The Physician and Sportsmedicine

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Effect of Timing of ACL Reconstruction in Surgery

and Development of Meniscal and Chondral
Lesions

D. Edmund Anstey BA, Benton E. Heyworth MD, Mark D. Price MD, PhD &
Thomas J. Gill MD

To cite this article: D. Edmund Anstey BA, Benton E. Heyworth MD, Mark D. Price MD, PhD &
Thomas J. Gill MD (2012) Effect of Timing of ACL Reconstruction in Surgery and Development of
Meniscal and Chondral Lesions, The Physician and Sportsmedicine, 40:1, 36-40

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 C L I N I C A L F O C U S : O RT H O P E D I C S A N D S P O RT S I N J U R I E S
Effect of Timing of ACL Reconstruction in Surgery
and Development of Meniscal and Chondral
Lesions
D. Edmund Anstey, BA 1
Benton E. Heyworth, MD 2
Mark D. Price, MD, PhD 3
Downloaded by [University of Otago] at 13:46 29 October 2015
Thomas J. Gill, MD 1
1
Department of Orthopedic Surgery,
Division of Sports Medicine,
Massachusetts General Hospital,
Boston, MA; 2Department of
Orthopedic Surgery, Childrens
Hospital Boston, Boston, MA;
3
Department of Orthopedic Surgery,
Division of Sports Medicine,
University of Massachusetts Medical
School, Memorial Medical Center,
Worcester, MA
Correspondence: D. Edmund Anstey, BA,
Massachusetts General Hospital
Sports Medicine Service,
175 Cambridge St., 4th floor,
Boston, MA 02114.
Tel: 617-726-7500
Fax: 617-643-2030
E-mail: david_anstey@hms.harvard.edu
36 The Physician and Sportsmedicine,Volume 40, Issue 1, February 2012, ISSN 0091-3847
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DOI: 10.3810/psm.2012.02.1949
Abstract
Purpose: To investigate whether a delay in the timing of surgery of.6months compared with
performing the surgery6months after the anterior cruciate ligament (ACL) injury leads to an
increased risk of injuries or degenerative changes in the ACL-deficient knee. Methods: Patients
who underwent primary ACL reconstruction at an academic tertiary care center, and had pre-
operative magnetic resonance imaging (MRI) performed within 2months of the time of the
ACL injury were included. The prevalence of degenerative changes at the time of surgery was
assessed and related to the timing of ACL surgery, with early reconstruction defined as a surgery
performed 6months and delayed reconstruction defined as surgery performed.6months
after ACL injury. New meniscal tears were defined as lesions detected at the time of surgery
that were not detected by MRI. Results: Of 195 patients who were selected based on inclusion
criteria, 171 patients underwent surgery6months after their ACL injury, and 24 patients
underwent surgery.6months after their ACL injury. The prevalence of new medial meniscal
tears in the early reconstruction group was 4.1%, while in the delayed reconstruction group, the
prevalence was 16.7% (P=0.012). Conclusion: A delay in the timing of ACL reconstruction
from6months to.6months following injury is associated with a significant increase in the
prevalence of medial meniscal tears (P=0.012), with a relative risk of 4.07 (CI, 1.2912.88).
Keywords: anterior cruciate ligament; anterior cruciate ligament reconstruction; meniscal tears;
cartilage lesions; timing of surgery
Introduction
Anterior cruciate ligament (ACL) rupture is a common cause of knee instability, with
an annual incidence in the United States estimated to be as high as 1in 3000.1 In active
individuals, ACL deficiency may lead to degenerative changes in the knee over time,
including tears of the lateral menisci (LM) and medial menisci (MM), and injury to the
articular cartilage. Meniscal lesions are of particular concern, as numerous studies have
illustrated the role of the meniscus in shock absorption and protection of the articular
surfaces.24 Moreover, an absent meniscus has been linked to an increased incidence
of knee arthrosis following ACL reconstruction.1,5,6
Currently, the most commonly favored approach for treating the ACL-deficient knee
is surgical reconstruction. However, there is some controversy regarding the optimal
timing of surgery. Although there is evidence to suggest that early restoration of knee
function may be protective to intra-articular surfaces from damage that develops during
ACL deficiency,1,712 a recent meta-analysis suggests that delaying surgery may not be
harmful as once thought, both in terms of intra-articular damage and patient outcome.12
Delaying surgery is often more feasible for patients, both in their mental preparation

for the procedure and their ability to complete appropriate
rehabilitation.13 Moreover, the prevalence of degenerative
changes is widely variable, with meniscal injury reported
anywhere from 16% to 82% in the acutely injured ACL and
up to 96% in chronic cases.1,9,12
This study sought to determine how the timing of surgical
ACL reconstruction affects the incidence of meniscal and
chondral damage, comparing magnetic resonance imag-
ing (MRI) findings prior to surgery and operative findings
at the time of surgery. Our hypothesis is that a delayed
surgical reconstruction is associated with an increased risk
of meniscal lesions and degenerative changes in the ACL-
deficient knee that are not detectable at the time of injury.
Materials and Methods
Demographic, Clinical, and Imaging Data
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This was a retrospective cohort study. Records of all
patients who underwent primary ACL reconstruction by 3
primary surgeons at a tertiary care, urban, academic medical
center were reviewed. Age, sex, mechanism of injury, date
of injury (DOI), date of MRI (DOM), date of surgery (DOS),
MRI findings, and arthroscopic findings were performed
retrospectively for all patients and analyzed. Patients were
divided into 2subgroups: early reconstruction for recon-
struction occurring6months after the DOI and delayed
reconstruction for reconstruction occurring.6months
after the DOI.
For patients who underwent MRI within 60days of DOI,
imaging findings of meniscal tears or chondral injuries were
considered to have occurred on the DOI. The incidence and
location of any degenerative changes and meniscal damage,
as determined by MRI, were compared with arthroscopic
findings at surgery. Any new injuries found on the DOS
that had not been seen on MRI were assumed to have occurred
between the DOM and the DOS. Severity of chondral damage
was classified using the Outerbridge scoring classification
system.4
Table 1. Patient Demographics
Demographic Early Reconstruction Group
( 6 Months After DOI)
Patients, n 171
Men:women 102:69
Mean age, y (range; SD) 33.4 (16.460.2; 10.9)
Mean DOI to DOM days (range; SD) 11.8 (060; 12.0)
Mean DOI to DOS, days (range; SD) 77.6 (10174; 31.6)
Mean DOM to DOS, days (range; SD) 65.7 (9161; 28.6)
Comparative demographic data for study patients in the early and delayed reconstruction groups.
Abbreviations: DOI, date of injury; DOM, date of magnetic resonance imaging; DOS, date of surgery; SD, standard deviation.
The Physician and Sportsmedicine,Volume 40, Issue 1, February 2012, ISSN 0091-3847 37
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Effect of Timing of ACL Reconstruction in Surgery
Patients were excluded if they had undergone prior knee
surgery on the affected side, if their records were incomplete
(eg, unknown DOI, unknown DOM, or unobtainable MRI
results), or if the DOM was > 60days from the DOI.
Statistical Analysis
Analysis of categorical variables, such as the presence of
a chondral lesion or meniscal tear, was performed using
Fischers exact test. A P value of,0.05 was considered
significant. OpenEpi statistical software was used to assist
with the statistical analysis.14,15
Results
Patient Demographics
Of the 244 patients initially identified as having an ACL
injury, 195had MRIs within 60days of DOI (Table1). The
mean age was 33.7years, with a range of 16 to 60years.
The study population included 115 (59%) men and 80 (41%)
women. Of these patients, the mean duration of time between
the DOI and DOM was 13.1days, with a mean delay in sur-
gery of 105.1days from the DOI. In the early reconstruction
group, there were 171 patients, with a mean delay between
DOI and DOS of 77.6days. In the delayed reconstruction
group, there were 24 patients, with a mean delay between
DOI and DOS of 301.1days.
Meniscal Injury
Based on the MRI findings, 150 (76.9%) of the 195 patients
examined had meniscal tears. There were 87 (44.6%) patients
with tears in the LM and 94 (48.2%) patients with tears in the
MM; 45 (23.1%) patients had no detectable meniscal lesion.
On the DOS, 179 (91.8%) of the 195 patients examined were
found to have meniscal tears (Table2). Therefore, 41 new
tears were detected intraoperatively that were not seen on the
DOM, with 30 new LM tears and 11 new MM tears (Table3).
Subgroup analysis by time to intervention and location
of meniscal injury was also investigated. In the patients
Delayed Reconstruction Group P Value
(. 6 Months After DOI)
24
13:11 0.31
36.1 (19.354.2; 11.5) 0.26
21.9 (256; 16.1) , 0.01
301.1 (188878; 152.6) , 0.01
279.2 (162836; 150.8) , 0.01
 Anstey etal

Table 2. Magnetic Resonance Imaging and Surgical Findings of the Chondral Injury
Early V
ersus Delayed Reconstruction Groups
In 58 knees, 81 chondral injuries were detected on the DOS, with
Early Delayed P Value a distribution by severity as follows: grade 1, 11; grade 2, 20;
Reconstruction Reconstruction
grade 3, 49; grade 4, 1. The prevalence of chondral injuries
( 6 Months); (. 6 Months);
N = 171 N = 24 in the early and delayed reconstruction groups was analyzed.
MRI findings Fischers exact test revealed no statistically significant
None, n (%) 36 (21.1) 9 (37.5) 0.07 difference between these groups across all grades. When
MM, n (%) 85 (49.7) 9 (37.5) 0.26 analyzing the early versus delayed reconstruction groups, the
LM, n (%) 78 (45.6) 9 (37.5) 0.45
prevalence of chondral lesions (any grade) was 28.7% versus
Surgical findings
37.5%, respectively (P =0.37). For high-grade chondral
None, n (%) 13 (7.6) 3 (12.5) 0.41
MM, n (%) 71 (41.5) 12 (50.0) 0.43
lesions ($grade3), the prevalence was 19.8% versus 25%,
LM, n (%) 114 (66.6) 13 (54.2) 0.23 respectively (P=0.56).
MRI findings: total number and incidence of meniscal injuries identified in the early
and delayed reconstruction groups by MRI performed , 60 days after injury. Surgical Discussion
findings: total number and incidence of meniscal injuries identified in the early and
delayed reconstruction groups at the time of surgery. The purpose of the current study was to investigate the
Abbreviations: LM, lateral menisci; MM, medial menisci; MRI, magnetic resonance relationship between timing of ACL reconstruction and
Downloaded by [University of Otago] at 13:46 29 October 2015

imaging.
the incidence of meniscal and chondral injuries that were
with LM tears, comparing early with delayed intervention, sustained between the DOI and the DOS. Although new
no statistically significant difference was found for new meniscal injuries were found in both the early and delayed
tears between the 2groups (early, 26 [15.2%] vs delayed, reconstruction groups, our findings indicate that a delay
4 [16.7%] [P =0.85]). In the patients with MM tears, a in surgery has a statistically significant association with
significant difference was found between new tears in the an increase in the prevalence of MM tears, with 16.7%
early compared with the delayed reconstruction group (early, affected in the delayed reconstruction group compared
7 [4.1%] vs delayed, 4 [16.7%] [P=0.012]). The relative with 4.1% in the early reconstruction group (P=0.012).
risk (RR) associated with MM injury in the delayed versus Although new LM injuries were found in both groups
early reconstruction was 4.07 (CI, 1.2912.88). One patient (early, 15.2%; delayed, 16.7%), a statistically significant
in the early reconstruction group had no meniscal injury on difference was not observed. This suggests that MM may
the DOM and was subsequently found to have tears in both be more susceptible to injury in ACL-deficient knees when
the MM and LM. compared with LM. Our investigation into the effects of
Intraoperative and MRI findings were compared to delayed ACL reconstruction on the incidence of chondral
assess if tears had been found radiographically that were injury did not demonstrate a significant difference between
not present intraoperatively. Of the 390 combined MM and the early and delayed reconstruction groups. Although
LM tears, there were 21 (5.4%) cases in which meniscal higher-grade injuries were found more frequently in the
tears were observed on the MRI but were then not observed delayed reconstruction group, a statistically significant
during surgery (19 MM tears and 2LM tears). correlation could not be established for timing of ACL
reconstruction.
The results of the current study may be explained by
Table 3. New Meniscal Tears in the Early Versus Delayed the relative importance of the mechanical role of MM
Reconstruction Groups versus LM in ACL-deficient knees.4,16 Levy etal4 and
New Meniscal T
ears Early Delayed P Value Sullivan etal16 have emphasized the interaction between
Reconstruction Reconstruction
axial loading and a valgus moment on the DOI, and the
Group Group
( 6 Months); (. 6 Months); resulting anterolateral subluxation of the tibia, which more
N = 171 N = 24 frequently causes acute tears in LM17 concurrently with
New MM tears, n (%) 7 (4.1) 4 (16.7) 0.012 ACL tears. However, MM more specifically resist anterior
New LM tears, n (%) 26 (15.2) 4 (16.7) 0.85 tibial motion in ACL-deficient knees. The change in knee
Number and incidence of new tears (seen at the time of surgery and not observed kinematics in ACL-deficient knees compared with ACL-
radiographically) in the early and delayed subgroups. Results separated based on
anatomic location. intact knees increases weight bearing in MM by as much
Abbreviations: LM, lateral meniscus; MM, medial meniscus. as 2-fold.2,9,16,17 In the long term, such stresses may lead to

38 The Physician and Sportsmedicine,Volume 40, Issue 1, February 2012, ISSN 0091-3847
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tears of MM, consistent with the increased incidence of new
MM tears that were observed.
These findings are highly relevant given the correlation
between the amount of intact meniscus and the development
of arthrosis in later life after ACL injury,1,1820 which is likely
due to the biomechanical protective role of MM, as well as
MM function in joint lubrication and nutrient distribution.2
Because the average age in the cohort of this current study
is ,35years, prevention of meniscal injury is critical for
this patient population undergoing ACL reconstruction.
In some ways, the results of the current study echo
previous investigations into the association between menis-
cal and chondral injury and timing of ACL repair, which
have demonstrated that delayed repair is associated with an
increased incidence of meniscal damage.1,611 The overall
reported incidence of meniscal injury has varied greatly in
Downloaded by [University of Otago] at 13:46 29 October 2015
such studies, with rates in the acute setting ranging between
16% and 82%, and reaching incidences as high as 96% in
patients with chronic ACL deficiency.1,9 Results from the
Norwegian National Knee Ligament Registry similarly sug-
gest that delays in surgery increase the likelihood of finding
a meniscal injury intraoperatively, with the odds of meniscal
injury and cartilage lesion increasing by 1% for every month
that surgery is delayed.8 This study focused on the influences
of ACL deficiency on meniscal injuries over many years.
However, our study demonstrates that such injury may
occur within a much shorter period than has been previously
recognized. The primary strength of the current study is its
ability to detect if injuries found arthroscopically are in fact
related to even a relatively short delay in repair. An unantici-
pated finding was that while the overall incidence of meniscal
injury was consistent with previously reported data, only
19.5% of the meniscal injuries found on the DOS were new
injuries not detected by MRI. This suggests that a significant
percentage of injuries likely occur either at the time of ACL
rupture or very early in the course of the natural history of
the ACL-deficient knee. This result could influence how we
view prior retrospective studies regarding the optimal tim-
ing of ACL reconstruction; it may also have implications
for how orthopedic surgeons advise patients with regard to
the timing of their surgery.
The primary limitation of the current study is its reliance
on MRI as the principle measure of the presence of menis-
cal tears and chondral lesions on the DOI. However, a great
amount of research has shown the sensitivity and specificity
of MRI to be extremely high (as high as 93%100%).2124
In fact, our series showed a significant number of false-
positive tears, suggesting that this radiological tool may be
The Physician and Sportsmedicine,Volume 40, Issue 1, February 2012, ISSN 0091-3847 39
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Effect of Timing of ACL Reconstruction in Surgery
slightly oversensitive, and the rate of new tears seen at the
time of arthroscopypresumed to have occurred between the
DOI and DOSmay actually be an underestimate. Alterna-
tively, these may reflect meniscal tears that healed between
the DOI and DOS.25 A second limitation is that our results
do not offer insight as to why the integrity of the meniscus
remains intact in some patients and not in others, and whether
there may be early markers to help the physician determine
who is most at risk for sustaining chondral, meniscal, or other
intra-articular injury. Finally, an important issue that could
not be sufficiently examined in this study is the potential
correlation between instability episodes or elevated activity
levels and the development of new injuries over the period
between the DOM and DOS. This article underscores the
need for a randomized controlled trial to definitively evalu-
ate the degree of meniscal and chondral damage in relation
to the timing of ACL reconstruction.
Conclusion
This study suggests that there are potential risks in delaying
reconstruction of the ACL-deficient knee, principally the
occurrence of MM tears. Moreover, by using radiographic
evidence as part of the initial assessment, this study dem-
onstrates that such injury may occur in a much shorter time
period than previously recognized. This result may influence
how clinicians interpret the results of other, similarly focused
retrospective analyses.
Conflict of Interest Statement
D. Edmund Anstey, BA, Benton E. Heyworth, MD, MarkD.
Price, MD, PhD, and Thomas J. Gill, MD disclose no con-
flicts of interest.
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