 increased 0 no firm end point

Results Very good 100-90 points G o o d 85-75 points Fair 70-50 points Poor less than 50 points

the time of operation was 22 years (range 14-42 years). When first injured 112 patients were active in sport, with 74 enjoying vigorous activity and 38 recreational sport. In all of the 55 acute cases the ACL was completely torn. In addition to the reconstruction, suture of the torn ends of the ligament was carried out in 21 cases. At operation a serious lesion of the medial collateral ligament was also found in 13 cases, and was treated by direct repair. A tear of the lateral ligament was identified and repaired in a further 13 patients. There were 24 tears of the medial meniscus and 13 of the lateral. Meniscectomy was performed in 20 patients ( l l medial, 7 lateral and 2 both medial and lateral). Thirteen meniscal repairs were undertaken, 9 medial, 2 lateral and 2 medial and lateral. An osteochondral fracture of the lateral femoral condyle was identified in one patient, and transosseous suture of the fragment performed. In the 59 knees with chronic ACL deficiency the ligament was reconstructed using the same technique. An extra-articular procedure was also carried out in all cases, using the Andrews technique [2] in 10 cases, and a Macintosh procedure, as modified by Coker Arnold [3], in 49. Meniscal tears were identified in 55 patients (44 medial, 7 lateral, and 4 medial and lateral). Meniscectomy was undertaken in 45 cases, 35 medial, 6 lateral, 4 medial and lateral, with meniscal repair in 10 (9 medial, and 1 lateral). At follow up all patients were assessed according to a scoring system introduced in 1986 for assessment of knees following ACL reconstruction [15] (Table 1). A KT 1000 arthrometer was used to measure anterior laxity in 20 ° of flexion in all cases [4]. Radiographs of both knees were taken with the patient standing and assessed for degenerative changes following the criteria described by Fairbank [5] and McDaniel and Dameron [11] (Table 2).

Results

2. Radiological changes following ACL reconstruction (114 knees)

Table

Fairbank grades

N u m b e r of knees

Follow-up months

0 = no changes 1 = flattening or squaring of femoral condyles 2 = osteophytes 3 = narrowing of joint space 4 = osteoarthritis

46 (40.4%) 39 (34.2 %)

59.3 57.3

19 (16.7 %) 7 (6.1%) 3 (2.6%)

66.9 65.8 58.7

Material and methods We have reviewed 114 knees which had undergone reconstruction of the ACL at a mean of 61 months (range 2 4 - 9 2 months). The tendons of semitendinous and gracilis had been detached distally with a bone block and transferred intra-articularly according to the technique suggested by Puddu [14] and Perugia et al. [13]. Fifty five cases were operated on within ten days from injury, and 59 later with a mean interval from injury of 30 months (range 2 - 7 7 months). The mean age of patients at

The average score at follow up was 88 out of 100 points. Only 13 patients were rated as having fair or poor results. The jerk test was negative in 81 cases, mildly positive at l + in 28 patients, and 2 + in5. The Lachman test was negative in 78 cases, was mildly positive with increased excursion but a firm end point in 21 cases, and positive with excursion and no firm end point in 15 patients. Measurement with the KT 1000 arthrometer showed an average passive movement with 20 lbs of loading of 2.7 mm; the mean compliance index was 0.3 mm. Seventy six patients were able to return to their previous level of sporting activity, 37 reduced their participation in sport, but only 7 because of problems associated with the knee. One patient increased his sporting level. Radiographic assessment using Fairbank's criteria showed no evidence of change in 46 patients, flattening or squaring of the femoral condyles in 39, osteophyte formation in 19, narrowing of the joint space in 7, and frank osteoarthritis in 3 (Table 2, Figs. 1-5).

A. Ferretti et al.: Osteoarthritis of the knee after ACL reconstruction

369

Fig. 1. Fairbank 0 (no changes). N.P. Female, recreational skier, 22 years old. 49 months after acute ACL reconstruction with semitendinosus and gracilis on left side. No meniscal tears. (Cotur scoring system 100 points). R = right, L = left Fig. 3. Fairbank Grade 2. A. P. Male, recreational water polo player, 22 years old. 72 months after chronic ACL reconstruction with semitendinosus and gracilis and medial menscectomy on left side. (Cotur scoring system 90 points). R = right, L = left

Fig. 2. Fairbank Grade I. B.S. Male, recreational soccer player, 23 years old. 64 months after chronic ACL reconstruction with semitendinosus and gracilis and medial meniscectomy on right side. (Cotur scoring system 100 points). R = right, L = left

Discussion

In this series reconstruction of the ACL with semitendinosus and gracilis yielded clinical resuits comparable with other surgical techniques [6, 15]. Only 11 patients showed unsatisfactory stabilisation of the joint at follow up. Measurement with the KT 1000 arthrometer showed resuits very similar to those obtained by Roth et al. [17] after reconstruction of the ACL using the patellar tendon. In a radiological study before operation in 1081 knees with chronic insufficiency of the ACL, Lynch and Henning [9] found a high incidence of degenerative change in patients who had previ-

Fig. 4. Fairbank Grade 3. B.R. Female, professional volleyball player, 24 years old. 49 months after acute ACL reconstruction with semitendinosus and gracilis and medial menisectomy on left side. (Cotur scoring system 80 points). R = right, L = left

ously undergone meniscectomy, but if the menisci were intact the incidence of osteoarthritis was much lower. The incidence of meniscal tears was directly correlated with the time between the first injury and operation. No correlation was found between the severity of the knee laxity and the degree of osteoarthritis. In another study of osteoarthritis following ACL reconstruction using the iliotibial band, Lynch et al. [10] found a higher incidence of ra-

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A. Ferretti et al.: Osteoarthritis of the knee after ACL reconstruction 25 2O co

E 15 ~- 1 0 5 0

0-2

2.1-4

4.1-6

>6.1

MM. excursion No signs

~

Fairbank 1

~

Fairbank 2-3-4

Fig. 6. KT-1000 arthrometer 20 lb side to side difference and Fairbank grades. ( P = 0.15) 4O Fig. 5. Fairbank 4. A.R. Female, professional basket-ball player, 18 years old. 53 months after chronic ACL reconstruction with semitendinosus and gracilis and medial menisectomy on left side. (Cotur scoring system 85 points). R = right, L = left Table 3. Meniscectomies performed in acute and chronic ACL deficient knees (difference significant at p < 0.05)

Medial Lateral Both menisci Total

Acute ACL tear (55 knees)

Chronic ACL tear (59 knees)

I 1 (20 %) 7 (13 %) 2 ( 3 %) 20 (36 %)

35 (59 %) 6 (10%) 4 ( 7 %) 45 (76 %)

Table 4. Radiological changes following ACL reconstruction with and without meniscectomy Fairbank gradings

Meniscectomies 65 knees (100%)

No meniscectomies 49 knees (100%)

0

17 (26 %)

29 (59 %)~'

1

24 (37%)

15 (31%)

2- 4

24 (37 %)

5 b ( 10 %),,

~ Difference significant (p < 0.05) b Included a patient with an osteochondral fracture

diographic changes in knees which had undergone meniscal removal compared with knees which did not have meniscal abnormality. They concluded that degenerative osteoarthritis in knees with anterior cruciate deficiency was inevitable, but that the speed of onset depended on the state of the menisci. Our results strongly support these findings. In our patients a statistically significant correlation existed between the number of meniscectomies performed in the acute state and those undertaken in chronic cases (Table 3). There was also significant correlation between meniscectomy and the Fairbank grading at follow

35

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30

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f_ 20 15 10

.

.

.

.

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.

.

.

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.

.

.

................................... ................................... '

_....................................

Negative I

No signs

+ Jerk test NIN Fairbank 1

++ ~

Fairbank 2 - 3 - 4

Fig. 7. Jerk test (residual instability) and Fairbank grades. ( P = 0.16)

up (Table 4). No correlation was found between clinical results, the residual laxity as measured by the KT 1000 arthrometer, and the development of osteoarthritis (Fig. 6). The extent of injury to the lateral or medial ligament in acute cases did not affect the final outcome of the articular cartilage. McDaniel and Dameron reviewed 52 patients in whom an anterior cruciate tear had been untreated for 10 years. In 45 a meniscectomy was undertaken when first seen, or subsequently. We observed less evidence of radiological change than these authors, but our follow up is only for 5 years. Noyes et al. [12] reviewed 91 knees in which ACL injury had been left untreated for a mean of 5.5 years, and considered that 54% of these knees were radiologically normal. They found a definite correlation between the degree of osteoarthritis and meniscectomy, and statistically significant correlation between time from injury to follow up and the presence of a positive Fairbank grading. In our study a definite, but not statistically significant, correlation is present between the time from first injury to operation and the develop-

A. Ferretti et al.: Osteoarthritis of the knee after ACL reconstruction Table 5. Radiological changes in ACL deficient knees following meniscectomy, without and with ACL reconstruction Fairbank gradings

Meniscectomy and no ACL rec. (series of McDaniels and Dameron) 45 patients

Meniscectomy and ACL rec. (our series) 65 patients

0 1 2 3 4

10 (22%) 21 (46 %) 3(7%) 8(18%) 3(7%)

17 (26%) 24 (37 %) 15(23%) 6(9%) 3(5%)

(P = 0.14)

ment of subsequent osteoarthritis. A similar correlation was found between residual instability, as demonstrated by the jerk test, and the degree of degenerative changes seen on the articular surface (Fig. 7). Preservation of the menisci is the most important factor in preventing articular changes in ACL deficient knees. The appearance of osteoarthritis can be related directly to the inability of such knees to protect the meniscus, which is in itself directly responsible for preservation of the joint surface. However, reconstruction of the ACL, even if it may preserve the menisci from subsequent tears, does not completely protect the joint surfaces from minor wear. At follow up of 49 reconstructed knees with intact or sutured menisci, 19 showed some degree of positive Fairbank grading, but only one had narrowing of the joint space and none showed frank osteoarthritis. Changes such as flattening or squaring of the femoral condyles and the tibial plateau were mainly found in the lateral compartment after ACL reconstruction with intact or sutured menisci, and similar findings were present in a number of ACL deficient knees which had not undergone operation. If any irreparable tear of the meniscus is found at operation, and a meniscectomy is performed, the development of osteoarthritis seems to be independent of the stabilisation which may be achieved. In our series the incidence of Fairbank grading in patients with meniscectomy and ACL reconstruction, and in patients with ACL deficient knees treated by meniscectomy alone [11], is very similar (Table 5). The decision to undertake surgical reconstruction in patients with ACL deficiency in a knee should be based on the need to stabilise the joint in order to undertake activity without giving way or other symptoms. A degree of osteoarthritic

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change is inevitable in the long term, particularly if a meniscus has been removed. However, when the menisci are intact, stabilisation appears to decrease the rate of onset of osteoarthritic change within the joint.

References 1, Allman FL (1983) cited by De Haven KE: Arthroscopy in the diagnosis and management of anterior cruciate ligament deficient knee. Clin Orthop 172:52-56 2. Andrews JR, Sanders RA, Morin B (1985) Surgical treatment of anterolateral rotatory instability. A follow-up study. Am J Sports Med 13:112-119 3, Coker TP, Park JP, Harris WD, Arnold GA, Cunning LA (1982) Coker Arnold modified Mac Intosh procedure for anterior cruciate ligament insufficiency. Presented at the 49th Annual Meeting AAOS, New Orleans 4. Daniel DM, Malcom LL, Lovee G, Stone ML, Sachs R, Burks R (1985) Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg [Am] 67:720-726 5. Fairbank TJ (1948) Knee joint changes after meniscectomy. J Bone Joint Surg [Br] 30:664-670 6. Ferretti A, De Carli A, Conteduca F, Mariani PP, Fontana M (1989) Risultati della ricostruzione del legamento crociato anteriore con i tendini del semitendinoso e gracile helle lassita' croniche del ginocchio. G Ital Ortop Traumatol 15 : 441-451 7. Funk FJ (1983) Osteoarthritis of the knee following ligamentous injury. Clin Orthop Rel Res 172:154-157 8. Gillquist J (1990) Knee stability: its effect on articular cartilage. In: Ewing JW (ed) Articular cartilage and knee joint function. Raven Press, New York, pp 267-272 9. Lynch MA, Henning CE (1988) Osteoarthritis in acl deficient knee. In: Feagin JA (ed) The crucial ligament. Churchill Livingstone, N J, pp 385-391 10. Lynch MA, Henning CE, Glick KR (1983) Knee joint surface changes. Clin Orthop 172:148-153 11. McDaniels WJ, Dameron TB Jr (1980) Untreated ruptures of the anterior cruciate ligament: a follow-up study. J Bone Joint Surg [Am] 62:696-705 12. Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The symptomatic anterior cruciate deficient knee. J Bone Joint Surg [Am] 65 : 154-162 13. Perugia L, Puddu G, Ferretti A, Mariani PP (1983) La patologia capsulo legamentosa cronica. Progr Med Sport 2: 97-125 14. Puddu G (1980) Method for reconstruction of the anterior cruciate legament using the semitendinosus tendon. Am J Sports Med 8:402-404 15. Puddu G, Ferretti A, Conteduca F, Mariani PP (1988) Risultati della ricostruzione del crociato anteriore con il semitendinoso nelle lassita' croniche anteriori del ginocchio. G Ital Ortop Traumatol 14:189-196 16. Radin EL (1990) Factors influencing the progression of osteoarthrosis. In: Ewing JW (ed) Articular cartilage and knee joint function. Raven Press, New York 17. Roth JH, Kennedy JC, Lockstadt H, McCallum CL, Cunning LA (1987) Intra-articular reconstruction of the anterior cruciate ligament with end without extra-articular supplementation by transfer of the biceps femoris tendon. J Bone Joint Surg [Am] 69:275-278