Does ACL-reconstruction prevent early OA? Does ACL-reconstruction prevent early OA? Ejnar Eriksson,...

Does ACL-reconstruction Does ACL-reconstruction prevent prevent early OA?early OA?

Does ACL-reconstruction Does ACL-reconstruction prevent prevent early OA?early OA?

Ejnar Eriksson, M.D.Ejnar Eriksson, M.D.Karolinska Institute,Karolinska Institute,Stockholm, SwedenStockholm, Sweden

This is a highly debated subject!This is a highly debated subject!

I wish I could give you a true andI wish I could give you a true and

definitive answer. No consensus!definitive answer. No consensus!

So unfortunately, we still do notSo unfortunately, we still do not

know the answer to this question.know the answer to this question.

I I willwill give you some information that give you some information that

might give you a little “food formight give you a little “food for

thoughts”, though.thoughts”, though.

Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?Does ACL-reconstr. prevent OA?

We all know thatWe all know that

joint cartilage lacksjoint cartilage lacks

blood supply andblood supply and

receives its nutritionreceives its nutrition

from the joint fluid.from the joint fluid.

The cartilage actsThe cartilage acts

like a sponge – whenlike a sponge – when

compressed, fluid iscompressed, fluid is

squeezed out and squeezed out and

when unloaded when unloaded

(during walking or (during walking or

running) it sucks up running) it sucks up

nutritious joint fluid. nutritious joint fluid.

Joint cartilageJoint cartilageJoint cartilageJoint cartilage

The easiest way toThe easiest way to

produce degenerativeproduce degenerative

arthritis in a rabbitarthritis in a rabbit

joint – is to immobilizejoint – is to immobilize

the joint in a cast.the joint in a cast.

Within some Within some

time you havetime you have

severe arthrosis.severe arthrosis.

With that background,With that background,

sports ought to besports ought to be

very good for ourvery good for our

joints. During runningjoints. During running

we regularly loadwe regularly load

and unload our joints.and unload our joints.

This ought to improveThis ought to improve

the nutrition of the the nutrition of the

cartilage of ourcartilage of our

joints a lot.joints a lot.

Why then do we seeWhy then do we see

50-year old football50-year old football

players with horribleplayers with horrible

arthrosis after anarthrosis after an

ACL-injury likeACL-injury like

in this guy??in this guy??

..or young football players..or young football players

like these two in their like these two in their

20-ies with severe cartilage20-ies with severe cartilage

injuries/gonarthrosis afterinjuries/gonarthrosis after

ACL-injuries?ACL-injuries?

The explanation for theirThe explanation for their

cartilage injuries is :cartilage injuries is :

25 years old25 years old

27 years old27 years old

..that it is not ..that it is not the sport per sethe sport per se – the cartilage – the cartilage

damage is caused by the damage is caused by the injuries injuries that the players that the players

have sustained!!have sustained!!


An ACL-reconstruction would of course An ACL-reconstruction would of course

stabilize the knee and could prevent furtherstabilize the knee and could prevent further

dangerous pivot shifts. dangerous pivot shifts.

But if the cartilage damage is already there, But if the cartilage damage is already there,

an ACL reconstruction could only possibly an ACL reconstruction could only possibly

stop further cartilage damage.stop further cartilage damage.

The only way to find out more about this, isThe only way to find out more about this, is

to search the literature…to search the literature…

Annual incidence of ACL Annual incidence of ACL injuries?injuries?

Annual incidence of ACL Annual incidence of ACL injuries?injuries?

3 /10 0003 /10 000– In the In the

populationpopulation 6 / 10 0006 / 10 000

– In the active In the active age groupage group

18 /10 00018 /10 000– Soccer playersSoccer players

27 /10 000 27 /10 000 – Female soccer Female soccer

playersplayers

Nielsen & Yde -91Nielsen & Yde -91

Daniel & Fritchy -Daniel & Fritchy -9494

Roos et al. -95Roos et al. -95

Medline 1960-2007: 3770 papersMedline 1960-2007: 3770 papers Human studies, injury: 1203Human studies, injury: 1203 Prospective: 48Prospective: 48 Randomized: 16Randomized: 16 Controlled: 4Controlled: 4

Comparing surgery with no surgery : 1 Comparing surgery with no surgery : 1 Andersson, Odensten, Gillquist, 1991 (but they compared Andersson, Odensten, Gillquist, 1991 (but they compared

repair (+possible augmentation) with non-op treatment.repair (+possible augmentation) with non-op treatment.


Will reconstructive ACL-surgery increase or decrease the risk of OA after an ACL injury? Let’s look at the literature.


Lohmander & Lohmander & Roos 1994Roos 1994

Neyret et al. Neyret et al. Am J Sport Am J Sport Med, 1993Med, 1993

Review, 50% OA after 15 ysReview, 50% OA after 15 ys

Soccer players, surg. treatedSoccer players, surg. treated77% OA after 20 ys77% OA after 20 ys


Segawa et al. Knee, Segawa et al. Knee, 20012001

Myklebust et al. Am Myklebust et al. Am J Sports Med, 2003J Sports Med, 2003

Lohmander et al Lohmander et al

20042004 Neuman et al. 2005Neuman et al. 2005

42-46 % OA 8 years 42-46 % OA 8 years after after ACL injuries in handballACL injuries in handball

42% and 48% OA, 12-14 42% and 48% OA, 12-14 ysys

Non op treated, 12 ys, Non op treated, 12 ys, 37% JSN, 63% OA-changes37% JSN, 63% OA-changes

16 % after 15 ys, 0% if no 16 % after 15 ys, 0% if no meniscus injury in non-op.meniscus injury in non-op.


Meunier et al: Scand J Med Sci Sports June 2007Meunier et al: Scand J Med Sci Sports June 2007

ACL reconstruction:ACL reconstruction: – IncreasesIncreases Daniel et al. 1994Daniel et al. 1994– Patellar OAPatellar OA Lohmander et al. -Lohmander et al. -

0404– DecreasesDecreases Hart et al. JBJS Br Hart et al. JBJS Br

20052005

– DecreasesDecreases

Does ACL-reconstruction influence Does ACL-reconstruction influence the development of arthrosisthe development of arthrosisDoes ACL-reconstruction influence Does ACL-reconstruction influence the development of arthrosisthe development of arthrosis

Fink et al, ESSKA 2006Fink et al, ESSKA 2006Kessler et al. ESSKA 2006Kessler et al. ESSKA 2006

Increase of arthrosis after ACL-Increase of arthrosis after ACL-reconstructionreconstruction

Effect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosisEffect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosis

The group in Lund, Sweden with Harald The group in Lund, Sweden with Harald

Roos and Stefan Lohmander maintains Roos and Stefan Lohmander maintains

that football players with ACL-injuries that football players with ACL-injuries

get arthrosis whether operated or not.get arthrosis whether operated or not.

This is a hot subject today. In Lund This is a hot subject today. In Lund

they are therefore right now making a they are therefore right now making a

propspective randomised study of ACL-propspective randomised study of ACL-

reconstruction versus non-operative reconstruction versus non-operative

treatment of ACL. treatment of ACL.



High incidence irrespective of treatmentHigh incidence irrespective of treatment

Effect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosisEffect of ACL-reconstruction on Effect of ACL-reconstruction on development of arthrosisdevelopment of arthrosis

Positive effect of ACL-Positive effect of ACL-reconstructionreconstruction


Karl-Peter Benedetto and his group from InnsbruckKarl-Peter Benedetto and his group from Innsbruck

saw less arthrosis after surgery than in non-op casessaw less arthrosis after surgery than in non-op cases

We know from a series of excellentWe know from a series of excellentstudies by Lohmander and his groupstudies by Lohmander and his groupin Lund, Sweden, that all injuriesin Lund, Sweden, that all injuriesto a joint lead to release of harmfulto a joint lead to release of harmfulcytokines, that remain for quite acytokines, that remain for quite atime and can cause cartilage damage.time and can cause cartilage damage.

Tesch et al showed in 2002 that activation ofTesch et al showed in 2002 that activation ofbody adenosine A2a is the mechanism by which thebody adenosine A2a is the mechanism by which thebody controls inflammatory joint-phenomena…body controls inflammatory joint-phenomena…

Tesch et al showed in 2002 that activation ofTesch et al showed in 2002 that activation ofbody adenosine A2a is the mechanism by which thebody adenosine A2a is the mechanism by which thebody controls inflammatory joint-phenomena…body controls inflammatory joint-phenomena…

Will be published in KSSTA in July 2007Will be published in KSSTA in July 2007

This is a very preliminary experimental study.This is a very preliminary experimental study.If this holds true in larger controlled studiesIf this holds true in larger controlled studieswith longer follow-ups, maybe we could stopwith longer follow-ups, maybe we could stopthe cartilage damage caused by cytokines afterthe cartilage damage caused by cytokines afterinjuries or surgery. I have actually written…injuries or surgery. I have actually written…


Between 1968 and 1972, we operated 134Between 1968 and 1972, we operated 134

patellar tendon ACL-reconstructions atpatellar tendon ACL-reconstructions at

the Karolinska Hospital in Stockholm.the Karolinska Hospital in Stockholm.

In 1978, a young Robert J Johnson fromIn 1978, a young Robert J Johnson from

Burlington, Vermont, USA came to StockholmBurlington, Vermont, USA came to Stockholm

to follow up 84 of them after 5-10 years…to follow up 84 of them after 5-10 years…


These patients are now 35-40 years post These patients are now 35-40 years post

surgery. We have therefore invited Bobsurgery. We have therefore invited Bob

Johnson to come back to Stockholm and Johnson to come back to Stockholm and

re-examine the same cases.re-examine the same cases.


KT-1000KT-1000KT-1000KT-1000 Heel-heightHeel-heightHeel-heightHeel-height

IsokineticsIsokineticsIsokineticsIsokinetics One leg jumpOne leg jumpOne leg jumpOne leg jump


All the 86 we have studied so far haveAll the 86 we have studied so far have

undergone X-ray and motion MRI.undergone X-ray and motion MRI.

Unfortunately many of these patients Unfortunately many of these patients

had already had a meniscectomy before had already had a meniscectomy before

our ACL-reconstructions.our ACL-reconstructions.

5-10 years after the ACL-reconstruction, 5-10 years after the ACL-reconstruction,

Bob Johnson did not find any difference in Bob Johnson did not find any difference in

arthrosis between the guys without arthrosis between the guys without

menisci and the ones with intact menisci.menisci and the ones with intact menisci.

35 years later, the ones 35 years later, the ones

without menisci all have had without menisci all have had

a knee replacement or are a knee replacement or are

waiting for one due to waiting for one due to

severe degenerative severe degenerative

arthrosis.arthrosis.

The ones with intact menisci The ones with intact menisci

and stable knees, are and stable knees, are

surprisingly good, though.surprisingly good, though.



These guys have been able These guys have been able

to do pivoting sports ever since to do pivoting sports ever since

their surgery. They are nowtheir surgery. They are now

in their 60-ies and very satisfiedin their 60-ies and very satisfied

with the operation.with the operation.

They do not have more arthrosis They do not have more arthrosis

in the operated knee than in their in the operated knee than in their

healthy control knee.healthy control knee.

On motion MRI – one can see a normal-On motion MRI – one can see a normal-

looking ACL that resists anterior looking ACL that resists anterior

drawer.drawer.

Our study is not completed yet. But we Our study is not completed yet. But we

already now can say that the “late” already now can say that the “late”

arthrosis evidently depends veryarthrosis evidently depends very

much on absence of their menisci.much on absence of their menisci.



The reason for performing an ACL-The reason for performing an ACL-

reconstruction thus seems to be to reconstruction thus seems to be to

protect the menisci. Hogervorst protect the menisci. Hogervorst

found the samefound the same

in his 2002 study like Meunier et al. in his 2002 study like Meunier et al.

in their 15 yr follow-up, 2007.in their 15 yr follow-up, 2007.

But note this is for prevention of But note this is for prevention of latelate

osteoarthrosis.osteoarthrosis.


But your question to me was: But your question to me was:

Does ACL-reconstruction prevent Does ACL-reconstruction prevent

EARLYEARLY osteo-arthrosis?? osteo-arthrosis??

Let me therefore tell you the story of aLet me therefore tell you the story of a

young football player some 20 years ago.young football player some 20 years ago.

He came after an acute pivot-shift andHe came after an acute pivot-shift and

ACL-injury…ACL-injury…

These are his acute cartilageThese are his acute cartilage

fractures .fractures .

One can easily understand One can easily understand

why such injuries lead towhy such injuries lead to

degenerative arthrosis indegenerative arthrosis in

the future. In this case,the future. In this case,

it is questionable if anit is questionable if an

ACL-reconstruction couldACL-reconstruction could

prevent prevent earlyearly osteoarthrosis. osteoarthrosis.


I am sorry that I have not been able toI am sorry that I have not been able to

give a clear-cut answer to your question.give a clear-cut answer to your question.

I hope, however, that I have given youI hope, however, that I have given you

some food for thoughts…some food for thoughts…

If you need an excuse for coming to beautifulIf you need an excuse for coming to beautifulStockholm in September this year, we areStockholm in September this year, we arearranging a fantastic conference then…arranging a fantastic conference then…

InvitationsInvitationsInvitationsInvitations


If you like downhillIf you like downhillskiing and Italianskiing and Italianpasta – why not join mepasta – why not join meand the top faculty inand the top faculty inbeautiful Courmayeurbeautiful Courmayeurin Italy Jan. 13-18, 2008.in Italy Jan. 13-18, 2008.Our course alwaysOur course alwaysreceives high pointsreceives high pointsfrom the participants..from the participants..

11th11th

13-18, 200813-18, 2008

We eat lunch out on the slope…We eat lunch out on the slope…We eat lunch out on the slope…We eat lunch out on the slope…

……and look at Mont Blanc when we ski..and look at Mont Blanc when we ski..……and look at Mont Blanc when we ski..and look at Mont Blanc when we ski..

Thank you Thank you very much very much

for for your kind attentionyour kind attention

Thank you Thank you very much very much

for for your kind attentionyour kind attention

Does ACL-reconstruction prevent early OA? Does ACL-reconstruction prevent early OA? Ejnar Eriksson,...

Documents

Transcript of Does ACL-reconstruction prevent early OA? Does ACL-reconstruction prevent early OA? Ejnar Eriksson,...