cruciate ligament injuries are common (Daniel, Ellison, Del Pizzo,
Cross/Harris/Slater) and cause significant short term and long term
disability. With each episode of ACL instability there is subluxation
of the tibia on the femur, causing stretching of the enveloping
capsular ligaments and abnormal shear forces on the menisci and
on the articular cartilage. Delay in diagnosis and treatment gives
rise to increased intra-articular damage as well as stretching of
the secondary stabilising capsular structures (Cross).
deficiency is associated with an increased incidence of meniscal
injury and arthrosis (Daniel, Shelton, Eriksson). Reported rates
of associated meniscal injury range from 49% (Daniel) to 59% (Shelton).
Evidence of osteoarthritis has been shown in 77% (Eriksson) to 96%
(Johnson) of chronic ACL tear groups and lead to a large number
of permanent disabilities (Eriksson). Some authors argue that there
is no difference in the outcome of ACL injuries in operatively and
non-operatively treated patients (Roos). However the conservative
treatment of the anterior cruciate deficient knee leads to a reduced
number of satisfied patients (Bonamo).
our study of 1960 patients we found that 58% had secondary intra-articular
pathology at the time of primary ACL reconstruction. Furthermore
the incidence of secondary pathology increased from 41% at 1 year
to 88% after 10 years delay from injury to reconstruction. Of interest
is the fact that the majority of secondary pathology (79%) occurs
in the unstable knee within 5 years of injury. Thereafter there
is a relative steady state with little increased pathology until
after 10 years. At this point a second increase in incidence occurs,
probably due to increasing degenerative damage within the knee joint.
This is supported by our findings of an increasing percentage of
chondral, relative to meniscal damage, from 15.8% at 5 years to
53.3% after 10 years.
between injury and ACL reconstruction has been noted to increase
meniscal injury and degenerative articular damage (McDaniel, Jacobsen).
Jomha et al ( ) revealed that knees with chronic ACL deficiency,
even those with intact menisci before reconstruction, suffered early
osteoarthiritic changes. Acute ACL reconstruction with meniscal
preservation was shown to have the lowest incidence of degenerative
change. A statistically significant increase in the incidence of
menisectomy required at the time of ligament reconstruction in chronically
injured knees has been reported (Jomha). Early ligament reconstruction
is recommended before further intra-articular damage occurs (Jomha,
Noyes, Cross/Slater). Bonamo () states that reconstruction should
be considered earlier rather than repeatedly nibbling away at the
menisci and articular surfaces while the grossly unstable knee deteriorates.
study confirms the relationship between an unstable ACL deficient
knee and the incidence of secondary intra-articular pathology. Furthermore
our study reveals the increasing incidence of meniscal and chondral
pathology the greater the delay from injury to ACL reconstruction.
To prevent unnecessary secondary intra-articular pathology we recommend
ACL reconstruction be performed with minimal delay.
M.J., Harris J., Slater H.K: Recent developments in the Treatment
and repair of Anterior cruciate ligament Injuries in the Athlete.
Sports Medicine 10 (6): 349-354, 1990
DM, Stone ML, Dobson BE, et al: Fate of the ACL-injured patient.
A prospective outcome study. Am J Sports Med 22: 632-644,
DD, Min R, Skyhar M, et al: Nonoperative treatment of acute anterior
cruciate ligament injuries in a selected group of patients. Am
J Sports Med 23: 160-165, 1995
MF, Warren RF, Marshall JL, et al: A clinical and radiographical
analysis of 127 anterior cruciate insufficient knees. Clin Orthop
227: 229-237, 1988
E, Svensson LI, San TK, et al: Late results and sequelae after soccer.
The US soccer sports medicine book: 374-382, 1996
WR, Barrett GR, Dukes A: Early season anterior cruciate ligament
tears. A treatment dilemma. Am J Sports Med 25: 656-658,
JJ, Fay C, Firestone T: The conservative treatment of the anterior
cruciate deficient knee. Am J Sports Med 18: 618-623, 1990
WJ, Dameron TB: Untreated ruptures of the anterior cruciate ligament.
A follow-up study. J Bone Joint Surg 62-A: 696-704, 1980
NM, Borton DC, Clingeleffer AJ, et al: Long term osteoarthritic
changes in anterior cruciate ligament reconstructed knees. Clin
Orthop 358: 188-193, 1999
RJ, Eriksson E, Haggmark T, et al: Five to ten year follow-up evaluation
after reconstruction of the anterior cruciate ligament. Clin
Orthop 183: 122-140, 1984
AE: The pathogenesis and treatment of anterolateral rotatory instability.
Clin Orthop 147: 51-55, 1980
Pizzo W, Norwood LA, Kerlan RK, et al: Analysis of 100 patients
with anterolateral rotatory instability of the knee. Clin Orthop
122: 178-180, 1977
K: Osteoarthrosis following insufficiency of the cruciate ligaments
in man. Acta Orthop Scand 48: 520-526, 1977
FR, Barber-Westin SD: Anterior cruciate ligament reconstruction
with autogeneous patellar tendon graft in patients with articular
cartilage damage. Am J Sports Med 25: 626-634, 1997