Do I need ACL reconstruction surgery?

Physiotherapy in Richmond for Knee

Q: I'm weighing the pros and cons of having surgery for an unstable knee. The surgeon is proposing reconstructing the torn ACL and repairing the meniscus. I've been told that without this operation, I could end up with early arthritis and eventually need a total knee replacement. How do I know that won't happen anyway with or without the surgery?

A: When it comes to what will happen in the future after a decision of this type, there's no crystal ball. Surgeons make recommendations like this based on the current available evidence. Right now, there's enough data to show that arthritic changes occur faster with progressive joint degeneration when the knee is unstable from any kind of injury.

Anterior cruciate ligament (ACL) tears are the most common ligamentous injuries of the knee. Damage to the meniscus is often present as well. And studies of patients who have either avoided knee surgery or who had the meniscus removed have convinced us that surgical repair or reconstruction of many ACL injuries is really the best approach.

What happens 20 to 25+ years after the reconstructive surgery? Well, that's also being studied right now. The longest research reported comes out of France by a single surgeon who tracked over 100 patients for 24+ years.

Now 20 or more years later, more than half of those patients (57 per cent) rate their results as excellent. Another 27 per cent say they have good results. Only 16 per cent said that they felt their outcomes were poor (two per cent) to fair (14 per cent).

Patients who had damage to the articular cartilage or meniscus were more likely to have less knee function. And between 10 years post-op and the current study 24 years later, there's been an increase in the number of these patients with osteoarthritis.

Only 15 per cent of the group with osteoarthritic changes had similar changes in the other knee. So it wasn't the case that they would have ended up with arthritis anyway. The loss of the meniscus and damage to the joint cartilage were the biggest factors in the development of osteoarthritis.

Reference: Jerome Pernin, MD, et al. Long-Term Follow-Up of 24.5 Years After Intra-Articular Anterior Cruciate Ligament Reconstruction with Lateral Extra-Articular Augmentation. In The American Journal of Sports Medicine. June 2010. Vol. 38. No. 6. Pp. 1094-1102.

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