Acl & Oa

The American Journal of Sports Medicine, Vol. 37, No. 7 DOI: 10.1177/0363546509340131 © 2009 American Orthopaedic Society for Sports Medicine after reconstruction, the authors concluded that “it seems reasonable to question whether return to high-level pivoting sports really is in the player’s interest—if long-term knee health is the primary concern. ” Although that article has been cited at least 38 times since its publication, it created less of a stir than I anticipated. After all, it was only 1 study of athletes in 1 sport, at least some of whom had surgery with techniques currently deemed obsolete. In this month’s AJSM, a group that includes 1 of the same authors takes a comprehensive look at the available literature on the prevalence of osteoarthritis (OA) 10 to 27 years after ACL injury. “Knee Osteoarthritis After Anterior Cruciate Ligament Injury,” by Øiestad et al, is a systematic review of 31 studies comprising patients treated with and without surgery. The modified Coleman methodology scores of the 7 prospective studies examined ranged from 61 to 88 (on a scale of 90), whereas the scores of the 24 retrospective studies ranged from 22 to 59. The occurrence of OA was examined in a number of ways. Based on all 31 studies, the prevalence of OA varied from 1% to 100%, compared with 0% to 38% in the contralateral knees. In the better-quality studies, however, the prevalence of OA in patients with an isolated ACL rupture was only 0% to 13%, whereas in patients with combined ACL and meniscal tears, the prevalence was 21% to 48%. Overall, studies that compared surgery with nonsurgical treatment found a similar prevalence of OA in both groups. Two studies reported a higher prevalence of OA in patients treated surgically, although treatment was not randomized in either study. In general, the studies with higher methodology ratings reported a lower overall prevalence of OA. On the basis of their analysis, Øiestad et al decided that prior estimates placing the prevalence of OA after ACL rupture in the 50% to 100% range were too high. The authors further analyzed the reports to delineate risk factors for the development of OA after ACL injury. Different studies identified meniscal injury, surgical treatment, age, obesity, abnormal joint laxity, loss of extension, time from injury to surgery, and poor performance on a functional hop test as markers of increased risk of OA. Øiestad et al concluded that among all risk factors identified by various studies, meniscal injury and meniscectomy were the best documented. Given that returning to pivoting sports after ACL injury was not examined as a risk factor in the highest-rated studies, it was not possible to address the question raised by Myklebust et al concerning the advisability of doing so. Øiestad et al point out that the cited studies defined OA according to a bewildering array of radiographic criteria but failed to note whether symptoms of OA were present, as recommended by the American Rheumatism Association. This criticism may appear to be quibbling until one considers that radiographic signs of OA after ACL injury I am interested in medical research because I believe in it. I am interested in arthritis because I have it.