CONCOMITANT SURGERY

CARTILAGE REPAIR AND ITS RELATION WITH ACL RECONSTRUCTION – Written by Philippe Landreau, Qatar

Cartilage lesions are frequently observed during anterior cruciate ligament (ACL) reconstruction. Some of them are asymptomatic but it is currently unknown how they affect short-term clinical outcomes, return to sport or the risk of future osteoarthritis1. It is not known if these lesions can change the short- and longterm outcome after ACL reconstruction. It is therefore not clear if these lesions should be treated during the same surgical procedure. EPIDEMIOLOGY It is important to note that cartilage lesions do not occur only in combination with ACL rupture. The overall prevalence of full-thickness focal chondral defects in athletes has been estimated at around 36%, according to a systematic review reported by Flanigan et al2, including 931 subjects. Fourteen per cent of these athletes were

asymptomatic at the time of the diagnosis. Therefore, when an ACL tear occurs, it is sometimes difficult to identify whether the cartilage lesion is recent or not. The presence of cartilage and meniscal lesions in ACL tears is well recognised. Severe cartilage injuries combined with ACL tears occur in 16% to 46% of cases. Meniscal injuries present in 55% to 65% of cases4. Rotterud et al5 reported on the cartilage and meniscal lesions observed in 8476 knees registered in the Norwegian and the Swedish National Knee Ligament Registry from 2005 to 2008. They found that 27% of the patients had at least one cartilage lesion at the time of the ACL reconstruction. As a comparison, in the same population they found 43% had meniscal lesions, 20% of the patients had an International Cartilage Repair Society (ICRS) grade 1 to 2 cartilage lesion and 7% had a grade 3 to 4 cartilage lesion. These lesions

were mostly at the medial femoral condyle (34% to 51%) and approximately half of the lesions had a surface area less than 2 cm2. Tandogan et al6 found 19.1% of patients with an ACL tear had at least one chondral injury observed during an arthroscopy. Sixty percent were observed in the medial compartment, mainly on the weightbearing area of the medial condyle and 67% of the chondral lesions were ICRS grades 1 and 2, while 33%, were grades 3 and 4. The mean surface area was 2.19 +/- 1.75 cm2. There was a correlation between the presence of grade 3 or 4 lesions, age and the time between the injury and the arthroscopy. Cartilage injury can occur both at the time of the initial trauma or, in chronic ACL injuries, as a consequence of a variety of factors, including alteration of tibiofemoral biomechanics and recurrent knee injuries resulting from episodes of instability. The

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literature suggests that the incidence rate of cartilage lesions increases in chronic ACL cases in comparison with acute cases. Shelbourne7 found articular cartilage injury incidence to be more than double in chronic (54%) compared to acute (23%) ACL tears. Joseph et al8 showed that both athletes and non-athletes are equally susceptible to long-term cartilage injuries if ACL reconstruction is not performed early. They found a significant increase in meniscal and cartilage injuries 1 year after an ACL tear, if a reconstruction wasn't performed. In Tandogan’s study6, the odds of having a grade 3 or 4 lesion were 2.7 times greater if the time elapsed from injury was 2 to 5 years versus 1 year. These odds increased to 4.7 when patients delayed surgery for more than 5 years after injury. In this study, multivariate analysis suggested that time from injury and age were equally important predictors of grade 3 or 4 chondral lesions. Yuksel et al9 arthroscopically evaluated the type, localisation and prevalence of meniscal and chondral lesions accompanying complete rupture of the ACL in patients who elected not to restrict their daily activities after the initial trauma. They compared three groups according to time from injury until treatment: acute

(0 to 6 weeks), subchronic (6 weeks to 12 months) and chronic (more than 12 months). Chondral lesions were noted to increase with delay to surgery, with rates of 8.9%, 25.9% and 69.9%, respectively, in each group. Similarly, Michalitsis et al10, in a series of 109 consecutive patients with ACL rupture found an increased prevalence of highgrade cartilage lesions in ACL-deficient knees when reconstruction was performed more than 12 months after injury. Anderson et al11 found that delayed ACL reconstruction increased the risks of secondary meniscal and chondral injuries in a population of paediatric patients. Bambrilla et al12 found that ACL reconstruction within 12 months of injury can significantly reduce the risk of meniscal tears and chondral lesions. In their study, older age and increased BMI were risk factors for the occurrence of at least one associated lesion. Therefore, attention should be paid to patients with an elevated BMI and older age when considering the timing of ACL reconstruction surgery if avoidance of cartilage injury is an aim. Very few studies have evaluated the incidence of cartilage injuries in cases of ACL revision. Wyatt et al4 showed in a case

series of 261 patients that the prevalence of cartilage injuries increased from 14.9% at primary ACL reconstruction to 31.8% at revision ACL reconstruction. Interestingly, in the same series they observed that the prevalence of meniscal lesions decreased between the two surgeries. Cartilage injuries influence outcomes after ACL reconstruction Among the predictors of poor outcome 5 to 15 years after ACL reconstruction, cartilage damage is the most important, followed by medial meniscectomy and then lateral meniscectomy. Rotterud et al5 evaluated the effect of articular cartilage lesions on patientreported outcome 2 years after an ACL reconstruction. They showed that concomitant full-thickness cartilage lesions (grade 3 to 4) in ACL reconstruction have negative effects on knee function (Knee Injury and Osteoarthritis Outcome Score – KOOS) at 2 years follow-up. Janssen et al13 conducted a prospective study of 100 patients who underwent an ACL reconstruction using four-strand hamstring tendon autograft. They showed that, at 10 years follow-up, radiological signs of osteoarthritis were present in 53.5 % of the cases. They concluded that CARTILAGE – SURGICAL OPTIONS TARGETED TOPIC

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a

b

c

d

Figure 1: Microfracture and ACL reconstruction performed during the same surgical procedure. In this case, an acute grade 4 cartilage lesion was found on the weight-bearing surface area of the medial condyle (a) and the ACL had a proximal tear (b). A medial condyle microfracture procedure was performed after cartilage flap resection (c) and the ACL was reconstructed using hamstrings graft (d). the primary risk factors for osteoarthritis were meniscectomy prior or during the ACL reconstruction and cartilage lesions observed at the time of the ACL surgery. In a study by Kowalchuk14 (402 subjects who had undergone primary singlebundle arthroscopic ACL reconstruction at a mean follow-up of 6.3 years) lower International Knee Documentation Committee (IKDC) score was correlated with chondral injuries observed at the time of ACL reconstruction. Cox et al15, in a 6-year multi-centre cohort study, concluded that both articular cartilage injury (grade 3 and 4) and meniscus tears/

treatment at the time of ACL reconstruction were significant predictors of lower IKDC and KOOS scores 6 years after ACL reconstruction. However, other studies7,16-18 have found that cartilage lesions didn’t affect the outcomes after ACL reconstruction. Shelbourne7 found no difference after 8.7 years. Widuchowski18 showed that at 10 and 15 years follow-up the presence of a deep cartilage injury found during ACL reconstruction, left with no treatment, does not appear to affect the Lysholm, Tegner and IKDC scores after ACL reconstruction in comparison with a control group.

With the above discrepancy and the absence of consensus, it is difficult to define an accurate algorithm to guide the surgeon in the decision whether or not to repair cartilage lesions during ACL reconstruction. However, knowing that isolated grade 3 or 4 cartilage knee injuries can cause pain, effusion and affect return to sport, it is difficult to ignore cartilage lesions observed during an ACL surgery. Despite this lack of supporting literature, it seems appropriate to manage high-grade focal chondral defects simultaneously with ACL surgical treatment, particularly if a meniscus lesion is present.

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Table 1 Results of cartilage repair and ACL reconstruction Studies have shown that the treatment of cartilage injuries at the same time as ACL reconstruction has resulted in an acceptable outcome3. Imade et al19 found no differences between IKDC scores in patients with concomitant ACL reconstruction and osteochondral lesions treated by drilling, or autologous osteochondral grafting at a minimum follow-up of 1 year, regardless of the differences in arthroscopic grading (using the ICRS classification), however, only 40 patients were included in this control study. There is a potential for spontaneous healing after cartilage injuries. During ACL reconstruction, intra-articular enrichment in growth factors and progenitor cells might be involved in the repair processes of injured cartilage, as has been observed in meniscal repair. Nakamura et al20 showed that at second-look arthroscopy, after ACL reconstruction without any intervention to the articular cartilage, there was significant recovery of chondral lesions by Outerbridge grading on both the medial and lateral femoral condyles. Conversely, there was no significant recovery of chondral lesions observed at the patello-femoral joint or tibial plateaus. They concluded that there was a locationspecific difference in the natural healing response of chondral injury.

The literature suggests that severe cartilage lesions (grade 3 and 4) should be treated at the same time as the ACL reconstruction

ICRS grading system Grade 0

Normal

Grade 1

Nearly normal

Superficial lesions. Soft indentation and/or superficial fissures and cracks

Grade 2

Abnormal

Lesions extending down to 50% of cartilage depth as well as down to calcified layer and down to but not through the subchondral bone. Blisters are included in this grade.

Grade 4

Severely abnormal

Osteochondral injuries, lesions extending just through the subchondral boneplate or deeper defects down into trabecular bone.

Table 1: International Cartilage Repair Society grading system for cartilage defects21.

Surgical indication — which cartilage lesions must be repaired at the time of ACL reconstruction? There is little evidence to indicate whether full-thickness cartilage lesions should be repaired at the time of ACL reconstruction. However, in Rotterud’s study5, the difference in outcomes between absence of cartilage lesion, or partial lesion and full-thickness lesion suggests performing a cartilage repair at the same time as ACL reconstruction may be the best treatment option, especially in case of ICRS grade 3 or 4 cartilage lesions. In addition, further cartilage injury can be prevented by shortening the time between injury and the ACL reconstruction to avoid any episode of instability which likely provokes cartilage lesions. Patient information Patients should be informed at the time of ACL surgery about the possible outcome if there is a full-thickness cartilage lesion observed during the surgery, whether the treatment is conservative or not. It is particularly important in the athlete population where the expectations after ACL reconstruction may not be met if the cartilage lesion causes residual pain or swelling and prevents return to sport. CONCLUSION The presence of full-thickness cartilage injury in conjunction with ACL tear leads

to worse outcomes after ACL reconstruction than those with absence of cartilage lesion or even partial thickness cartilage lesion. These results have been noticed from short-time follow-up and should be confirmed at longer follow-up. There is a lack of understanding concerning the benefit of cartilage repair combined with ACL reconstruction. However, the current literature suggests that a full-thickness cartilage injury observed during an ACL reconstruction should be treated at the same time. A microfracture procedure, chondrocyte implantation or the use of scaffolds are the current options available and are chosen depending on the experience of the surgeon and on the surface of the cartilage damage. Currently there is no evidence to support the treatment of partial cartilage lesion (grade 1 to 2) during an ACL reconstruction and there are still some questions concerning the potential morbidity of this combined procedure. The literature suggests that severe cartilage lesions (grade 3 and 4) should be treated at the same time as the ACL reconstruction. The results of these concomitant surgeries are encouraging and could hope to decrease the incidence of future osteoarthritis. More studies should be conducted in the future to evaluate the evidence so that recommendations for specific treatments and techniques can be made according to the type of cartilage lesions (depth, size and localisation). CARTILAGE – SURGICAL OPTIONS TARGETED TOPIC

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References 1. Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med. 2009; 37:1434-1443. 2. Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH. Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc 2010; 42:17951801. 3. Brophy RH, Zeltser D, Wright RW, Flanigan D. Anterior cruciate ligament reconstruction and concomitant articular cartilage injury: incidence and treatment. Arthroscopy 2010; 26:112-120. 4. Wyatt RW, Inacio MC, Liddle KD, Maletis GB. Prevalence and incidence of cartilage injuries and meniscus tears in patients who underwent both primary and revision anterior cruciate ligament reconstructions. Am J Sports Med 2014; 42:1841-1846. 5. Røtterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Arøen A. Effect of meniscal and focal cartilage lesions on patientreported outcome after anterior cruciate ligament reconstruction: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med 2013; 41:535-543. 6. Tandogan RN, Taser O, Kayaalp A, Taskiran E, Pinar H, Alparslan B et al. Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 2004; 12:262-270. 7. Shelbourne KD, Jari S, Gray T. Outcome of untreated traumatic articular cartilage defects of the knee: a natural history study. J Bone Joint Surg Am 2003; 85:S8S16. 8. Joseph C, Pathak SS, Aravinda M, Rajan D. Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACLdeficient athlete and non-athlete population: an Indian experience. Int Orthop 2008;32:57-61. 9. Yüksel HY, Erkan S, Uzun M. The evaluation of intra-articular lesions accompanying ACL ruptures in military personnel who elected not to restrict their daily activities: the effect of age and time

from injury. Knee Surg Sports Traumatol Arthrosc 2006; 14:1139-1147. 10. Michalitsis S, Vlychou M, Malizos KN, Thriskos P, Hantes ME. Meniscal and articular cartilage lesions in the anterior cruciate ligament-deficient knee: correlation between time from injury and knee scores. Knee Surg Sports Traumatol Arthrosc 2015; 23:232-239. 11. Anderson AF, Anderson CN. Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43:275-281. 12. Brambilla L, Pulici L, Carimati G, Quaglia A, Prospero E, Bait C et al. Prevalence of associated lesions in anterior cruciate ligament reconstruction: correlation with surgical timing and with patient age, sex, and body mass index. Am J Sports Med 2015; 43:2966-2973. 13. Janssen RP, du Mée AW, van Valkenburg J, Sala HA, Tseng CM. Anterior cruciate ligament reconstruction with 4-strand hamstring autograft and accelerated rehabilitation: a 10-year prospective study on clinical results, knee osteoarthritis and its predictors. Knee Surg Sports Traumatol Arthrosc 2013; 21:1977-1988. 14. Kowalchuk DA, Harner CD, Fu FH, Irrgang JJ. Prediction of patient-reported outcome after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 2009; 25:457-463. 15. Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD et al. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 2014; 42:1058-1067. 16. Hjermundrud V, Bjune TK, Risberg MA, Engebretsen L, Arøen A. Full-thickness cartilage lesion do not affect knee function in patients with ACL injury. Knee Surg Sports Traumatol Arthrosc 2010; 18:298-303. 17. Spindler KP, Warren TA, Callison JC Jr, Secic M, Fleisch SB, Wright RW. Clinical outcome at a minimum of five years after reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 2005; 87:1673-1679.

18. Widuchowski W, Widuchowski J, Koczy B, Szyluk K. Untreated asymptomatic deep cartilage lesions associated with anterior cruciate ligament injury: results at 10and 15-year follow-up. Am J Sports Med 2009; 37:688-692. 19. Imade S, Kumahashi N, Kuwata S, Kadowaki M, Tanaka T, Takuwa H et al. A comparison of patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting for the treatment of articular cartilage defects combined with anterior cruciate ligament injury. Knee 2013; 20:354-359. 20. Nakamura N, Horibe S, Toritsuka Y, Mitsuoka T, Natsu-ume T, Yoneda K et al.The location-specific healing response of damaged articular cartilage after ACL reconstruction: short-term follow-up. Knee Surg Sports Traumatol Arthrosc 2008; 16:843-848. 21. International Cartilage Repair Society Clinical Cartilage Injury Evaluation System. Available from: www.cartilage.org/ society/publications/icrs-score

Philippe Landreau M.D. Orthopaedic Surgeon Chief of Surgery Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar Contact:[email protected]

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