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Am J Sports Med. 2014 Sep;42(9):2242-52. doi: 10.1177/0363546513508376. Epub 2013 Nov 8.

Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis.

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Department of Trauma & Orthopaedic, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
Department of Trauma & Orthopaedic, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
Fortius Clinic, London, United Kingdom.



Knee osteoarthritis after anterior cruciate ligament (ACL) injury has previously been reported. However, there has been no meta-analysis reporting the development and progression of osteoarthritis.


We present the first meta-analysis reporting on the development and progression of osteoarthritis after ACL injury at a minimum mean follow-up of 10 years, using a single and widely accepted radiologic classification, the Kellgren & Lawrence classification.




Articles were included for systematic review if they reported radiologic findings of ACL-injured knees and controls using the Kellgren & Lawrence classification at a minimum mean follow-up period of 10 years. Appropriate studies were then included for meta-analysis.


Nine studies were included for systematic review, of which 6 studies were further included for meta-analysis. One hundred twenty-one of 596 (20.3%) ACL-injured knees had moderate or severe radiologic changes (Kellgren & Lawrence grade III or IV) compared with 23 of 465 (4.9%) uninjured ACL-intact contralateral knees. After ACL injury, irrespective of whether the patients were treated operatively or nonoperatively, the relative risk (RR) of developing even minimal osteoarthritis was 3.89 (P < .00001), while the RR of developing moderate to severe osteoarthritis (grade III and IV) was 3.84 (P < .0004). Nonoperatively treated ACL-injured knees had significantly higher RR (RR, 4.98; P < .00001) of developing any grade of osteoarthritis compared with those treated with reconstructive surgery (RR, 3.62; P < .00001). Investigation of progression to moderate or severe osteoarthritis (grade III or IV only) after 10 years showed that ACL-reconstructed knees had a significantly higher RR (RR, 4.71; P < .00001) compared with nonoperative management (RR, 2.41; P = .54). It was not possible to stratify for return to sports among the patients undergoing ACL reconstruction.


Results support the proposition that ACL injury predisposes knees to osteoarthritis, while ACL reconstruction surgery has a role in reducing the risk of developing degenerative changes at 10 years. However, returning to sports activities after ligament reconstruction may exacerbate the development of arthritis.


anterior cruciate ligament; knee injury; meta-analysis; osteoarthritis; radiology; systematic review

[Indexed for MEDLINE]

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