Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries

Listen to Andrew Duckworth, Elvire Servien, Sébastien Lustig and Fares Haddad discuss the paper 'Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries' published in the September 2023 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of September. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to start by thanking all of you for your continued comments and support, as well as a big thanks to our many authors and colleagues who take part.

Our podcast continues to focus on some papers published each month here at the BJJ and highlights some of the great work our authors are doing. So today I have the pleasure of firstly welcoming Professor Elvira Servien, who is an orthopaedic surgeon at the FIFA Medical Center of Excellence in Kwaru Hospital in Lyon, to discuss their paper entitled 'Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries: a retrospective cohort study', which has been published in the September edition of the BJJ.

Welcome Elvire, it's great to have you join us today. Thank you, hello everyone. Joining Elvire is a colleague in Lyon and co-author for the paper, Professor Seb Lustig. Seb, thank you so much for joining us, we really appreciate you taking the time. It's a pleasure. And finally, to round off this great panel of experts.

We have our brilliant Editor-In-Chief here at the BJJ Professor Fares Haddad to give his insights into this really [00:01:00] important study. Prof great to have you back with us as always. Thanks for having me Andrew. So Elvire, if I could start with yourself. The aim of your study was to evaluate the association between chondral injury and the time interval from ACL tear to surgical reconstruction.

So maybe as a background to the study for our listeners, can you give us a, just a brief overview of the state of the current literature on this topic? And what caused you to look at this question in particular? Of course, there is, there has been already several papers on this topic, but the most recent ones are a bit controversial.

For example, the big meta analysis from Pro Domidis et al., published two years ago in HSM, found a higher risk of chondral low grade medial injuries when delaying ACL reconstruction for more than three months, and an increased risk of high grade medial injuries when delaying for more than one year.

However, because it is a meta analysis, it is difficult to compare different populations. [00:02:00] So I wanted the department to get a better answer for our patients. And indeed, in France, it's very common for the patients to ask about the risk of delaying surgery and how long they can wait. For personal and or professional reasons without damaging their knee.

Absolutely. Yeah, absolutely. And that's a really nice overview of that meta analysis and like you said, the controversy around it. And maybe if I come to Seb and Fares, maybe Seb first, giving you, is that your own sort of personal clinical experience with this? And I suppose, particularly maybe very relevant at the moment with the long wait list certainly we're experiencing here in the UK since the COVID pandemic.

Absolutely. We have the same problem facing, you know, you know, limited our time. So we have a lot of these, you know, young, active, you know patients who have, you know, sports injury, and we have to delay the, you know, their access to surgical field and the consequences we see more and more of these control, you know, injury associated when they get to the [00:03:00] OR.

So that's. potentially a big problem. Yeah, absolutely. Absolutely. And similar for us in the UK, would you say? Absolutely. Similar at the moment. I mean, I think to give you a bit of a backdrop, Andrew, we looked at this over 20 years ago when we were starting to set up acute knee clinics because knee injuries were going to general clinics.

Being seen in fractured clinics and essentially being dismissed and we published God must be 20 years ago now showing that we could reduce, we could reduce the time to diagnosis of ACL injury dramatically by having dedicated clinics, but also by bringing that forward. We saw many fewer chondral injuries.

So you know, this, this really replicates on a larger scale, something we all recognize. It's a huge danger with COVID when a lot of places just were not allowed to do this kind of soft-tissue knee reconstruction. And I think there are real implications here, not because pushing the fast forward button for surgery is one solution.

But another one of course, is just to advise patients what activities they can and can't do. And [00:04:00] one of the big confounders here is what are patients doing to cause this chondral damage? Is it relating to instability episodes or is it something that's happening anyway in a subtle and unstable knee.

There's lots we don't understand. Absolutely. Absolutely. That makes, and that makes a lot of sense. So maybe just conscious of time, we can move on to the study design. So this was a retrospective cohort study of an initial 1840 consecutive ACL reconstructions performed at your centre. Elvire if you could maybe give us a brief overview of the inclusion and exclusion for the study.

So our inclusion and exclusion criteria were pretty usual. We exclude partial tear, multiligament, education for uni and HTO and ACL of course. And a last exclusion criteria was patient under 16 or over 70. And so we use our ACL database from 2012 to 2022.

And from [00:05:00] 1800 patient we had 1317 patients reaching all the inclusion criteria. Yeah, absolutely. And it's very nicely laid out in the figure in your study and in your paper, sorry. And in terms of how you broke down, obviously that was the, how you got the patients. In terms of the timing of the surgery, how was that sort of determined during the study period?

And how did you break them down for this, this sort of this study? Actually in France. For nonprofessional athletes, the waiting list is not very long for ACL reconstruction, or to get an appointment with a surgeon. I know it's different in UK, but in France it's not so long. It's not two years, it's not one year for sure.

And so, in case of indication for ACL reconstruction, Patient complaining about instability playing sport, of course the surgery can be done as soon as the patient has recovered full range of motion. So [00:06:00] except in case of a bucket handle the patient can mostly choose a time of his surgery within one or two months.

So the waiting is not so, so, so long in France, but for the paper. We decide to break down the groups every three months because three months was a cutoff from previous paper. And so now I should say I didn't change really my indication. I may postpone now some patient with muscular insufficiency.

Yeah. Because I'm doing is a kinetic testing before surgery and sometime when the grade is really too bad, I will postpone surgery. Otherwise, I will not change my my indication. That's interesting. And we can go into the breakdown of those in those groups. That's that's really interesting. And Seb if maybe I could come to you and I suppose one of the key parts of it was the assessment of the chondral damage.

How was that sort of sort of done and by whom? So [00:07:00] it was, you know, objective in assessment during the arthroscopy. So every arthroscopy we've been, you know, assessing cartilage damage using the ICRS classification three senior surgeon involved through the 10 years, you know, period and the assessments, I would say really consistent throughout the three of us.

Yeah. And that's, that's a good thing about it, isn't it? I think with the three of you doing it, it's and then pick over that time period as well. And that's, that's very true. And maybe before we move on to the results, Seb, the, you mentioned that the pre, pre op, pre op rehab protocol was sort of, was it standardized?

And if so, what, what did it sort of briefly entail? Yeah, no, the aim, we did have this, you know, very standardized protocol. The aim was to have the patient ready for, you know, surgery, and so it was to go back to full range of motion. Absolutely no, no flexion contracture was tolerated. We did, you know, have some specific protocol for muscular reinforcements and try to aim for, you know, pain free knee.

So we had these three, you know, [00:08:00] features. We were giving the green light for, you know, surgery. Yeah, that's very clear. That's very clear. And I think that's very important part of, of how you progress that then on to surgery. I think that's, that's great. So I'll remember to come back to you moving on to what you found.

So there were a total of, like you said, 1317 ACL reconstructions were included over that. So just 10 year period with the median age of almost 30 years and two thirds were males. So sort of what you'd expect. And in terms of when the ACL rec- ACL reconstruction were done those sort of just under under a third less than three months.

Similarly, just under a third three to six months and then about almost 20 percent were done six to 12 months or over a year. And so what did you find in terms of, I suppose, both the rate and severity of the chondral injuries, and how that was associated with the timing as well. So in term of the rate and con of chondral injury, we found 17% of medial cartilage injury from ICRS, one to four and 9% on the lateral side.

But the main finding of this study is on [00:09:00] the medial compartment and the delayed ACL reconstruction in the medial compartment delaying surgery more than one year was highly associated with a significant increase both rate and severity of chondral injury compared to early surgery before three months.

On the other hand we didn't find any correlation for the lateral compartment and it looks delaying ACL reconstruction did not influence the risk of chondral lesion of the lateral side. Absolutely. Yeah. And I think that's like you said, that's, it's a very clear, clearly laid out that in your sort of primary analysis.

And in terms of you, you did some quite interesting, I thought, secondary and sensitivity analysis. What did you find with those? And regarding secondary analysis and increased technique activity score was significantly associated with a lower rate and severity of chondral injuries in the medial compartment. 

And the lateral compartment older age and BMI were both significant factors associated with chondral [00:10:00] injury. Yeah. In the activity analyzed, we found meniscal tear was significantly associated in the lateral and medial compartment. With the rate of severity of chondral injury. Yeah. Overall, delays seem to be associated with meniscal tears in the medial compartment, but not the lateral one.

Yeah, and I think those analysis, those secondary and sensitivity analysis really hammer home that key message, I think, really nicely. So if we move on to sort of the implication of it and spend a bit of time on this, you know, and, you know, the strengths and the importance of the study to my eye are very clear, you know, it's large, if not the largest single centre study looking at this association between delaying ACL reconstruction or the delay from tear to reconstruction and chondral injury.

And the study really highlights that delaying surgery was, as you said, associated with an increase in both the rate and severity of medial chondral injury dose effect fashion, particularly for delays more than a year. And, and as we've said, the younger patients seem to be at a higher risk. So maybe Seb, if I could come [00:11:00] back to you, how, how do you interpret the signings sort of moving forward?

And, and was, I suppose, was it what you expected them to be? So, yeah, I think number one regarding age of the patient was quite a surprise because we would think that, you know, you know, all patients will have more cartilage damage, but I think why young patient are at risk is because they are not quite, you know, they try to maintain their level of activity, but they have an unstable knee and they create cartilage damage.

So actually it makes a lot of sense when you think about why is it the medial compartment is just the well known biomechanics of the knee when you have an ACL rupture increase, you know the load on the, the, the medial part, you, you, you change, you know, the biomechanics of the knee with also more risk on the, on the, you know, medial you know, meniscus.

So we know that the lateral tear, the tear of the lateral meniscus occurred during the trauma and the, you know, tear of the medial meniscus most of the time, when you have, you know, unstable knee, and if you try to, to maintain your activity. So all these [00:12:00] together, actually makes sense. And I think that gives a pretty good idea of, you know, which kind of population is really at risk and that we should, you know, really get the, the optimized, you know, timing for ACL reconstruction for these patients, especially the young ones.

Yeah, that's a great, great, great way to bring it all together. So, and I think like you say, I think like you say, in terms of behaviour and activity of the younger patients, that sort of that sort of makes sense in terms of why that would be. And so Prof if I can maybe come back to you. What are your thoughts on this results?

And I suppose, was this also what you expected and what you experienced in your day to day practice? In short, it is. I think it's a great paper because I think it highlights the real world of what happens here. You've got to remember that this is an area where there's been a big, very lauded RCT from Scandinavia, the Frobel study, the Canon trial, which have basically emphasized the role of rehab as a primary [00:13:00] intervention in a large number of patients and shown, frankly, no major deleterious effect

to delaying in those, delaying those patients. Now, this is where you've got to look at the generalizability of the patients who go into that study compared to our younger population and the reality that away from Sweden and that group of patients, things are different. As, as you probably know we've undertaken, we've undertaken, David Beard led for us the ACL SNAP study, which I'll be mentioning in my November editorial.

And that has shown a slightly different scenario within NHS patients and in some patients it is right to intervene early rather than late. So I think you've got to treat the patient rather than the generality of the diagnosis. I think we've got to all remember that young patients don't always stop when you tell them to and they will go and have instability episodes.

So this will really shape people thinking around how unstable is this knee? How high risk is it? Because you want to save that medial meniscus, you lose that medial [00:14:00] meniscus, you're really going to get into trouble from that perspective. So I think it's a real eye opener. In terms of thinking how to deal with patients and just remember that each patient has to be treated as an individual.

And that's a really good point, Prof. And I think just generally, as we talk about, you know, RCT is hugely important. We all know the importance of them, but they give you a general answer and you still have to adapt that knowledge and that. and that data to the patient in front of you. I agree. And do you feel there's, you know, maybe implications?

It's maybe a strong word, but like with regards to these patients now in the NHS, you know, a lot of places still struggling to get back to prioritizing these injuries as best they can. Do you think there is implications for that? I think there is. I think what we're showing here is that these patients are going to damage their knees.

And one thing orthopaedics really lost out on during the pandemic is the prioritization process in that everything that was orthopaedic got deprioritized. And I think we've got to put it back on the agenda that we are compromising these patients' knee health. We're compromising their future [00:15:00] mobility.

We're adding future costs. Yes, it's not cancer, but in reality, this is something we need to do much better. And we need to advise these patients better. And we need to try and streamline them. Remember, this is day surgery. This is outpatient surgery. We shouldn't be that limited in being able to do it. So I'm really grateful to Elvire and Seb for putting this out there for the readers.

I totally agree. And I think like you say, it really allows you to counsel the patient very clearly. I think with this data here, maybe if I come back to you for the sort of final thoughts, you know, what are your sort of, I suppose, your feelings about how this fits into the current literature, the sort of take home messages, but also maybe sort of caveating it with any limitations of the study that you want to highlight?

Before we're speaking about the limitation, I really want to say the important finding of the study is the cutoff. It's really one year. If we need to remember something for the patient, the one year is a cutoff regarding the delay between [00:16:00] incident injury and surgery. So it's a very clear message we can give to our patient.

The first, first of all. And. It could be a limitation, but I believe because it's a single centre study, it's also a strength. As you can see, the study from Christiani published in Arthroscopy two years ago with a big database also, and it's a strength for a study to get to one single centre study. We could argue, of course, it's a retrospective study and blah, blah, with the limitation and as we all know, but actually the cartilage status was collected from the same operative report from the three senior surgeons using ICRS, as Professor Lustig said, and it's pretty accurate.

Yeah. And we are still collecting those data, I should say, prospectively. So, yeah. And, but the main limitation of these studies, we could not properly address the relationship between [00:17:00] the delay and meniscal tears. But it was not the main focus of the study. Absolutely. No, absolutely. And I think, I think that's a really nice balanced way to look at it.

And like you say, you can easily create limitations from retrospective work like this, but I think it adds so much and very clearly adds much. And there's a lot of control with that as well, with the fact that like you say, the single centre and the way it's all been assessed. Now, I think that's a very, very fair assessment.

Well guys, that was great. And I'm afraid that's all we have time for, but you know, really congratulations on, I think, I think a great study that, you know, it has a very clear message and a very clinically adaptable message, which I think is really important. And thank you so much to all of you for taking the time to join us today.

And to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media and like, feel free to post on social media about anything we've discussed here today, and thanks again for joining us take care of everyone.