53 - Changes in Arthroscopic Findings in The Anterior Cruciate Ligament Deficient Knee Prior To Reconstructive Surgery

The Knee 12 (2005) 33 – 35
www.elsevier.com/locate/knee
Changes in arthroscopic findings in the anterior cruciate ligament

deficient knee prior to reconstructive surgery
A. Foster *, C. Butcher, P.G. Turner
Department of Orthopaedics and Trauma, Stepping Hill Hospital, Stockport, UK
Received 20 June 2002; received in revised form 4 September 2002; accepted 31 October 2003
Abstract
We retrospectively compared the arthroscopic findings of 75 patients at the time of diagnosis of ACL rupture and the findings at
the time of ACL reconstruction. We found that in the ACL deficient knee the deterioration in meniscal tears and osteochondral lesions
was statistically greater with increased interval between diagnosis of ACL rupture and reconstruction. This study implies that in those
patients where ACL reconstruction is indicated, a delay in reconstructive surgery can have a deleterious effect on the articular surface
of the knee.
D 2004 Elsevier B.V. All rights reserved.
Keywords: Knee; Anterior ligament reconstruction; Degenerative change; Osteochondral defect
1. Introduction To our knowledge our study is unique in comparing the

arthroscopic appearances of the knee joint in the same
ACL injuries are common. The greatest number of patient group at the time of diagnosis and the time of
these injuries occurs during sporting activities, particularly reconstruction.
those involving decelerating, twisting and cutting [1].
Many patients are left disabled for sport following ACL
injury. It is commonly accepted that ACL injuries increase 2. Methods
the risk of an athlete developing meniscal tears and
premature osteoarthritis of the knee [2]. The treatment of Operation notes were reviewed on patients undergoing
choice is stabilisation by means of reconstruction of the primary ACL reconstruction performed by the senior author
ligament [1]. between March 1998 and December 2000.
The timing of ACL reconstructive surgery is controver- All patients had undergone primary arthroscopic ACL
sial though it is generally accepted that delaying surgery by reconstruction using four-strand hamstring graft.
3 weeks in the acutely injured knee minimises problems For inclusion in the study, the patients had to have
with post-operative motion [3]. undergone a prior diagnostic athroscopy of the knee
The objective of our study is to prove that a prolonged performed by the senior author or under direct super-
interval of many months before reconstructive surgery vision. The original operative findings had been docu-
results in an increase in the incidence of meniscal tears mented in a standard format by the senior author and
and osteochondral lesions. Previous studies have com- were recorded as part of this study on a specially
pared the incidence of these lesions found at the time of designed standard proforma.
reconstructive surgery, finding a greater incidence General demographic data collected included age at
amongst those undergoing late rather than early recon- injury and mechanism of injury. The dates of initial con-
struction [4]. sultation, diagnostic arthroscopy and reconstruction were
recorded.
* Corresponding author. Present address: 45 Brooklawn Drive, Arthroscopic findings documented included presence
Didsbury, Manchester M20 3GY, UK. Tel.: +44-161-434-0658. and type of meniscal tear, (radial, parrot beak, bucket-
E-mail address: [email protected] (A. Foster). handle, peripheral detachment) and therapeutic procedure
0968-0160/$ - see front matter D 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2003.10.007
34 A. Foster et al. / The Knee 12 (2005) 33–35
performed (partial or total meniscectomy or repair). All The most common arthroscopic deterioration was a
meniscal tears were of sufficient size to require resection meniscal tear, which occurred in 22 patients (62.9% of
of a segment of meniscus or undergo arthroscopic repair. those with deterioration), followed by degeneration of the
The presence, location and estimated size of any chondral articular surface (28.6%, 10 patients) and osteochondral
or osteochondral lesion were recorded. Degenerative lesions (14.3%, five patients).
changes of the articular surface were graded in accordance Of the total 75 patients 22 (29.3%) developed a further
with the Insall grading system for chondral lesions (specif- meniscal tear. Ten patients (13.3%) developed deterioration
ically, 1-swelling and softening of cartilage, 2-deep fissures in the articular surface of the knee (mean deterioration of 1.8
extending to subchondral bone, 3-fibrillation, 4-exposure on the Install grading system).
of subchondral bone) [5]. Five patients (6.7%) developed a new osteochondral
These data were analysed using the Student’s unpaired t- lesion whilst waiting for ACL reconstruction. All of these
test and the v-squared test. Statistical significance was taken patients had an interval time of over 6 months (mean 64
as a P value <0.05. weeks).
Overall the number of deteriorations in arthroscopic
findings increased with interval time (Fig. 1) and was
3. Results significantly greater in patients with an interval time greater
than 6 months between diagnosis and reconstruction (highly
In the study period a total of 92 ACL reconstructions significant at P<0.001).
were performed. Of these patients, 75 had undergone prior
diagnostic arthroscopy, and, therefore met with the inclusion
criteria. The diagnosis was confirmed in the remaining 4. Discussion
seventeen patients by either clinical examination alone or
with magnetic resonance imaging of the knee. The natural history of the ACL deficient knee is one of
The study group consisted of 61 men and 14 women. The progressive degenerative change [1,3]. Repeated episodes of
age at injury ranged from 12 to 51 with the mean and giving way result in recurrent trauma to the articular
median age at injury being 26. Sporting injuries accounted surfaces and menisci.
for the mechanism of injury in 54 patients (72%). The The purpose of ACL reconstruction is to confer stability,
mechanism of injury was an RTA in one case and unknown reduce progressive articular damage and to return the athlete
or not documented in the remaining 11 patients. to sporting activities. It is not known how much ACL
Thirty-five of the total number of patients (46.6%) had reconstruction reduces the frequency and severity of further
some deterioration in arthroscopic appearance in the interval meniscal or articular damage but it is generally accepted that
between diagnosis and reconstruction. it will at least in the short to medium term.
Twenty-five patients had an interval time less than 6 Wilson and Scranton and Wasilewski et al. have reported
months and of these patients four (16%) developed a further more frequent meniscal and osteochondral lesions in
lesion. The remaining 49 patients had an interval time patients who underwent late ACL reconstruction [6,7]. This
greater than 6 months and of these patients 31 (63%) had was a comparison of operative findings at the time of
developed a further lesion. reconstruction between two patient groups.
Fig. 1. Cumulative deteriorations in arthroscopic findings in the ACL deficient knee.

A. Foster et al. / The Knee 12 (2005) 33–35 35
Maletius and Messner reviewed weight bearing radio- References

graphs of patients with ACL deficient knees [8]. Eighty-four
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Our study shows the arthroscopic appearance of the ACL ligament deficiency. J Bone Joint Surg (Br) 1989;71-B:128 – 30.
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oped these changes had their ACLs been reconstructed study. J Bone Joint Surg 1976;58A:1 – 8.
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effect on the articular surface of the knee. Given the natural [8] Maletius W, Messner K. Eighteen to twenty-four year follow-up after
history of the ACL deficient knee in the first 2 years, we can complete rupture of the anterior cruciate ligament. Am J Sport Med
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53 - Changes in Arthroscopic Findings in The Anterior Cruciate Ligament Deficient Knee Prior To Reconstructive Surgery

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The Knee 12 (2005) 33 – 35

Changes in arthroscopic findings in the anterior cruciate ligament

Keywords: Knee; Anterior ligament reconstruction; Degenerative change; Osteochondral defect

1. Introduction To our knowledge our study is unique in comparing the

Fig. 1. Cumulative deteriorations in arthroscopic findings in the ACL deficient knee.

Maletius and Messner reviewed weight bearing radio- References

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