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Scientific Articles   |    
Does ACL Reconstruction Alter Natural History?A Systematic Literature Review of Long-Term Outcomes
Peter N. Chalmers, MD1; Nathan A. Mall, MD2; Mario Moric, MS3; Seth L. Sherman, MD4; George P. Paletta, MD4; Brian J. Cole, MD, MBA1; Bernard R. Bach, Jr., MD1
1 Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 200, Chicago, IL 60612
2 St. Louis Center for Cartilage Restoration and Repair, Regeneration Orthopedics, 6 McBride and Sons Center Drive, Suite 204, St. Louis, MO 63005. E-mail address: nathanmall@yahoo.com
3 Department of Anesthesiology, Rush University Medical Center, 1653 West Congress Parkway, Jelke 7, Chicago, IL 60612
4 Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212
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Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Investigation performed at the Departments of Orthopaedic Surgery and Anesthesiology, Rush University Medical Center, Chicago, Illinois, the St. Louis Center for Cartilage Restoration and Repair, Regeneration Orthopedics, St. Louis, and the Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Feb 19;96(4):292-300. doi: 10.2106/JBJS.L.01713
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Abstract

Background: 

Anterior cruciate ligament (ACL) injury can lead to tibiofemoral instability, decreased functional outcomes, and degenerative joint disease. It is unknown whether ACL reconstruction alters this progression at long-term follow-up.

Methods: 

A systematic literature review of the long-term results (minimum follow-up, more than ten years) after operative intra-articular reconstruction of ACL injuries and after nonoperative management was performed to compare (1) knee stability on physical examination, (2) functional and patient-based outcomes, (3) the need for further surgical intervention, and (4) radiographic outcomes. After application of selection criteria, forty patient cohorts with a mean of 13.9 ± 3.1 years of postoperative follow-up were identified. Twenty-seven cohorts containing 1585 patients had undergone reconstruction, and thirteen containing 685 patients had been treated nonoperatively.

Results: 

Comparison of operative and nonoperative cohorts revealed no significant differences in age, sex, body mass index, or rate of initial meniscal injury (p > 0.05 for all). Operative cohorts had significantly less need for further surgery (12.4% compared with 24.9% for nonoperative, p = 0.0176), less need for subsequent meniscal surgery (13.9% compared with 29.4%, p = 0.0017), and less decline in the Tegner score (−1.9 compared with −3.1, p = 0.0215). A difference in pivot-shift test results was observed (25.5% pivot-positive compared with 46.6% for nonoperative) but did not reach significance (p = 0.09). No significant differences were seen in outcome scores (Lysholm, International Knee Documentation Committee [IKDC], or final Tegner scores) or the rate of radiographically evident degenerative joint disease (p > 0.05 for all).

Conclusions: 

At a mean of 13.9 ± 3.1 years after injury, the patients who underwent ACL reconstruction had fewer subsequent meniscal injuries, less need for further surgery, and significantly greater improvement in activity level as measured with the Tegner score. There were no significant differences in the Lysholm score, IKDC score, or development of radiographically evident osteoarthritis.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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