Isokinetic training after ACL-reconstruction

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Does ACL-reconstruction prevent early OA?
Ejnar Eriksson, M.D. Karolinska
Institute, Stockholm, Sweden
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Does ACL-reconstr. prevent OA?
This is a highly debated subject! I wish I could
give you a true and definitive answer. No
consensus! So unfortunately, we still do not know
the answer to this question. I will give you some
information that might give you a little food
for thoughts, though.
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We all know that joint cartilage lacks blood
supply and receives its nutrition from the joint
fluid. The cartilage acts like a sponge
when compressed, fluid is squeezed out and when
unloaded (during walking or running) it sucks
up nutritious joint fluid.
Joint cartilage
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The easiest way to produce degenerative arthritis
in a rabbit joint is to immobilize the joint in
a cast. Within some time you have severe
arthrosis.
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With that background, sports ought to be very
good for our joints. During running we regularly
load and unload our joints. This ought to
improve the nutrition of the cartilage of
our joints a lot.
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Why then do we see 50-year old football players
with horrible arthrosis after an ACL-injury
like in this guy??
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25 years old
..or young football players like these two in
their 20-ies with severe cartilage injuries/gonar
throsis after ACL-injuries? The explanation for
their cartilage injuries is
27 years old
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..that it is not the sport per se the cartilage
damage is caused by the injuries that the players
have sustained!!
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Does ACL-reconstr. prevent OA?
An ACL-reconstruction would of course stabilize
the knee and could prevent further dangerous
pivot shifts. But if the cartilage damage is
already there, an ACL reconstruction could only
possibly stop further cartilage damage. The only
way to find out more about this, is to search the
literature
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Annual incidence of ACL injuries?

• 3 /10 000
• In the population
• 6 / 10 000
• In the active age group
• 18 /10 000
• Soccer players
• 27 /10 000
• Female soccer players

• Nielsen Yde -91
• Daniel Fritchy -94
• Roos et al. -95

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Does ACL-reconstr. prevent OA?

• Medline 1960-2007 3770 papers
• Human studies, injury 1203
• Prospective 48
• Randomized 16
• Controlled 4
• Comparing surgery with no surgery 1
• Andersson, Odensten, Gillquist, 1991 (but
  they compared repair (possible augmentation)
  with non-op treatment.

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Does ACL-reconstr. prevent OA?
Will reconstructive ACL-surgery increase or
decrease the risk of OA after an ACL injury?
Lets look at the literature.
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Does ACL-reconstr. prevent OA?

• Lohmander Roos 1994
• Neyret et al. Am J Sport Med, 1993

Review, 50 OA after 15 ys
Soccer players, surg. treated 77 OA after 20 ys
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Does ACL-reconstr. prevent OA?
Non op treated, 12 ys, 37 JSN, 63 OA-changes

• Segawa et al. Knee, 2001
• Myklebust et al. Am J Sports Med, 2003
• Lohmander et al
• 2004
• Neuman et al. 2005

42-46 OA 8 years after ACL injuries in
handball 42 and 48 OA, 12-14 ys
16 after 15 ys, 0 if no meniscus injury in
non-op.
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Meunier et al Scand J Med Sci Sports June 2007
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Does ACL-reconstruction influence the
development of arthrosis

• ACL reconstruction
• Increases Daniel et al. 1994
• Patellar OA Lohmander et al. -04
• Decreases Hart et al. JBJS Br 2005
• Decreases

Fink et al, ESSKA 2006 Kessler et al. ESSKA 2006
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Effect of ACL-reconstruction on development of
arthrosis
Increase of arthrosis after ACL-reconstruction
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Does ACL-reconstr. prevent OA?
The group in Lund, Sweden with Harald Roos and
Stefan Lohmander maintains that football players
with ACL-injuries get arthrosis whether operated
or not. This is a hot subject today. In Lund they
are therefore right now making a propspective
randomised study of ACL-reconstruction versus
non-operative treatment of ACL.
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Does ACL-reconstr. prevent OA?
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Does ACL-reconstr. prevent OA?
High incidence irrespective of treatment
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Does ACL-reconstr. prevent OA?
High incidence irrespective of treatment
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Effect of ACL-reconstruction on development of
arthrosis
Positive effect of ACL-reconstruction
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Does ACL-reconstr. prevent OA?
Karl-Peter Benedetto and his group from
Innsbruck saw less arthrosis after surgery than
in non-op cases
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We know from a series of excellent studies by
Lohmander and his group in Lund, Sweden, that all
injuries to a joint lead to release of
harmful cytokines, that remain for quite a time
and can cause cartilage damage.
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Tesch et al showed in 2002 that activation
of body adenosine A2a is the mechanism by which
the body controls inflammatory joint-phenomena
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Will be published in KSSTA in July 2007
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This is a very preliminary experimental study. If
this holds true in larger controlled studies with
longer follow-ups, maybe we could stop the
cartilage damage caused by cytokines
after injuries or surgery. I have actually
written
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Does ACL-reconstr. prevent OA?
Between 1968 and 1972, we operated 134 patellar
tendon ACL-reconstructions at the Karolinska
Hospital in Stockholm. In 1978, a young Robert J
Johnson from Burlington, Vermont, USA came to
Stockholm to follow up 84 of them after 5-10
years
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Does ACL-reconstr. prevent OA?
These patients are now 35-40 years post surgery.
We have therefore invited Bob Johnson to come
back to Stockholm and re-examine the same cases.
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Does ACL-reconstr. prevent OA?
Heel-height
KT-1000
One leg jump
Isokinetics
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Does ACL-reconstr. prevent OA?
All the 86 we have studied so far have undergone
X-ray and motion MRI. Unfortunately many of these
patients had already had a meniscectomy before
our ACL-reconstructions. 5-10 years after the
ACL-reconstruction, Bob Johnson did not find any
difference in arthrosis between the guys without
menisci and the ones with intact menisci.
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Does ACL-reconstr. prevent OA?
35 years later, the ones without menisci all have
had a knee replacement or are waiting for one due
to severe degenerative arthrosis. The ones with
intact menisci and stable knees, are surprisingly
good, though.
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Does ACL-reconstr. prevent OA?
These guys have been able to do pivoting sports
ever since their surgery. They are now in their
60-ies and very satisfied with the
operation. They do not have more arthrosis in
the operated knee than in their healthy control
knee.
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Does ACL-reconstr. prevent OA?
On motion MRI one can see a normal-looking ACL
that resists anterior drawer. Our study is not
completed yet. But we already now can say that
the late arthrosis evidently depends very much
on absence of their menisci.
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Does ACL-reconstr. prevent OA?
The reason for performing an ACL-reconstruction
thus seems to be to protect the menisci.
Hogervorst found the same in his 2002 study like
Meunier et al. in their 15 yr follow-up,
2007. But note this is for prevention of late
osteoarthrosis.
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Does ACL-reconstr. prevent OA?
But your question to me was Does
ACL-reconstruction prevent EARLY
osteo-arthrosis?? Let me therefore tell you the
story of a young football player some 20 years
ago. He came after an acute pivot-shift
and ACL-injury
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These are his acute cartilage fractures . One can
easily understand why such injuries lead
to degenerative arthrosis in the future. In this
case, it is questionable if an ACL-reconstruction
could prevent early osteoarthrosis.
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Does ACL-reconstr. prevent OA?
I am sorry that I have not been able to give a
clear-cut answer to your question. I hope,
however, that I have given you some food for
thoughts
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Invitations
If you need an excuse for coming to
beautiful Stockholm in September this year, we
are arranging a fantastic conference then
42
Invitations
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Invitations
11th
13-18, 2008
If you like downhill skiing and Italian pasta
why not join me and the top faculty in beautiful
Courmayeur in Italy Jan. 13-18, 2008. Our course
always receives high points from the
participants..
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We eat lunch out on the slope
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and look at Mont Blanc when we ski..
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Thank you very much for your kind attention
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