Dr. Spindler is involved in the Multicenter Orthopedic Outcomes Network (MOON), and one MOON study looked at patient-reported outcomes, pain scores and failure in patients who underwent ACL reconstruction surgery at two, six and 10 years of follow-up in 1,592 patients.23
A majority of patients in the study maintained good pain and quality of life scores, but “if you look at their activity level over time, it declines. Much of this is caused by social factors: People graduate from high school or college, or other things in their lives become more important” than sports, such as career or marriage, said Dr. Spindler. Numerous risk factors predict worse pain and quality of life scores at 10 years, including higher grade articular lesion, previous meniscus surgery, any type of subsequent surgery, higher body-mass index and smoking. Pain scores tend to stay the same over this period of time. Graft type, sports competition level and meniscus injury type do not predict worse outcomes.
“One of the concerns is that maybe they’re getting post-traumatic OA, but they’re controlling their symptoms by dialing back their activity,” said Dr. Spindler. Despite a 10-year follow-up on 83% of the patients in the cohort, this sample size was insufficient to model the effect of meniscus tears and treatment in articular cartilage chondromalacia within the same compartment. There was no on-site follow-up in the study, such as physical examination or X-ray data. “At 10 years, only a small percentage of patients have pain and symptoms consistent with post-traumatic OA,” although the average age of patients at the beginning of the study was 22.
Is pain a predictive marker for later articular changes? In his group’s study of 1,761 patients after ACL reconstruction, between 9% and 39% of patients had significant pain six years later, said Dr. Spindler.24 “The dominant risk factor for this outcome is any second surgery. If you think the first hemarthrosis is bad for the articular cartilage, what about the surgery? It’s even worse for the cartilage. Add a second surgery, and you keep adding these hits.”
Are there interventions to help prevent post-traumatic OA in these patients? Some pilot studies are looking at the potential benefits of a corticosteroid triamcinolone acetonide injection soon after ACL reconstruction.
“Even if you block all the inflammation at surgery, you have a conundrum. At the time of surgery, you are putting a graft in there that must heal. You can’t just block all inflammation and stop the healing,” said Dr. Spindler. He is involved in a new study of hyaluronic acid or triamcinolone acetonide injections, both administered one week after ACL surgery, compared to no intervention.
