SÉBASTIENLUSTIG, TARIKAITSISELMI, ELVIRESERVIEN, GIUSEPPETROTTA, PHILIPPENEYRET
Introduction
The direct correlation between competitive activity and early osteoarthritis is an assumption held by many individuals, medical authors, and the sport com- munity [1, 2]. Although it has been established in the hip and ankle joints of football players [3, 4], it seems that it cannot be generalized to the non-trau- matic knee. Klunder et al. [3] studied 57 retired European football players and a corresponding control group; they found a positive correlation between the development of osteoarthritis of the hip and football participation but no such relationship for the knee.
Football is a sport that puts maximal demands on the knee. The risk of trauma to the knee of a football player is 1.3 per 1,000 exposures, with a par- ticular risk of rupture of the anterior cruciate ligament (ACL) between 0.31 and 0.87 [5]. These traumas and the lesions that result from them can be responsible for the evolution of arthritis [we exclude true articular fractures (patellar or lateral plateau), which are specific problems].
Osteoarthritis Definition
The rheumatologist, the radiologist, and the arthroscopist do not share the same definition of osteoarthritis. Superficial chondral lesions seen through the arthroscope are not osteoarthritis. Osteoarthritis is present when there is wearing away of the two joint surfaces (a mirror lesion) with abrasion of the cartilage and, at least at one site, the subchondral bone is exposed on the two joint surfaces [6].
These lesions always follow a stage of pre-osteoarthritis. In this condition, there are mirror chondral lesions, but the subchondral bone is not exposed and joint-space narrowing is incomplete. An isolated unipolar lesion (trau- matic, osteochondritis) is not osteoarthritis. This type of lesion may lead to
osteoarthritis, but the delay between a unipolar chondral lesion and osteoarthritis is often more than 20 years.
Osteoarthritis and Meniscus Lesion
The risk of osteoarthritis of the knee following meniscectomy is well known [7]. It increases with a reported rate of 20–40% within 30 years when com- pared with normal knees [8–10]. In a study of the knee joints of 81 veteran soccer players between the ages of 40 and 74 [11], all players who had under- gone a meniscectomy presented with radiological signs of osteoarthritis.
Even if discrete medial femorotibial remodelling can appear quickly after meniscectomy, there will be no evolution during at least 20 or 30 years. By comparison, an associated varus (or valgus) morphotype will be responsible for a hyper-pressure syndrome and faster degenerative change.
Intact versus Non-Intact ACL
A study of 91 knees in a population of soccer players who had undergone a partial meniscectomy, with an average follow-up of the 27 years [12], showed that radiological osteoarthritis was present in only 24% of the intact ACL group compared with 77% of the ruptured ACL group. Moreover, only 2% of the intact ACL group required operation for osteoarthritis compared with 16% of the ruptured ACL group. The main prognostic factor in the manage- ment of a meniscus lesion seems to be the state of the ACL [13].
Medial versus Lateral Meniscectomy
In knees with an isolated medial meniscal lesion, the prognosis is better if the patient is young, participates in sports, has a vertical tear, has no cartilage damage, and has an intact meniscal rim at the end of the meniscectomy. By comparison, age over 35 years, operative findings of medial compartment degeneration, posterior one-third resection, and meniscal wall resection all predict a poor outcome [14]. In knees with an isolated lateral meniscal lesion, a better prognosis can be predicted if the patient is young and has an intact meniscal rim at the end of the meniscectomy [15].
Clinical Implications
In the management of meniscal tear, it is essential to take into account the age and the level of the football player. In a young, professional player who pres- ents with a medial meniscus lesion, one will propose a meniscectomy while trying to preserve the meniscal rim. Recovery will be faster than for a menis- cal repair, and the risk of osteoarthritis is low at short- and middle-term fol-
low-up. In the case of a lesion of the lateral meniscus, if the player is very young (16–18 years), a lateral meniscectomy will risk shortening their foot- ball career due to a poor functional result and will also lead to a lateral femorotibial osteoarthritis in the following 10 years. One will consequently propose a meniscal repair even if the time to return to sport is longer and the risk of failure (and thus of re-intervention) is higher.
Anterior Instability and Osteoarthritis
Natural History of Osteoarthritis after ACL Rupture
After the initial accident during which the ligament was ruptured, the func- tional tolerance is variable. In the case of isolated ACL rupture, if the patient (without lower-limb misalignment) keeps a low level of activity, the tolerance may be excellent. Most such patients will present no disabling osteoarthritis before a mean delay of 35 years. However, if ACL rupture is followed by a sub- sequent medial meniscectomy, then the duration of tolerance drops to 20 years [13].
Arthrogenic Factors
Factors that can favour the onset of osteoarthritis after an ACL rupture are not well established. Nevertheless, some authors [6, 13] have studied the mechanical factors.
Anterior Tibial Translation
Rupture of the ACL is accompanied by an abnormal anterior tibial translation at the time of contraction of the quadriceps. This translation is very clearly amplified when landing from a jump and when the quadriceps contract vio- lently. These kinetic disturbances involve a loss of balance between rolling and gliding, with an increase in gliding. This repetitive translation–reduction generates shear stresses in articular cartilage and leads to cartilage wear.
Anterior translation leads to posterior third lesions of the medial meniscus.
Lesions of the medial meniscus, loosening of the posteromedial corner, and an excessive tibial slope contribute to an increase of anterior tibial translation and favour the onset of osteoarthritis [6].
Articular Lesions
Lesions of articular cartilage: These are due either to new episodes of insta- bility (medial compartmental cartilaginous lesions) or to the pivot shift (lat- eral cartilaginous lesions). True osteochondral or chondral fractures are located on the medial condyle. A recent study including 33 patients with acute
ACL injuries, normal radiographs, and occult osteochondral lesions revealed by MRI (chondral fractures and bone bruise) [16] showed a cartilage thinning adjacent to the site of the initial osteochondral lesion 6 years after ACL recon- struction. Moreover, marrow signal changes persisted in 65% of patients. This suggests that the initial injury resulted in irreversible changes in the knee.
Injuries causing marrow signal changes may result in an alteration in the load-bearing properties of subchondral bone, which in turn allows for changes in the overlying cartilage. We do not yet know if this signal modifi- cation will lead to arthrosis at long-term follow-up.
Less commonly, lateral chondral lesions may be observed. They occur dur- ing the pivot shift or following a previous lateral meniscectomy. These lateral lesions could explain pain and swelling, but they rarely lead to lateral com- partment osteoarthritis (except in the case of lateral meniscectomy).
True articular fractures (patellar or lateral plateau) are a different problem with a worse prognosis.
Medial meniscus lesions: These are the most significant factors in the onset of osteoarthritis after ACL rupture. In the event of isolated ACL rup- ture, the medial meniscus plays a fundamental role in anteroposterior stabil- ity. It limits anterior tibial translation and thus shear stresses of the cartilage.
Statistics show that with or without a graft of the ACL, loss of the medial meniscus leads in the medium term to medial femorotibial osteoarthritis [6].
Posterolateral Lesions
Associated injury of the lateral collateral ligament (LCL) and/or the popliteus complex are uncommon in ACL rupture (5%). If this diagnosis is missed, however, the following laxity allows deviation of the knee in varus when walk- ing or running. It is a very significant factor in the progression of medial femorotibial osteoarthritis.
Genu Varum
Varus knee is not an arthrogenic factor in itself. However, in the event of meniscus lesion, genu varum and the tibial slope in the sagittal plane can potentiate the onset of osteoarthritis.
Radiological Aspect
We want to emphasize the particular aspect and specificities of osteoarthritis following ACL insufficiency. The development of osteoarthritis takes place in two ways. The most common is one in which there is a medial compartmen- tal osteoarthritis with deviation of the knee into varus. Less frequently, bicompartmental total osteoarthritis is seen without deformity in the frontal plane. Isolated lateral compartmental osteoarthritis is rare. Osteoarthritis due to anterior cruciate laxity presents four characteristic signs:
Tibiofemoral remodeling: It is characterized by osteophytosis developing on the femoral condyles and on the tibial plateau associated with some degree of flattening of the condyles. The feature that is characteristic of anterior cru- ciate laxity is its localisation in both compartments.
Osteophytes in the intercondylar notch: The tibial spines develop a classic hooked appearance (Fig. 1). A view of the intercondylar notch shows that this tibial osteophytosis is accompanied by osteophyte formation on the inner aspects of both femoral condyles, tending to narrow the intercondylar notch.
Posterior tibial osteophytosis: This can best be seen on lateral radiographs.
The osteophyte is a horizontal one that elongates the medial tibial plateau posteriorly. This posterior osteophyte is recognized on lateral radiographs in monopodal stance with the knee at 30° of flexion. The early narrowing of the joint space in the posterior part of the medial tibial plateau seems to be due to an exaggeration of the concavity of the plateau by the posterior tibial osteophyte. In primary osteoarthritis not associated with ACL insufficiency, the osteophyte has a very different vertical disposition.
Fig. 1.Medial meniscectomy and anterior cruciate ligament (ACL) lesion with 10 years follow-up. The tibial spines have developed a classic hooked appearance. The medial compartment is at pre-arthrosis stage
Anterior translation of the tibial plateaus: This is the final characteristic ele- ment of osteoarthritis, the origin of which lies in ligamentous laxity. On the lateral radiographic view in monopodal stance, one may observe the medial femoral condyle passing into the cupped posterior part of the medial tibial plateau and appearing to rest on the posterior osteophyte.
Degenerative Changes after ACL Surgery
Does ACL reconstruction prevent the onset of osteoarthritis? Numerous clin- ical studies [13, 17] reported that ACL reconstruction may protect the knee from meniscal tear, particularly medial meniscal lesion. The preservation of the medial meniscus is the key point to protect the knee from osteoarthritis.
A recent study [17] of the long-term result after ACL reconstruction gives us some information.
ACL Reconstruction with Intact Medial Meniscus
At 10 years follow-up (Fig. 2), 88% of patients did not develop osteoarthritis, 9% were at the stage of pre-osteoarthritis, and only 2% had femorotibial osteoarthritis.
ACL Graft and Medial Meniscectomy
If a previous medial meniscectomy had been performed before the ACL graft, 26% had osteoarthritis, 33% pre-osteoarthritis, and only 41% had a normal knee at the 10-year follow-up. If the meniscectomy was performed during ACL reconstruction, then 16% had osteoarthritis, 16% pre-osteoarthritis, and 70% a normal knee.
A recent study [17] demonstrated that ACL reconstruction associated with extra-articular tenodesis can provide good functional and radiological results at 17 years mean follow-up for patients with preserved (sound or sutured) menisci. The status of the medial meniscus at long-term follow-up appears to be the key feature determining the low rate of degenerative changes.
Significant factors in the onset of osteoarthritis after ACL reconstruction are: the status of the medial meniscus, age, residual anterior tibial translation, duration since ligament reconstruction, and sporting level after ACL recon- struction (more osteoarthritis among patients playing pivot-contact sports, such as football) [6].
Clinical Implications
In the event of rupture of the ACL, the practice of football requires a surgical correction of laxity by an intra-articular graft with or without an extra-artic- ular tenodesis. An isolated extra-articular tenodesis (Lemaire, for example) is not recommended and, we believe, is contra-indicated if a previous prelimi- nary medial meniscectomy has been performed. There is no place nowadays for a ligament reconstruction using synthetic materials.
Fig. 2a, b. a Right knee. Anterior cruciate ligament (ACL) reconstruction with 10 years follow-up. b Left knee. ACL rup- ture with 11 years follow-up
a
b
The age and the competitive level of the football player must be taken into account [18]. In the case of young, non-professional players, one must con- sider long-term results. An ACL reconstruction (possibly associated with a meniscal repair) is recommended. In the case of a professional player near the end of his or her career, one must take into account the need for a rapid recov- ery; one will prefer a meniscectomy.
Time between injury and intervention may also influence the decision. If the rupture occurred in a 20-year-old player and the patient is seen at 40 years, pre-osteoarthritis can be present, modifying the indication. In case of pre-osteoarthritis with incomplete joint-space narrowing but presence of car- tilage, a combined valgus high tibial osteotomy (Fig. 3) must be discussed [19]. This combined osteotomy allows the player to return to recreational sports, but only a small percentage is able, in our experience, to return to competitive sports. In a high-level, competitive soccer player, we propose an ACL graft immediately and an osteotomy later, despite the risk of early osteoarthritis.
Where there is evolved osteoarthritis with a posteromedial cupping of the tibial plateau, an ACL graft is useless; an isolated valgus high tibial osteotomy
Fig. 3.Same patient, left knee. Anteri- or cruciate ligament (ACL) graft with high tibial valgisation osteotomy asso- ciated
without ACL reconstruction is recommended. Whatever the type of osteoto- my, one must not increase the posterior tibial slope.
Posterior Instability and Arthrosis
PCL lesions frequently involve goalkeepers. They generally occur following a direct anteroposterior trauma at the level of the upper extremity of the tibia, with the knee at 90° flexion. After a rehabilitation period, the tolerance is often good, and most patients are able to return to recreational (80%) or even full competitive sport activities (64%) [20]. Over time, PCL insufficiency leads to degenerative changes in the medial femorotibial and femoropatellar joint. This progression of osteoarthritis is accelerated in the event of medial meniscectomy [21].
The majority of isolated PCL ruptures do not require surgical treatment.
When there is pain or instability, one can propose a surgical reconstruction of the PCL. Recent results are encouraging. In the event of associated osteoarthritis, one may discuss a tibial osteotomy, either of valgisation in the event of a predominantly medial femorotibial lesion, or of flexion, by anteri- or opening, to increase the posterior tibial slope.
Bi-Cruciate Lesions, Dislocations and Osteoarthritis
The management of such a lesion is complex. Anatomical repair is the best option if the patient wants to return to sport. In the chronic phase, one can consider ligament reconstruction, but in some cases, multiple ligament injuries are best treated with an osteotomy [22].
Conclusion
It remains unproven that playing football increases the risk of osteoarthritis of the knee. However, injuries caused by playing football are without doubt an important factor in the onset of osteoarthritis. Strenuous sport activities induce the majority of detachments or ruptures of the medial meniscus, espe- cially as a complication of ACL rupture. Direct trauma to joint surfaces can lead to osteoarthritis. In addition, indirect trauma can occur as a conse- quence of cruciate ligament or meniscal injuries that result in repetitive, abnormal, anterior tibial translation. Such translation generates shear forces in cartilage, leading to premature osteoarthritis.
Acknowledgments to Andrew Davis
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