The following question is another one that I received after giving a talk at a medical conference recently. Since it is one that I receive very frequently from patients, and since it is actually a somewhat counterintuitive answer, I thought it would make a great Ask Dr. Geier column. Will undergoing ACL surgery prevent arthritis?

Does ACL surgery prevent arthritis?

There is a simple answer and a more complicated one to this question. The simple answer is no.

A systematic review of scientific literature performed by Øiestad et al in the July 2009 issue of the American Journal of Sports Medicine examined the data from 31 studies of osteoarthritis after ACL reconstruction. These authors found that studies looking at patients with isolated ACL injuries had rates of later osteoarthritis between 0% and 13% at a minimum of 10-year follow up. Studies that looked at patients with combined ACL and meniscal tears treated surgically (which are common coexisting injuries) showed that 21% to 48% developed osteoarthritis.

Arthritis of the knee
This is an arthroscopic view of fraying of the articular cartilage on the end of the femur. Essentially this cartilage damage represents early osteoarthritis.

Some individual studies place the rates of osteoarthritis after ACL reconstruction much higher. Several studies have shown long-term findings of osteoarthritis in 50% or more of patients. Studies looking at combined ACL tears and meniscal tears claim 70% of patients develop radiographic signs of osteoarthritis at long-term follow up.

One point worth noting for readers who have had ACL surgery is that x-ray or MRI findings of osteoarthritis do not necessarily correlate with pain or other symptoms. An athlete can develop x-ray signs of osteoarthritis, such as bone spurs and joint space narrowing, but still play sports and have little functional deficit. On the other hand, as surgeons largely consider osteoarthritis to be a progressive deterioration of the joint, we often worry that the x-ray changes could progress with more time after surgery and that functional ability could gradually decrease.

I’ve heard that some orthopaedic surgeons tell patients that they should undergo ACL reconstruction because they will develop osteoarthritis if they don’t have surgery. Essentially there is little data to support that claim.

Will ACL surgery prevent arthritis for this soccer player?

On the other hand, preventing arthritis isn’t really the goal of ACL reconstruction. We perform these surgeries to restore stability to the knee. Sedentary people and possibly some athletic people who only run or walk might do well with nonoperative treatment. However most people who participate in sports or exercise with cutting or pivoting motions can’t do those activities without their knees giving way.

If an athlete’s knee buckles with attempts to quickly change direction or land from a jump, she risks further damage to the joint. Secondary injuries to the menisci and articular cartilage would likely occur pretty quickly if she returned to sports with an ACL-deficient knee.

In theory, stabilizing the knee to prevent secondary damage should decrease later osteoarthritis. But as these studies show, arthritis seems to develop anyway. We don’t know why rates would be higher (or at least not lower). Maybe the rates of later osteoarthritis will decrease with newer anatomic ACL reconstructions, as most of these studies involve patients who underwent surgery years ago. But I suspect that the impact from the ACL injuries themselves can create articular cartilage damage that could progress over time.

Regardless, while later development of arthritis can occur, I would argue that it shouldn’t be the primary factor in an athlete’s decision-making process. If she wants to continue to play sports, she should strongly consider ACL surgery.

ACL injury illustration

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Reference:
Øiestad BE, Engebretsen L, Storheim, Risberg MA. Knee Osteoarthritis After Anterior Cruciate Ligament Injury: A Systematic Review. Am J Sports Med. 2009;37(7)1434-43.

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