The symptomatic anterior cruciate-deficient knee. Part I

Abstract

This study reports on the disability of 103 patients with symptomatic chronic laxity of the an tenor cruciate ligament that was uncomplicated by other associated major ligament deficiency or prior lig ament reconstructive procedures. All of the patients were evaluated at an average of 5.5 years after injury but a subgroup of thirty-nine patients was evaluated at an average of 11.2 years after injury. All had been ac tive in sports, with two-thirds participating in high school or college athletics. The diagnosis of a tear of the anterior cruciate ligament was made by the original treating physician in only seven (6.8 per cent) of the 103 knees. Sixty-four patients (62 per cent) stated that the pain that followed the injury restricted normal ac tivities for longer than three weeks. Eighty-five patients (82 per cent) had returned to some form of sports ac tivity. This gave a false initial impression that the in jury was not eventually disabling for sports, as a sig nificant reinjury occurred in thirty-six patients (35 per cent) within six months and in fifty-three patients (51 per cent) within one year after the original injury. At follow-up five years later, only thirty-six patients (35 per cent) were participating in strenuous sports. A significantumber of patients withlonger follow-up had knee symptoms that affected their routine daily and recreational activities. A subjective moderate to severe over-all disability was reported by thirty-two patients (31 per cent) for walking activities alone, by forty-five patients (44 per cent) for over-all routine activities of daily living, and by seventy-seven patients (74 per cent) for turning or twisting sports ac tivities. Pain occurred in thirty-one patients (30 per cent) during walking activities, in forty-eight patients (47 per cent) during recreational activities, and in seventy-one patients (69 per cent) during strenuous sports activities. Twenty-two patients (21 per cent) complained of giving-way during walking activities; thirty-four patients (33 per cent), during recreational sports; and sixty-six patients (65 per cent), during 4 Supported in part by National Institutes of Health Grants AM2I 172 and AM27517 from the Musculoskeletal Disease Program of the National Institute of Arthritis, Diabetes, Digestive and Kidney Dis eases. t Cincinnati Sports Medicine and Orthopaedic Center, 1 Lytle Place, Cincinnati, Ohio 45202. @ Department ofOrthopaedic Surgery, Hospital ofthe University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. §Department of OrthopaedicSurgery,Universityof Pittsburgh, Pittsburgh, Pennsylvania 15213. strenuous sports. Joint swelling occurred four to five times as frequently in the patients who had had the in jury for the longest time (average, 11.2 years). If the patient had had a meniscectomy, there was a statisti cally significant twofold to fourfold increase in symp toms of pain and swelling related to activity. Giving way was not affected, as this is related to instability of the anterior cruciate ligament. Significant roentgeno graphic changes of arthritis were noted in nineteen (21 per cent) of ninety-one patients starting at an average of 109 months after injury. Seventeen patients (44 per cent) in the subset with the longest follow-up had sig nificant roentgenographic changes. These changes cor related statistically with participation in strenuous sports activities, with running activities, and with giving-way. Important qualifications to this retrospective study are: (1) the patients studied were limited to those with tears of the anterior cruciate ligament who sought treatment for relief of their symptoms, (2) these pa tients continued to be active athletically and thus con tinued to abuse their knees, and (3) none of the patients had had proper initial treatment, rehabilitation, or counseling which might have prevented joint deterio ration. As a whole, the results show the significant functional disability found in the patient with a symp tomatic anterior cruciate-deficient knee, initially for sports activities but later, following reinjury, for meniscal damage, joint arthritis, and the activities of daily living. A dilemma still exists concerning the proper treat ment of a knee with a deficient anterior cruciate ligament, largely because of a lack of knowledge of the extent of the functional disability caused by such an injury'5'8'9―2―@ 21.23.25.27 Our goal was to study a sufficient number of pa tients whose knees demonstrated anterior cruciate laxity alone, without the superimposed variables introduced by previous operative procedures or complicated by other types of ligament instability. The study group also had to contain a sufficient number of patients whose injuries had been sustained at least five years and ten years previously, to allow statistical evaluation of long-term disability. Of importance in this study, as contrasted to many prior studies, is the rigorous grading of symptoms and their severity as related to the specific type of activity during which they occurred. 154 THE JOURNAL OF BONE AND JOINT SURGERY on December 4, 2006 www.ejbjs.org Downloaded from THE SYMPTOMATIC ANTERIOR CRUCIATE-DEFICIENT KNEE 155 years earlier (range, three months to 33.3 years). Twelve patients had been injured one year earlier and thirty-three, two years earlier. For a portion of the analysis, the group was divided into sixty-four patients who had been injured less than five years earlier and thirty-nine patients who had been injured at or more than five years earlier. The symptoms of pain, swelling, and giving-way were ranked as slight, moderate, or severe, as follows: slight —? occasional recurrent minor discomfort, not inter fering with activity; moderate —? symptoms usually brought on by an activity, interfering with activity, and relieved by stopping activity or rest; and severe —? symp toms occurring with activity, persisting and lasting over night or days, significantly interfering with activity (usu ally the patient must stop activity). Of the 103 patients in this study, fifty-one had had a meniscectomy, including six patients who had two menis cectomies. A total ofsixty-five menisci had been removed, of which forty-seven were medial, thirteen were lateral, and five were unknown. Fourteen patients had had both menisci removed. Fourteen meniscectomies had been per formed within three weeks after the initial injury and thirty-seven, within one year after injury. The remainder of the procedures were distributed throughout the remain ing years. Roentgenograms of ninety-one of the 103 knees were graded for degenerative arthritic changes, as follows: mm imum —? squaring of femoral and tibial margins, sub chondral sclerosis, no joint narrowing, and no significant osteophyte formation; moderate —? narrow joint-cartilage space, significant subchondral sclerosis, and osteophyte formation; or severe —? the aforementioned criteria plus obliteration of the joint-cartilage space.