Reconstruction After an Anterior Cruciate Ligament Injury Does Not Reduce the Osteoarthritis Risk But Lowers the
Benjamin Blackman1, Matey Juric2, Seth Ybema3
1Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
Background:
An anterior cruciate ligament (ACL) rupture is a common and debilitating knee injury. Although surgical management restores knee stability, its effectiveness in preventing long-term joint degeneration compared with nonoperative management remains unclear.
Purpose/Hypothesis:
The purpose of this study was to compare the long-term incidence of radiographic knee osteoarthritis (OA) after the operative versus nonoperative management of ACL injuries. It was hypothesized that operative management would lead to lower rates of OA.
Study Design:
Systematic review and meta-analysis; Level of evidence, 3.
Methods:
A systematic review and meta-analysis were conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Embase, and Scopus were searched through June 2025 for comparative studies evaluating the development of OA after an ACL injury that was treated with operative or nonoperative management. Radiographic OA was defined as Kellgren-Lawrence grade ≥2 or equivalent. Random-effects meta-analyses were performed to compare radiographic OA, secondary meniscal surgery, and total knee arthroplasty (TKA) rates between treatment groups. Study quality was assessed using the MINORS (Methodological Index for Non-Randomized Studies) instrument and the Cochrane RoB 2 (risk of bias tool). The certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.
Results:
A total of 18 studies comprising 33,540 patients (mean follow-up, 12.3 years) were included. A meta-analysis of 15 studies found no significant difference in radiographic OA between the ACL reconstruction (ACLR) and nonoperative groups (risk ratio [RR], 1.01 [95% CI, 0.79-1.27]; I 2 = 92%; P = .96). A sensitivity analysis of level 1 to 2 studies with low heterogeneity yielded similar findings (RR, 1.14 [95% CI, 0.87-1.48]; I 2 = 34%; P = .33). A meta-analysis of 2 studies assessing OA prevalence in the ACL repair versus nonoperative group also found no statistically significant difference, with moderate heterogeneity (RR, 0.78 [95% CI, 0.54-1.12]; I 2 = 55%; P = .18). Rates of secondary meniscal surgery did not differ significantly (RR, 0.79 [95% CI, 0.52-1.21]; I 2 = 56%; P = .29). However, ACLR significantly reduced the risk of TKA (RR, 0.17 [95% CI, 0.07-0.43]; I 2 = 59%; P = < .001).
Conclusion:
The operative management of ACL injuries did not decrease the long-term risk of developing radiographic OA compared with nonoperative management. ACLR was associated with a lower rate of TKA.