Disclaimers. Concerns after ACL Tear 3/13/2018. Outcomes after ACLR. Sports, Knee, Shoulder Symposium Snowbird, Utah February 24, 2018

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1 Outcomes after ACLR Sports, Knee, Shoulder Symposium Snowbird, Utah February 24, 2018 Christopher Kaeding M.D. Judson Wilson Professor of Orthopaedics Executive Director, OSU Sports Medicine Medical Director, OSU Athletics The Ohio State University Disclaimers I have no conflict with content of this talk Concerns after ACL Tear 1. Functional instability 2. Further injury to knee Meniscus Articular cartilage 3. Long Term Osteoarthritis 1

2 Rationale for ACL Surgery 1. Functional instability (return sports/activities) YES How functional and satisfied are patients after an ACLR? Global Hypothesis MOON Evaluate PROGNOSIS & PREDICTORS of Clinically Relevant Outcomes of ACLR Aim 1: Aim 2: Aim 3: Aim 4: Aim 5: Activity Level (Marx) Patient-Oriented Outcomes (KOOS, IKDC, SF-36,) Symptoms and Signs of Osteoarthritis Recurrent Ligament disruption Additional arthroscopic surgery 2012 Kappa Delta Award 2017 AOSSM O Donahue Award Population Results: KOOS 2,6,10 yr 1. IKDC Baseline Improved Improvement stable through at least 10 years 2

3 Population Results: IKDC 1. IKDC Improved Improvement stable through at least 10 years Population Results: MARX Activity Scale 1. IKDC Risk Factors for WORSE IKDC & KOOS Sports and QOL at 10 Years 1. G3/G4 Chondral injury 2. Previous Medial Meniscus Excision 3. Revision ACLR 4. Subsequent Surgery 5. Higher BMI 6. Smoker 7. Lower Baseline PROM 3

4 NOT Risk Factors for WORSE KOOS and IKDC Outcomes 1. Medial + Lateral meniscus injury 2. Graft type Auto HG, BT, Allograft 3. Sport or Competition level 4. Surgeon 5. MCL or LCL 6. High Grade Laxity Risk Factors for WORSE MARX activity at 10 Years 1. Previous medial meniscus surgery 2. High Grade Laxity 3. Higher BMI 4. Higher age 5. Smoker 6. Lower Baseline PROM 7. Lower education 8. Female KOOS Differences (10-2 yrs) 4

5 IKDC and Marx Differences (10-2 yrs) Conclusions 1. ACLR results remain stable from 2-10 years 1. Majority maintain KOOS and IKDC coupled with a steady decline in Marx activity level 1. At 10 years only a small percentage have PROMs (pain and symptoms) of post-traumatic OA Concerns after ACL Tear 1. Functional instability 2. Further injury to knee Meniscus YES 5

6 Rationale for ACL Surgery: - Protect the meniscus - In RCTs: ACLR decreased subsequent meniscus surgery: 1. Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up. J Bone Joint Surg Am. 1989;71(7): Engebretsen L, Benum P, Fasting O, Molster A, Strand T. A prospective, randomized study of three surgical techniques for treatment of acute ruptures o f the anterior cruciate ligament. Am J Sports Med. 1990;18(6): Concerns after ACL Tear 1. Functional instability 2. Further injury to knee Meniscus 3. Long Term Osteoarthritis NO ACL tear is a Post-Traumatic OA Model for Initiation and Treatment of Arthritis 1. ACL tears 20% more common Adults Symptomatic OA Hill CL, Arth & Rheum Early articular cartilage changes consistent with idiopathic OA observed after ACLR. Nelson F OA &Cart Presence of meniscus tear determines radiographic OA not ACLR or not (0-21 NO men tr, 21-48% Yes Men tr) Øiestad AJSM Loss of 20-25% PG s (proteoglycans)by dgemric MRI within 3 weeks ACL tear and not replaced 2 yr after ACLR Neuman OA & Cart

7 Acute ACL Tears - Associated Pathologies - 1. MCL injuries 10-20% 2. Meniscus tears >50% 3. Articular cartilage injures ~25% 4. Bone Bruises in 80% 5. Majority have hemarthrosis 6. Quadriceps muscle inhibition 7. Altered Gait biomechanics Currently well-performed ACLR does not prevent PTOA - despite the ability to perform meniscus repair - decrease ACLR decreasing risk of future meniscus tear - despite recognition and new treatments for articular cartilage injuries ACLR Toxic Effect on Articular Cartilage? 1. Well-performed ACLR may induce a toxic environment 2. Irrigation rinses out the Lubricin and HA from the joint 3. Induced a hemarthrosis with the addition of bone fragments and potential articular cartilage and meniscus fragments. 7

8 ACLR - Short Term Complications - Pulmonary Embolism Infection ACLR - Short Term Complications - Systematic Review: DVT: 8% (73% asymptomatic) PE: 0.2% Rates of Deep Venous Thrombosis and Pulmonary Embolus After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Erickson BJ1, Saltzman BM1, Campbell KA1, Fillingham YA1, Harris JD1, Gupta AK1, Bach BR Jr1 Sports Health May;7(3): doi: / RISK FACTORS FOR ADDITIONAL SURGERY What is my infection risk after ACLR? 0.4% 8

9 Factors Associated with Infection Following Anterior Cruciate Ligament Reconstruction Brophy JBJS Am March Data MOON = 2198 ACLR 1. Follow-up > 85% with Multivariable anlaysis 1. Diabetes significant Increased risk OR = Autograft BTB significantly lower risk infection then Autograft HG or Allografts The Future Continue efforts to optimize: - Anatomy + mechanical function - Neuromuscular function - Decrease graft re-tear risk The Future ADD BIOLOGIC FOCUS Toxic joint environment after injury and after surgery Improve healing of meniscus and articular cartilage Understand Genetics and individual response to injury Explore RCT using chondro-protective agents 9

10 Thank You 10