Operative treatment for anterior cruciate ligament ruptures in adults [protocol]
Linko E, Harilainen A, Malmivaara A, Seitsalo S
This protocol should be cited as: Linko E, Harilainen A, Malmivaara A, Seitsalo S. Operative treatment for anterior cruciate ligament ruptures in adults (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
Cover sheet - Background - Methods - References
Background
Each year around one in hundred people suffer a serious knee injury (Kannus 1989). Anterior cruciate ligament (ACL) rupture is the most common cause of acute, traumatic haemarthrosis (bleeding) of the knee, an isolated rupture being found in about 38% of patients with acute knee haemarthrosis (Harilainen 1990).
The ACL is the primary passive restraint to anterior translation of the tibia relative to the femur (Seitz 1996). A rupture of the ACL compromises the stability of the knee in active individuals resulting in chronic instability, recurrent injury, and associated intra-articular pathology (O'Neill 1996). ACL rupture may also lead to changes in lifestyle and disability. Both conservative and operative interventions are used in the treatment of ACL injuries. While operative treatment of ACL lesions in athletes is widely performed, conservative treatment has been considered to have a good outcome in the general population (Casteleyn 1996).
Hey Groves 1917 presented the first report of a procedure to reconstruct torn ACL by using a tethered fascia lata graft through anatomically placed drill holes in the femur and tibia. Surgical techniques include simple repair by suturing or suturing with augmentation, intra- or extra-articular reconstruction, open or arthroscopic operations, use of different kinds of grafts as well as various graft fixation methods. The materials used for ACL replacement can be broadly classified as follows:
1) autogenous (from the patient) or allogenous (for example cadaveric) grafts (for example fascia lata, hamstring tendons and patellar ligament);
2) heterogenous (from different species) grafts (for example lyophilized fascia lata and dura mater);
3) artificial ligaments (for example carbon fibres and dacron) (Franke 1985; Shino 1993).
Despite the growing and widespread use of ACL reconstruction and the many reports of different operative treatment options for the reconstruction of ruptured ACL, the benefit (both efficacy and cost-effectiveness) of ACL reconstruction surgery still needs to be established, as do the relative benefits of the different methods used. This review is being undertaken to look at the evidence from randomised trials for the various surgical options available in an attempt to address these issues. The benefit of ACL reconstruction versus conservative treatment also needs clarification.
benefit of cruciate surgery has not been established
5 posts
• Page 1 of 1
medical vs surgical ACL treatment same for return to sports
by whistle blower » Thu Dec 11, 2003 8:47 am
© 1996 British Editorial Society of Bone and Joint Surgery
Volume 78-B(3) May 1996 pp 446-451
Non-Operative Management of Anterior Cruciate Ligament Injuries in the General Population
[Knee]
Casteleyn, Pierre-Paul; Handelberg, Frank
From the Vrije Universiteit Brussel, Brussels, Belgium.
P.-P. Casteleyn, MD, Professor, Department of Human Anatomy and Associate Clinical Professor, Department of Orthopaedics and Traumatology
F. Handelberg, MD, Assistant Clinical Professor, Department of Orthopaedics and Traumatology, Academisch Ziekenhuis, AZ-VUB Laarbeeklaan 101, B-1090 Brussels, Belgium.
Correspondence should be sent to Professor P.-P. Casteleyn.
Received 25 August 1995; Accepted after revision 29 November 1995
The operative treatment of lesions of the anterior cruciate ligament (ACL) in athletes has been widely advocated and performed.We have investigated the outcome of non-operative management in a lower-demand, general population. We reviewed a consecutive group of 228 patients, which excluded professional and high-level athletes, for two to 12 years after an ACL lesion had been diagnosed by arthroscopy.
There was a low incidence of secondary ACL and meniscal surgery, 5.4 percent and 3.5 percent respectively, and all these procedures were performed during the first three years after the ACL injury.
We studied a subgroup of 109 patients with follow-up of at least five years (mean 8.5 years) and evaluated them using the IKDC score. The general outcome was reasonably satisfactory, with 23 percent in grade A, 50 percent in grade B, 21 percent in grade C and only 6.4 percent in grade D. We found no statistically significant prognostic effect within this group as regards age, activity levels, or the incidence of associated lesions.
J Bone Joint Surg [Br] 1996;78-B:446-51.
Lesions of the anterior cruciate ligament (ACL) in athletes have been studied extensively in orthopaedic sports medicine, and operative treatment using grafts is widely advocated for this particular group of patients (Fetto and Marshall 1980; Noyes et al 1983a; Kannus and Jarvinen 1987; Andersson et al 1989; Barrack et al 1990; Daniel and Fithian 1994). [1,2,6,8,16,20] Many ACL lesions, however, are seen in non-athletes as a result of accidents or low-grade recreational activities (Jain, Swanson and Murdoch 1983; Casteleyn, Handelberg and Opdecam 1988). [5,15]
We aimed to investigate the outcome of the conservative treatment of ACL lesions in a lower-demand population.
PATIENTS AND METHODS
Over a period of 12 years, we managed a total of 274 patients with acute traumatic knee haemarthrosis. All had examination under anaesthesia and arthroscopy.
Of these, we treated 46 by ACL reconstruction. They included patients with gross or multidirectional joint laxity (grade-3 or grade-4 pivot shift, combined lesions of the ACL and lateral collateral ligament (LCL) or posterior cruciate ligament (PCL)) and in addition all high-level or professional athletes. These 46 cases (16.8 percent) were excluded from the study group.
This left a consecutive group of 228 patients (83 percent) who were managed conservatively. There was an almost fourfold male to female ratio and the mean age at the time of injury was 33.2 years (16 to 66). The main causes of injury were daily living activities (28.1 percent), traffic accidents (11.8 percent), and recreational activities (60.1 percent) Table 1.
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Table 1. Details of the whole series and of the subgroups with secondary ACL and meniscal surgery
Initial management.
In 83 percent of the cases, arthroscopic evaluation was within three weeks of the index injury. The proportions of isolated ACL ruptures and those associated with meniscal and ligamentous lesions were comparable with those reported in previous studies (Casteleyn et al 1988) [5] Table 1 and Table 2; only 21 of the ACL tears (9 percent) were partial. Intrasynovial ACL lesions (14; 6.1 percent) were left as much as possible within the synovial sheath. There was spontaneous partial reattachment of the distal ACL stump to the PCL in 18 knees (7.9 percent): these were left undisturbed. Some ACL remnants which seemed likely to impinge between the femur and tibia and limit extension were trimmed. No reconstructive ACL surgery was performed during the initial arthroscopy.
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Table 2. Lesions diagnosed during initial arthroscopy
Meniscal surgery was performed if indicated and feasible. Three of 27 torn lateral menisci and 17 of 105 medial menisci were sutured. Minor lesions, of one lateral and seven medial menisci, were left untreated. All other meniscal lesions (77.1 percent of the medial and 85.2 percent of the lateral meniscal lesions) were treated by partial arthroscopic meniscectomy. No surgery was performed for medial collateral ligament (MCL) lesions.
All patients were treated by a comprehensive rehabilitation programme for six to eight weeks. Early weight-bearing was allowed with the eventual protection of a cast or a brace in cases of partial ACL and intrasynovial ACL, MCL and LCL lesions.
Follow-up.
The initial 228 patients have been followed up for 2 to 12 years. Data were collected during annual examinations or by written questionnaire or telephone interviews. Of these patients, 25 (11 percent) have been lost to follow-up leaving 203 with known results at over two years. Records were maintained of pre- and postinjury levels of activity and of the reasons for any long-term modification of the level of activity.
We classified activity levels into four groups:
1) strenuous activity which included jumping, pivoting and cutting (soccer);
2) moderate activity, involving heavy manual work (skiing, tennis);
3) light activity such as jogging or running; and
4) sedentary activity such as housework and the normal activities of daily living.
We recorded all subsequent surgery for the ACL lesion (intra-articular or extra-articular) and all subsequent meniscal surgery. These data were then used to construct survival tables with ACL or meniscal surgery or both considered as end-points. The age, gender, activity level, aetiology of the injury and any associated lesions in the patients who required secondary ACL and/or meniscal surgery were then compared with similar data from the patients who had no subsequent operations Table 1.
We tried to review all 132 patients with at least five years' follow-up for their subjective opinion, clinical examination, and radiological assessment. Of these, 23 (17 percent) refused further clinical and radiological examination. The 109 patients who were studied in detail did not differ significantly from the initial cohort as regards mean age, gender, or distribution of activity level, cause of injury or associated lesions. The mean period from the initial injury was 8.5 years (5 to 12). The final assessment was recorded on the International Knee Documentation form (Hefti et al 1993). [14] This assesses results in seven separate subgroups (see Table 4). These are subjective assessment, symptoms, range of motion, ligament examination (which in our study included use of the KT 2000 tester (Medmetric Corporation, San Diego, California) with 134 N displacement force), compartmental crepitus, radiography and a one-leg hop test. The result in each subgroup is scored on a four-point scale. The lowest grade determines the global grade of the subgroup, and the worst evaluation group determines the final score.
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Table 4. IKDC evaluation of 109 patients. The numbers in bold type are the global results for each group (see text)
We tried to find correlations between the final grade and age at injury, associated lesions, activity level or modification and length of follow-up, using the analysis of variance, the paired t-test, and the Mann-Whitney U test.
RESULTS
Survival.
Only 11 of the 203 patients followed for two to 12 years had needed secondary ACL surgery (5.4 percent) and seven had secondary meniscal surgery (3.5 percent) Table 1. All these procedures had been performed during the first three years after the index injury with none later than this. These figures give a high survival rate which persists for three to 12 years Figure 1.
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Figure 1. Survival curves after non-operative management of ACL injuries, using as end-points secondary ACL surgery, secondary meniscal surgery, and both together.
We found no correlation between survival and cause of injury, associated lesions or activity levels, but the patients who had needed subsequent ACL surgery were younger and had a lower male-to-female ratio Table 1.
Activity levels.
The initial activity levels were those of a general population with a fair proportion of manual workers, some of them involved in moderate sport and recreational activities Table 1. None of the patients who needed secondary ACL and meniscal surgery had modified their activity level since the injury and its treatment. Less than half of all the patients had modified their activity levels after the ACL injury Table 3 and of those who reported a decrease, only 57 (65.5 percent) considered that this decrease in activity level was related to their ACL injury.
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Table 3. Activity level modification after ACL injury in 203 patients
As expected, the relationship between decrease in activity level and the original injury became less important with length of follow-up. Any decrease in activity was reported to be injury-related by 78 percent when it occurred less than five years after injury, by 57 percent between five and eight years, and by only 17 percent when it occurred after more than eight years.
IKDC examination.
The results in 109 patients are summarised in Table 4. The subjective results were satisfactory: 82.4 percent of the patients stated that their knee was normal or nearly normal. This was confirmed by the rather benign nature of the symptoms; 61 percent achieved a normal grade and 21 percent a nearly normal grade. The range of motion was marginally limited in only 19 percent, with no important extension or flexion deficits. The lowest grades were found as expected in the KT 2000 ligament examination sub-group, but even for this test 32.1 percent of the knees had a nearly normal grade. As regards compartmental crepitus 84 percent were normal and there was no radiological narrowing of the joint space in 76 percent.
For the one-leg hop test, 57 percent had normal rates; this confirmed the low intensity of any symptoms and the reasonably good function of most of the knees. The overall evaluations gave 23 percent in grade A, 50 percent in grade B, 21 percent in grade C and 6.4 percent in grade D.
We could find no prognostic correlation between age at the time of injury, associated lesions, activity level at time of injury and at time of evaluation, and the final evaluation grade. There was no marked decrease in evaluation grades with increasing length of follow-up Figure 2.
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Figure 2. Changes in the proportions of A and B global evaluation grades with length of follow-up showing no significant deterioration.
DISCUSSION
The results of our study must be analysed with caution, since 11 percent of the patients were lost to follow-up, and 17 percent of the patients whom we traced at over five years refused further clinical examination. The main strength of our work is that the population of patients was selected at the time of the initial injury; many previous studies of the non-operative management of ACL injuries were based on patients who were seeking further treatment because of significant complaints (Fetto and Marshall 1980; McDaniel and Dameron 1980; Giove et al 1983; Noyes et al 1983a; Finsterbush et al 1990). [8,9,12,19,20]
The conservative management which we used during the 14 years of the study must be considered in relation to the evolving knowledge on ligament healing; some of our earliest patients were treated during the early 1980s. We would not now use casting for ligament sprains or partial ruptures of the ACL (Daniel et al 1994). [7]
Our review of a general patient population, less interested in sporting activities, also means that precise data about physical activity are more difficult to obtain. The IKDC assessment form does not offer the same refinement of analysis as the Tegner score, but seems to be more applicable to this type of population. It should also be noted that the mean time between injury and latest radiological examination in our 103 patients (8.5 years; 5 to 12) may be too short to show significant degenerative changes in this low-demand population.
The most surprising result of our study was the fairly limited laxity shown by ligament examination; only 44.9 percent of Lachmann tests showed side-to-side differences of more than 3 mm, and only 15.5 percent showed gross pivot shifts. Among possible explanations are the exclusion from the study of knees with gross instability and the appreciable percentages of isolated ACL lesions, intrasynovial lesions, and spontaneous reattachments to the PCL. Other factors may be a rehabilitation programme designed to protect and enhance the healing of the secondary knee restraints, and the population which included many heavy manual workers who do not undertake jumping, cutting and pivoting activities.
The low rate of meniscal injuries and the absence of meniscal surgery later than three years after the index injury are also rather surprising. The same factors and the progressive reduction of activity levels with time may provide an explanation. Only actual surgery on the menisci was recorded, and it is possible that some meniscal lesions in this low-demand population produced only slight symptoms which did not result in recorded meniscal surgery. For obvious ethical and economical reasons, it was impossible to conduct second-look arthroscopic or MRI examinations to provide more rigorous data on secondary meniscal lesions.
Most of the recent papers on ACL lesions deal mainly with athletic or high-demand patient populations, and many focus on the poor results of conservative treatments in this population, with their high incidence of secondary injuries (Noyes et al 1983a; Finsterbush et al 1990), [9,20] degenerative changes (Fetto and Marshall 1980; Kannus and Jarvinen 1987; Pattee et al 1989), [8,16,22] cessation of sport activities (Andersson et al 1989; Sommerlath, Lysholm and Gillquist 1991) [1,26] and on the need for secondary joint stabilisation (Noyes et al 1983b; Barrack et al 1990). [2,21] These reports led to the concept that only surgical reconstruction could allow unrestricted return to sport and prevent secondary problems (Daniel and Fithian 1994). [6]
This view remains controversial: a recent study failed to show a higher proportion of contact sports participation at seven years after surgical reconstruction as compared with conservative treatment (Roos et al 1995). [23] It has also been shown that subsequent degenerative changes cannot be avoided, even after the latest surgical techniques which take full account of ACL anatomy and biomechanics (Sommerlath and Gillquist 1992). [27] Such degenerative changes may be less important in conservatively treated patients (Daniel et al 1994); [6] our limited data support these observations. Various hypotheses have been put forward to explain subsequent degeneration in apparently stable knees.
The extent of concomitant meniscal injury is of course important, but its influence has not been proven (Daniel et al 1994; Kullmer, Letsch and Turowski 1994). [6,17] Bone `bruises', sustained at the time of injury, may perhaps damage the subchondral bone (Graf et al 1993; Fowler 1994). [10,13] Even the geometry of the femoral condyle has been evoked (Friden et al 1993). [11] The mechanical properties of articular cartilage (Setton et al 1994) [25] and changes in synovial fluid cytokines (Cameron et al 1994) [4] have been reported to be influenced by the initial ACL lesion; these changes may help to induce degenerative changes in a reconstructed knee which is subjected to further high-demand activities.
Our long-term study indicates that patients who are willing to avoid these activities can have acceptable functional results after non-operative treatment of an ACL injury. The outcome does not appear to deteriorate with time, and includes only very limited osteoarthritic changes. Our findings support previous short-term and medium-term reports on the conservative treatment of ACL injuries (Giove et al 1983; Satku, Kumar and Ngoi 1986; Buss et al 1995). [3,12,24] Despite the very numerous publications on the subject, the management of ACL lesions is almost as controversial today as it has been for 50 years (Lindstrand 1995). [18]
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
REFERENCES
1. Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. J Bone Joint Surg [Am] 1989;71-A:965-74. Library Holdings Bibliographic Links [Context Link]
2. Barrack RL, Bruckner JD, Kneisl J, Inman WS, Alexander AH. The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults. Clin Orthop 1990;259:192-9. [Context Link]
3. Buss DD, Min R, Skyhar M, et al. Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients. Am J Sports Med 1995;23:160-5. Library Holdings Bibliographic Links [Context Link]
4. Cameron ML, Fu FH, Paessler HH, Schneider M, Evans CH. Synovial fluid cytokine concentrations as possible prognostic indicators in the ACL-deficient knee. Knee Surg Sports Traumatol Arthroscopy 1994;2:38-44. [Context Link]
5. Casteleyn PP, Handelberg F, Opdecam P. Traumatic haemarthrosis of the knee. J Bone Joint Surg [Br] 1988;70-B:404-6. Library Holdings Bibliographic Links [Context Link]
6. Daniel DM, Fithian DC. Indications for ACL surgery. Arthroscopy 1994;10:434-41. Library Holdings Bibliographic Links [Context Link]
7. Daniel DM, Stone ML, Dobson BE, et al. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med 1994;22:632-44. Library Holdings Bibliographic Links [Context Link]
8. Fetto JF, Marshall JL. The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38. Library Holdings Bibliographic Links [Context Link]
9. Finsterbush A, Frankl U, Matan Y, Mann G. Secondary damage to the knee after isolated injury of the anterior cruciate ligament. Am J Sports Med 1990;18:475-9. Library Holdings Bibliographic Links [Context Link]
10. Fowler PJ. Bone injuries associated with anterior cruciate ligament disruption. Arthroscopy 1994;10:453-60. Library Holdings Bibliographic Links [Context Link]
11. Friden T, Jonsson A, Erlandsson T, Jonsson K, Lindstrand A. Effect of femoral condyle configuration on disability after an anterior cruciate ligament rupture: 100 patients followed for 5 years. Acta Orthop Scand 1993;64:571-4. Library Holdings Bibliographic Links [Context Link]
12. Giove TP, Miller SJ III, Kent BE, Sanford TL, Garrick JG. Non-operative treatment of the torn anterior cruciate ligament. J Bone Joint Surg [Am] 1983;65-A:184-92. [Context Link]
13. Graf BK, Cook DA, De Smet AA, Keene JS. `Bone bruises' on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med 1993;21:220-3. Library Holdings Bibliographic Links [Context Link]
14. Hefti F, Muller W, Jakob RP, Staubli H.-U. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthroscopy 1993;1:226-34. [Context Link]
15. Jain AS, Swanson AJG, Murdoch G. Hemarthrosis of the knee joint. Injury 1983;15:178-81. Library Holdings Bibliographic Links [Context Link]
16. Kannus P, Jarvinen M. Conservatively treated tears of the anterior cruciate ligament: long-term results. J Bone Joint Surg [Am] 1987;69-A:1007-12. [Context Link]
17. Kullmer K, Letsch R, Turowski B. Which factors influence the progression of degenerative osteoarthritis after ACL surgery? Knee Surg Sports Traumatol Arthroscopy 1994;2:80-4. [Context Link]
18. Lindstrand A. The anterior cruciate ligament problem. Acta Orthop Scand 1995;66:105-6. Library Holdings Bibliographic Links [Context Link]
19. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament: a follow-up study. J Bone Joint Surg [Am] 1980;62-A:696-705. Library Holdings Bibliographic Links [Context Link]
20. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate-deficient knee. Part I. The long-term functional disability in athletically active individuals. J Bone Joint Surg [Am] 1983a;65-A:154-62. Library Holdings Bibliographic Links [Context Link]
21. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II. The results of rehabilitation, activity modification and counselling in functional disability. J Bone Joint Surg [Am] 1983b;65-A:163-74. [Context Link]
22. Pattee GA, Fox JM, Del Pizzo W, Friedman MJ. Four to ten year follow-up of unreconstructed anterior cruciate ligament tears. Am J Sports Med 1989;17:430-5. Library Holdings Bibliographic Links [Context Link]
23. Roos H, Ornell M, Gardsell P, Lohmander LS, Lindstrand A. Soccer after anterior cruciate ligament injury: an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players. Acta Orthop Scand 1995;66:107-12. Library Holdings Bibliographic Links [Context Link]
24. Satku K, Kumar JP, Ngoi SS. Anterior cruciate ligament injuries: to counsel or operate? J Bone Joint Surg [Br] 1986;68-B:458-61. Library Holdings Bibliographic Links [Context Link]
25. Setton LA, Mow VC, Muller FJ, Pita JC, Howell DS. Mechanical proprieties of canine articular cartilage are significantly altered following transection of the anterior cruciate ligament. J Orthop Res 1994;12:451-63. [Context Link]
26. Sommerlath K, Lysholm J, Gillquist J. The long-term course after treatment of acute anterior cruciate ligament ruptures: a 9 to 16 year follow-up. Am J Sports Med 1991;19:156-62. Library Holdings Bibliographic Links [Context Link]
27. Sommerlath K, Gillquist J. The long term course of various meniscal treatments in anterior cruciate ligament deficient knees. Clin Orthop 1992;283:207-14. Library Holdings Bibliographic Links [Context Link]
Accession Number: 00004624-199605000-00021
Copyright (c) 2000-2003 Ovid Technologies, Inc.
Version: rel9.0.0, SourceID 1.8300.1.161
Volume 78-B(3) May 1996 pp 446-451
Non-Operative Management of Anterior Cruciate Ligament Injuries in the General Population
[Knee]
Casteleyn, Pierre-Paul; Handelberg, Frank
From the Vrije Universiteit Brussel, Brussels, Belgium.
P.-P. Casteleyn, MD, Professor, Department of Human Anatomy and Associate Clinical Professor, Department of Orthopaedics and Traumatology
F. Handelberg, MD, Assistant Clinical Professor, Department of Orthopaedics and Traumatology, Academisch Ziekenhuis, AZ-VUB Laarbeeklaan 101, B-1090 Brussels, Belgium.
Correspondence should be sent to Professor P.-P. Casteleyn.
Received 25 August 1995; Accepted after revision 29 November 1995
The operative treatment of lesions of the anterior cruciate ligament (ACL) in athletes has been widely advocated and performed.We have investigated the outcome of non-operative management in a lower-demand, general population. We reviewed a consecutive group of 228 patients, which excluded professional and high-level athletes, for two to 12 years after an ACL lesion had been diagnosed by arthroscopy.
There was a low incidence of secondary ACL and meniscal surgery, 5.4 percent and 3.5 percent respectively, and all these procedures were performed during the first three years after the ACL injury.
We studied a subgroup of 109 patients with follow-up of at least five years (mean 8.5 years) and evaluated them using the IKDC score. The general outcome was reasonably satisfactory, with 23 percent in grade A, 50 percent in grade B, 21 percent in grade C and only 6.4 percent in grade D. We found no statistically significant prognostic effect within this group as regards age, activity levels, or the incidence of associated lesions.
J Bone Joint Surg [Br] 1996;78-B:446-51.
Lesions of the anterior cruciate ligament (ACL) in athletes have been studied extensively in orthopaedic sports medicine, and operative treatment using grafts is widely advocated for this particular group of patients (Fetto and Marshall 1980; Noyes et al 1983a; Kannus and Jarvinen 1987; Andersson et al 1989; Barrack et al 1990; Daniel and Fithian 1994). [1,2,6,8,16,20] Many ACL lesions, however, are seen in non-athletes as a result of accidents or low-grade recreational activities (Jain, Swanson and Murdoch 1983; Casteleyn, Handelberg and Opdecam 1988). [5,15]
We aimed to investigate the outcome of the conservative treatment of ACL lesions in a lower-demand population.
PATIENTS AND METHODS
Over a period of 12 years, we managed a total of 274 patients with acute traumatic knee haemarthrosis. All had examination under anaesthesia and arthroscopy.
Of these, we treated 46 by ACL reconstruction. They included patients with gross or multidirectional joint laxity (grade-3 or grade-4 pivot shift, combined lesions of the ACL and lateral collateral ligament (LCL) or posterior cruciate ligament (PCL)) and in addition all high-level or professional athletes. These 46 cases (16.8 percent) were excluded from the study group.
This left a consecutive group of 228 patients (83 percent) who were managed conservatively. There was an almost fourfold male to female ratio and the mean age at the time of injury was 33.2 years (16 to 66). The main causes of injury were daily living activities (28.1 percent), traffic accidents (11.8 percent), and recreational activities (60.1 percent) Table 1.
[Help with image viewing]
Table 1. Details of the whole series and of the subgroups with secondary ACL and meniscal surgery
Initial management.
In 83 percent of the cases, arthroscopic evaluation was within three weeks of the index injury. The proportions of isolated ACL ruptures and those associated with meniscal and ligamentous lesions were comparable with those reported in previous studies (Casteleyn et al 1988) [5] Table 1 and Table 2; only 21 of the ACL tears (9 percent) were partial. Intrasynovial ACL lesions (14; 6.1 percent) were left as much as possible within the synovial sheath. There was spontaneous partial reattachment of the distal ACL stump to the PCL in 18 knees (7.9 percent): these were left undisturbed. Some ACL remnants which seemed likely to impinge between the femur and tibia and limit extension were trimmed. No reconstructive ACL surgery was performed during the initial arthroscopy.
[Help with image viewing]
Table 2. Lesions diagnosed during initial arthroscopy
Meniscal surgery was performed if indicated and feasible. Three of 27 torn lateral menisci and 17 of 105 medial menisci were sutured. Minor lesions, of one lateral and seven medial menisci, were left untreated. All other meniscal lesions (77.1 percent of the medial and 85.2 percent of the lateral meniscal lesions) were treated by partial arthroscopic meniscectomy. No surgery was performed for medial collateral ligament (MCL) lesions.
All patients were treated by a comprehensive rehabilitation programme for six to eight weeks. Early weight-bearing was allowed with the eventual protection of a cast or a brace in cases of partial ACL and intrasynovial ACL, MCL and LCL lesions.
Follow-up.
The initial 228 patients have been followed up for 2 to 12 years. Data were collected during annual examinations or by written questionnaire or telephone interviews. Of these patients, 25 (11 percent) have been lost to follow-up leaving 203 with known results at over two years. Records were maintained of pre- and postinjury levels of activity and of the reasons for any long-term modification of the level of activity.
We classified activity levels into four groups:
1) strenuous activity which included jumping, pivoting and cutting (soccer);
2) moderate activity, involving heavy manual work (skiing, tennis);
3) light activity such as jogging or running; and
4) sedentary activity such as housework and the normal activities of daily living.
We recorded all subsequent surgery for the ACL lesion (intra-articular or extra-articular) and all subsequent meniscal surgery. These data were then used to construct survival tables with ACL or meniscal surgery or both considered as end-points. The age, gender, activity level, aetiology of the injury and any associated lesions in the patients who required secondary ACL and/or meniscal surgery were then compared with similar data from the patients who had no subsequent operations Table 1.
We tried to review all 132 patients with at least five years' follow-up for their subjective opinion, clinical examination, and radiological assessment. Of these, 23 (17 percent) refused further clinical and radiological examination. The 109 patients who were studied in detail did not differ significantly from the initial cohort as regards mean age, gender, or distribution of activity level, cause of injury or associated lesions. The mean period from the initial injury was 8.5 years (5 to 12). The final assessment was recorded on the International Knee Documentation form (Hefti et al 1993). [14] This assesses results in seven separate subgroups (see Table 4). These are subjective assessment, symptoms, range of motion, ligament examination (which in our study included use of the KT 2000 tester (Medmetric Corporation, San Diego, California) with 134 N displacement force), compartmental crepitus, radiography and a one-leg hop test. The result in each subgroup is scored on a four-point scale. The lowest grade determines the global grade of the subgroup, and the worst evaluation group determines the final score.
[Help with image viewing]
Table 4. IKDC evaluation of 109 patients. The numbers in bold type are the global results for each group (see text)
We tried to find correlations between the final grade and age at injury, associated lesions, activity level or modification and length of follow-up, using the analysis of variance, the paired t-test, and the Mann-Whitney U test.
RESULTS
Survival.
Only 11 of the 203 patients followed for two to 12 years had needed secondary ACL surgery (5.4 percent) and seven had secondary meniscal surgery (3.5 percent) Table 1. All these procedures had been performed during the first three years after the index injury with none later than this. These figures give a high survival rate which persists for three to 12 years Figure 1.
[Help with image viewing]
Figure 1. Survival curves after non-operative management of ACL injuries, using as end-points secondary ACL surgery, secondary meniscal surgery, and both together.
We found no correlation between survival and cause of injury, associated lesions or activity levels, but the patients who had needed subsequent ACL surgery were younger and had a lower male-to-female ratio Table 1.
Activity levels.
The initial activity levels were those of a general population with a fair proportion of manual workers, some of them involved in moderate sport and recreational activities Table 1. None of the patients who needed secondary ACL and meniscal surgery had modified their activity level since the injury and its treatment. Less than half of all the patients had modified their activity levels after the ACL injury Table 3 and of those who reported a decrease, only 57 (65.5 percent) considered that this decrease in activity level was related to their ACL injury.
[Help with image viewing]
Table 3. Activity level modification after ACL injury in 203 patients
As expected, the relationship between decrease in activity level and the original injury became less important with length of follow-up. Any decrease in activity was reported to be injury-related by 78 percent when it occurred less than five years after injury, by 57 percent between five and eight years, and by only 17 percent when it occurred after more than eight years.
IKDC examination.
The results in 109 patients are summarised in Table 4. The subjective results were satisfactory: 82.4 percent of the patients stated that their knee was normal or nearly normal. This was confirmed by the rather benign nature of the symptoms; 61 percent achieved a normal grade and 21 percent a nearly normal grade. The range of motion was marginally limited in only 19 percent, with no important extension or flexion deficits. The lowest grades were found as expected in the KT 2000 ligament examination sub-group, but even for this test 32.1 percent of the knees had a nearly normal grade. As regards compartmental crepitus 84 percent were normal and there was no radiological narrowing of the joint space in 76 percent.
For the one-leg hop test, 57 percent had normal rates; this confirmed the low intensity of any symptoms and the reasonably good function of most of the knees. The overall evaluations gave 23 percent in grade A, 50 percent in grade B, 21 percent in grade C and 6.4 percent in grade D.
We could find no prognostic correlation between age at the time of injury, associated lesions, activity level at time of injury and at time of evaluation, and the final evaluation grade. There was no marked decrease in evaluation grades with increasing length of follow-up Figure 2.
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Figure 2. Changes in the proportions of A and B global evaluation grades with length of follow-up showing no significant deterioration.
DISCUSSION
The results of our study must be analysed with caution, since 11 percent of the patients were lost to follow-up, and 17 percent of the patients whom we traced at over five years refused further clinical examination. The main strength of our work is that the population of patients was selected at the time of the initial injury; many previous studies of the non-operative management of ACL injuries were based on patients who were seeking further treatment because of significant complaints (Fetto and Marshall 1980; McDaniel and Dameron 1980; Giove et al 1983; Noyes et al 1983a; Finsterbush et al 1990). [8,9,12,19,20]
The conservative management which we used during the 14 years of the study must be considered in relation to the evolving knowledge on ligament healing; some of our earliest patients were treated during the early 1980s. We would not now use casting for ligament sprains or partial ruptures of the ACL (Daniel et al 1994). [7]
Our review of a general patient population, less interested in sporting activities, also means that precise data about physical activity are more difficult to obtain. The IKDC assessment form does not offer the same refinement of analysis as the Tegner score, but seems to be more applicable to this type of population. It should also be noted that the mean time between injury and latest radiological examination in our 103 patients (8.5 years; 5 to 12) may be too short to show significant degenerative changes in this low-demand population.
The most surprising result of our study was the fairly limited laxity shown by ligament examination; only 44.9 percent of Lachmann tests showed side-to-side differences of more than 3 mm, and only 15.5 percent showed gross pivot shifts. Among possible explanations are the exclusion from the study of knees with gross instability and the appreciable percentages of isolated ACL lesions, intrasynovial lesions, and spontaneous reattachments to the PCL. Other factors may be a rehabilitation programme designed to protect and enhance the healing of the secondary knee restraints, and the population which included many heavy manual workers who do not undertake jumping, cutting and pivoting activities.
The low rate of meniscal injuries and the absence of meniscal surgery later than three years after the index injury are also rather surprising. The same factors and the progressive reduction of activity levels with time may provide an explanation. Only actual surgery on the menisci was recorded, and it is possible that some meniscal lesions in this low-demand population produced only slight symptoms which did not result in recorded meniscal surgery. For obvious ethical and economical reasons, it was impossible to conduct second-look arthroscopic or MRI examinations to provide more rigorous data on secondary meniscal lesions.
Most of the recent papers on ACL lesions deal mainly with athletic or high-demand patient populations, and many focus on the poor results of conservative treatments in this population, with their high incidence of secondary injuries (Noyes et al 1983a; Finsterbush et al 1990), [9,20] degenerative changes (Fetto and Marshall 1980; Kannus and Jarvinen 1987; Pattee et al 1989), [8,16,22] cessation of sport activities (Andersson et al 1989; Sommerlath, Lysholm and Gillquist 1991) [1,26] and on the need for secondary joint stabilisation (Noyes et al 1983b; Barrack et al 1990). [2,21] These reports led to the concept that only surgical reconstruction could allow unrestricted return to sport and prevent secondary problems (Daniel and Fithian 1994). [6]
This view remains controversial: a recent study failed to show a higher proportion of contact sports participation at seven years after surgical reconstruction as compared with conservative treatment (Roos et al 1995). [23] It has also been shown that subsequent degenerative changes cannot be avoided, even after the latest surgical techniques which take full account of ACL anatomy and biomechanics (Sommerlath and Gillquist 1992). [27] Such degenerative changes may be less important in conservatively treated patients (Daniel et al 1994); [6] our limited data support these observations. Various hypotheses have been put forward to explain subsequent degeneration in apparently stable knees.
The extent of concomitant meniscal injury is of course important, but its influence has not been proven (Daniel et al 1994; Kullmer, Letsch and Turowski 1994). [6,17] Bone `bruises', sustained at the time of injury, may perhaps damage the subchondral bone (Graf et al 1993; Fowler 1994). [10,13] Even the geometry of the femoral condyle has been evoked (Friden et al 1993). [11] The mechanical properties of articular cartilage (Setton et al 1994) [25] and changes in synovial fluid cytokines (Cameron et al 1994) [4] have been reported to be influenced by the initial ACL lesion; these changes may help to induce degenerative changes in a reconstructed knee which is subjected to further high-demand activities.
Our long-term study indicates that patients who are willing to avoid these activities can have acceptable functional results after non-operative treatment of an ACL injury. The outcome does not appear to deteriorate with time, and includes only very limited osteoarthritic changes. Our findings support previous short-term and medium-term reports on the conservative treatment of ACL injuries (Giove et al 1983; Satku, Kumar and Ngoi 1986; Buss et al 1995). [3,12,24] Despite the very numerous publications on the subject, the management of ACL lesions is almost as controversial today as it has been for 50 years (Lindstrand 1995). [18]
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
REFERENCES
1. Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. J Bone Joint Surg [Am] 1989;71-A:965-74. Library Holdings Bibliographic Links [Context Link]
2. Barrack RL, Bruckner JD, Kneisl J, Inman WS, Alexander AH. The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults. Clin Orthop 1990;259:192-9. [Context Link]
3. Buss DD, Min R, Skyhar M, et al. Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients. Am J Sports Med 1995;23:160-5. Library Holdings Bibliographic Links [Context Link]
4. Cameron ML, Fu FH, Paessler HH, Schneider M, Evans CH. Synovial fluid cytokine concentrations as possible prognostic indicators in the ACL-deficient knee. Knee Surg Sports Traumatol Arthroscopy 1994;2:38-44. [Context Link]
5. Casteleyn PP, Handelberg F, Opdecam P. Traumatic haemarthrosis of the knee. J Bone Joint Surg [Br] 1988;70-B:404-6. Library Holdings Bibliographic Links [Context Link]
6. Daniel DM, Fithian DC. Indications for ACL surgery. Arthroscopy 1994;10:434-41. Library Holdings Bibliographic Links [Context Link]
7. Daniel DM, Stone ML, Dobson BE, et al. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med 1994;22:632-44. Library Holdings Bibliographic Links [Context Link]
8. Fetto JF, Marshall JL. The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38. Library Holdings Bibliographic Links [Context Link]
9. Finsterbush A, Frankl U, Matan Y, Mann G. Secondary damage to the knee after isolated injury of the anterior cruciate ligament. Am J Sports Med 1990;18:475-9. Library Holdings Bibliographic Links [Context Link]
10. Fowler PJ. Bone injuries associated with anterior cruciate ligament disruption. Arthroscopy 1994;10:453-60. Library Holdings Bibliographic Links [Context Link]
11. Friden T, Jonsson A, Erlandsson T, Jonsson K, Lindstrand A. Effect of femoral condyle configuration on disability after an anterior cruciate ligament rupture: 100 patients followed for 5 years. Acta Orthop Scand 1993;64:571-4. Library Holdings Bibliographic Links [Context Link]
12. Giove TP, Miller SJ III, Kent BE, Sanford TL, Garrick JG. Non-operative treatment of the torn anterior cruciate ligament. J Bone Joint Surg [Am] 1983;65-A:184-92. [Context Link]
13. Graf BK, Cook DA, De Smet AA, Keene JS. `Bone bruises' on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med 1993;21:220-3. Library Holdings Bibliographic Links [Context Link]
14. Hefti F, Muller W, Jakob RP, Staubli H.-U. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthroscopy 1993;1:226-34. [Context Link]
15. Jain AS, Swanson AJG, Murdoch G. Hemarthrosis of the knee joint. Injury 1983;15:178-81. Library Holdings Bibliographic Links [Context Link]
16. Kannus P, Jarvinen M. Conservatively treated tears of the anterior cruciate ligament: long-term results. J Bone Joint Surg [Am] 1987;69-A:1007-12. [Context Link]
17. Kullmer K, Letsch R, Turowski B. Which factors influence the progression of degenerative osteoarthritis after ACL surgery? Knee Surg Sports Traumatol Arthroscopy 1994;2:80-4. [Context Link]
18. Lindstrand A. The anterior cruciate ligament problem. Acta Orthop Scand 1995;66:105-6. Library Holdings Bibliographic Links [Context Link]
19. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament: a follow-up study. J Bone Joint Surg [Am] 1980;62-A:696-705. Library Holdings Bibliographic Links [Context Link]
20. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate-deficient knee. Part I. The long-term functional disability in athletically active individuals. J Bone Joint Surg [Am] 1983a;65-A:154-62. Library Holdings Bibliographic Links [Context Link]
21. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II. The results of rehabilitation, activity modification and counselling in functional disability. J Bone Joint Surg [Am] 1983b;65-A:163-74. [Context Link]
22. Pattee GA, Fox JM, Del Pizzo W, Friedman MJ. Four to ten year follow-up of unreconstructed anterior cruciate ligament tears. Am J Sports Med 1989;17:430-5. Library Holdings Bibliographic Links [Context Link]
23. Roos H, Ornell M, Gardsell P, Lohmander LS, Lindstrand A. Soccer after anterior cruciate ligament injury: an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players. Acta Orthop Scand 1995;66:107-12. Library Holdings Bibliographic Links [Context Link]
24. Satku K, Kumar JP, Ngoi SS. Anterior cruciate ligament injuries: to counsel or operate? J Bone Joint Surg [Br] 1986;68-B:458-61. Library Holdings Bibliographic Links [Context Link]
25. Setton LA, Mow VC, Muller FJ, Pita JC, Howell DS. Mechanical proprieties of canine articular cartilage are significantly altered following transection of the anterior cruciate ligament. J Orthop Res 1994;12:451-63. [Context Link]
26. Sommerlath K, Lysholm J, Gillquist J. The long-term course after treatment of acute anterior cruciate ligament ruptures: a 9 to 16 year follow-up. Am J Sports Med 1991;19:156-62. Library Holdings Bibliographic Links [Context Link]
27. Sommerlath K, Gillquist J. The long term course of various meniscal treatments in anterior cruciate ligament deficient knees. Clin Orthop 1992;283:207-14. Library Holdings Bibliographic Links [Context Link]
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- whistle blower
knee cruciate surgery Truth or consequences
by malernee » Sun Nov 28, 2004 1:12 pm
1: Acta Orthop Scand. 1994 Dec;65(6):605-9. Related Articles, Links
Knee ligament injury, surgery and osteoarthrosis. Truth or consequences?
Lohmander LS, Roos H.
Department of Orthopedics, University Hospital, Lund, Sweden.
We reviewed reports that describe development of osteoarthrosis of the knee after anterior cruciate ligament or meniscus injury. The occurrence of posttraumatic osteoarthrosis varied considerably from one report to another. The literature does not lend support to the efficacy of cruciate ligament repair or reconstruction in retarding the progression of osteoarthrosis after knee injury. We encourage prospective, controlled, randomized and masked studies that aim to evaluate the utility of ligament reconstruction, meniscus suture or meniscus transplantation for preventing posttraumatic osteoarthrosis.
Knee ligament injury, surgery and osteoarthrosis. Truth or consequences?
Lohmander LS, Roos H.
Department of Orthopedics, University Hospital, Lund, Sweden.
We reviewed reports that describe development of osteoarthrosis of the knee after anterior cruciate ligament or meniscus injury. The occurrence of posttraumatic osteoarthrosis varied considerably from one report to another. The literature does not lend support to the efficacy of cruciate ligament repair or reconstruction in retarding the progression of osteoarthrosis after knee injury. We encourage prospective, controlled, randomized and masked studies that aim to evaluate the utility of ligament reconstruction, meniscus suture or meniscus transplantation for preventing posttraumatic osteoarthrosis.
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unproven anterior cruciate knee surgery cost pet owners
by guest » Tue Jan 03, 2006 10:15 am
Estimate of the Annual Economic Impact of Treatment of Cranial Cruciate Ligament Injury in Dogs in the United States
J Am Vet Med Assoc 227[10]:1604-1607 Nov 15'05 Economic Impact Survey 12 Refs
* Vicki L. Wilke, DVM, DACVS, Duane A. Robinson, DVM; Rich B. Evans, PhD; Max F. Rothschild, PhD; Michael G. Conzemius, DVM, PhD, DACVS
Department of Animal Sciences and Center for Integrated Animal Genomics, College of Veterinary Medicine, Iowa State University, Ames, IA 50011-1250 [*address correspondence]
OBJECTIVE: To estimate the economic impact to veterinary clients for the medical and surgical treatment of rupture of the cranial cruciate ligament (RCCL) in dogs for the year 2003.
DESIGN: Economic impact survey.
SAMPLE POPULATION: 501 diplomates of the American College of Veterinary Surgeons (ACVS) indicating that their area of surgical emphasis was small animal orthopedic surgery or small animal general and orthopedic surgery and 4,000 veterinarians indicating to the AVMA that their professional area was small animal practice exclusive or mixed animal practice (at least 80% small animal).
PROCEDURE: Veterinarians were surveyed concerning the cost for medical and surgical treatment of RCCL for 2003. The economic impact was calculated by multiplying the number of RCCL surgeries performed by the mean cost of surgery. This was added to the number of RCCL cases managed medically multiplied by the mean cost of medical management. This estimate for survey responders was extrapolated to the total number of veterinarians in the study population for the ACVS or AVMA.
RESULTS: Estimates for the total cost of surgery were $171,730,134.72 and $1,020,167,907 for veterinarians in the ACVS and AVMA populations, respectively. The cost of medical management was $2,885,687.86 and $126,558,155.16 for veterinarians in the ACVS and AVMA populations, respectively. After combining the ACVS and AVMA populations, we estimated that owners spent $1.32 billion for the treatment of RCCL in the United States in 2003.
CONCLUSIONS & CLINICAL RELEVANCE: RCCL is a prevalent, costly injury. Results may motivate veterinary and consumer agencies to prioritize funding for a better understanding of the injury.
J Am Vet Med Assoc 227[10]:1604-1607 Nov 15'05 Economic Impact Survey 12 Refs
* Vicki L. Wilke, DVM, DACVS, Duane A. Robinson, DVM; Rich B. Evans, PhD; Max F. Rothschild, PhD; Michael G. Conzemius, DVM, PhD, DACVS
Department of Animal Sciences and Center for Integrated Animal Genomics, College of Veterinary Medicine, Iowa State University, Ames, IA 50011-1250 [*address correspondence]
OBJECTIVE: To estimate the economic impact to veterinary clients for the medical and surgical treatment of rupture of the cranial cruciate ligament (RCCL) in dogs for the year 2003.
DESIGN: Economic impact survey.
SAMPLE POPULATION: 501 diplomates of the American College of Veterinary Surgeons (ACVS) indicating that their area of surgical emphasis was small animal orthopedic surgery or small animal general and orthopedic surgery and 4,000 veterinarians indicating to the AVMA that their professional area was small animal practice exclusive or mixed animal practice (at least 80% small animal).
PROCEDURE: Veterinarians were surveyed concerning the cost for medical and surgical treatment of RCCL for 2003. The economic impact was calculated by multiplying the number of RCCL surgeries performed by the mean cost of surgery. This was added to the number of RCCL cases managed medically multiplied by the mean cost of medical management. This estimate for survey responders was extrapolated to the total number of veterinarians in the study population for the ACVS or AVMA.
RESULTS: Estimates for the total cost of surgery were $171,730,134.72 and $1,020,167,907 for veterinarians in the ACVS and AVMA populations, respectively. The cost of medical management was $2,885,687.86 and $126,558,155.16 for veterinarians in the ACVS and AVMA populations, respectively. After combining the ACVS and AVMA populations, we estimated that owners spent $1.32 billion for the treatment of RCCL in the United States in 2003.
CONCLUSIONS & CLINICAL RELEVANCE: RCCL is a prevalent, costly injury. Results may motivate veterinary and consumer agencies to prioritize funding for a better understanding of the injury.
- guest
tplo makes arthritis worse study
by malernee » Fri Jun 29, 2007 3:15 pm
Abstract
Journal of the American Veterinary Medical Association
June 1, 2007, Vol. 230, No. 11, Pages 1674-1679
doi: 10.2460/javma.230.11.1674
Progression of radiographic evidence of osteoarthritis following tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 295 cases (2001–2005)
Connie R. Hurley, DVM; Douglas L. Hammer, DVM, DACVS; Susan Shott, PhD
Surgical Referral Services, Norwood Park Animal Hospital, 4321 N Harlem Ave, Norridge, IL 60706 (Hurley, Hammer); Department of Medicine, Rush University Medical Center, 1725 W Harrison St, Chicago, IL 60612 (Shott)
Address correspondence to Dr. Hurley.
Objective—To determine whether radiographic signs of osteoarthritis became progressively worse and tibial slope angle (TSA) changed substantially following tibial plateau leveling osteotomy for treatment of cranial cruciate ligament rupture in dogs.
Design—Retrospective case series.
Animals—295 dogs (373 stifle joints).
Procedures—Medical records were reviewed. Radiographs obtained before and 8 weeks after surgery were used to determine the degenerative joint disease (DJD) score, calculated as the sum of individual scores (0 through 3) assigned to 30 radiographic factors. Radiographs obtained immediately and 8 weeks after surgery were used to measureTSA. For dogs that underwent bilateral surgery, data for the first joint treated were used in analyses. Data for the second joint treated in dogs that underwent bilateral surgery were analyzed separately.
Results—A small, but significant, increase was found in mean DJD score 8 weeks after surgery, compared with mean preoperative score. An inverse relationship was found between preoperative DJD score and the difference between postoperative and preoperative DJD scores. Mean TSA 8 weeks after surgery was significantly higher than mean TSA immediately after surgery. Analysis of data for the second stifle joints in the 78 dogs that underwent bilateral surgery yielded similar results.
Conclusions and Clinical Relevance—Results suggested that there was a small, but measurable, increase in the severity of radiographic changes attributed to osteoarthritis in the stifle joints of dogs that underwent tibial plateau leveling osteotomy because of cranial cruciate ligament rupture.
Journal of the American Veterinary Medical Association
June 1, 2007, Vol. 230, No. 11, Pages 1674-1679
doi: 10.2460/javma.230.11.1674
Progression of radiographic evidence of osteoarthritis following tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 295 cases (2001–2005)
Connie R. Hurley, DVM; Douglas L. Hammer, DVM, DACVS; Susan Shott, PhD
Surgical Referral Services, Norwood Park Animal Hospital, 4321 N Harlem Ave, Norridge, IL 60706 (Hurley, Hammer); Department of Medicine, Rush University Medical Center, 1725 W Harrison St, Chicago, IL 60612 (Shott)
Address correspondence to Dr. Hurley.
Objective—To determine whether radiographic signs of osteoarthritis became progressively worse and tibial slope angle (TSA) changed substantially following tibial plateau leveling osteotomy for treatment of cranial cruciate ligament rupture in dogs.
Design—Retrospective case series.
Animals—295 dogs (373 stifle joints).
Procedures—Medical records were reviewed. Radiographs obtained before and 8 weeks after surgery were used to determine the degenerative joint disease (DJD) score, calculated as the sum of individual scores (0 through 3) assigned to 30 radiographic factors. Radiographs obtained immediately and 8 weeks after surgery were used to measureTSA. For dogs that underwent bilateral surgery, data for the first joint treated were used in analyses. Data for the second joint treated in dogs that underwent bilateral surgery were analyzed separately.
Results—A small, but significant, increase was found in mean DJD score 8 weeks after surgery, compared with mean preoperative score. An inverse relationship was found between preoperative DJD score and the difference between postoperative and preoperative DJD scores. Mean TSA 8 weeks after surgery was significantly higher than mean TSA immediately after surgery. Analysis of data for the second stifle joints in the 78 dogs that underwent bilateral surgery yielded similar results.
Conclusions and Clinical Relevance—Results suggested that there was a small, but measurable, increase in the severity of radiographic changes attributed to osteoarthritis in the stifle joints of dogs that underwent tibial plateau leveling osteotomy because of cranial cruciate ligament rupture.
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