Commentary & Perspective

Commentary & Perspective on
"Occupational Disability After Hospitalization for the Treatment of an Injury of the Anterior Cruciate Ligament"
by Warren R. Dunn, MD, MPH, et al.

Commentary & Perspective by
James R. Andrews, MD*,
Alabama Sports Medicine, Birmingham, Alabama

The authors have done an admirable job of analyzing a large amount of data collected over a nine-year period in a group of Army personnel. As with any retrospective review, this study is subject to several biases, which are discussed in the manuscript. Nevertheless, meaningful information can be obtained from this report.

In their analysis of factors that were related to disability discharge after anterior cruciate ligament (ACL)-related hospitalization, the authors found that psychosocial and educational factors were the main predictors, the strongest of which was rank/pay grade. This is consistent with other reports of disability following musculoskeletal injury. Most studies on outcomes following ACL injury report not on return to work, but on return to sport, where clinical factors seem to play an important role. For example, Drongowski et al.¹, evaluated ninety-nine patients with ACL-deficient knees, confirmed by arthroscopy, at a mean of fifty-two months following surgery. They found that patients with articular cartilage injuries had an appreciable reduction in sports participation when compared with patients who had isolated ACL injuries.

Interestingly, in this group of Army personnel, clinical factors such as meniscal injury and whether or not ACL reconstruction was performed were not predictive of disability discharge. However, articular cartilage injury did show a trend toward significance, and when adjusted for age, there was a significant association between articular cartilage injury and disability discharge in patients who were less than thirty years old. Two studies have reported a high percentage of radiographic changes following ACL injury, suggesting that these patients have a higher risk of the development of arthritis^2,3. However, the controversy continues as to whether the injury to the articular surface occurs at the time of the ACL injury, is due to a ligamentous instability or a loss of meniscus, or is the result of a combination of factors. Further prospective studies must be done to sort out these factors and try to determine cause and effect.

Whatever the cause, it is becoming clear that the presence of arthritic changes following ACL injury is an indicator of poor prognosis regarding functional outcome, whether measuring return to work or return to sport. Much research is now focused on finding a treatment solution for articular injury in young patients. Many surgeons are now performing ACL reconstruction in conjunction with other procedures in an attempt to halt or prevent articular damage. ACL reconstruction is now commonly performed along with high tibial osteotomy, and the results are promising⁴. Possibly, meniscal transplants in conjunction with ACL reconstruction might help to diminish the number of patients who are in need of joint replacement at a young age. Autologous cartilage implantation is a promising new procedure for selected lesions in young patients who wish to avoid or delay more aggressive intervention.

This study gives us a further understanding of the natural history of ACL injury with and without concomitant damage to other knee structures, such as articular cartilage and menisci. How these factors affect outcome will vary with the particular patient population and the means by which outcome is determined (return to sport or return to work). Regardless of treatment, injury to a major weight-bearing joint in young patients results in a threefold increase in the prevalence of osteoarthritis later in life⁵. Damage to the articular cartilage seems to be a negative predictor regardless of patient population and outcome measure, and if this injury can be addressed, the risk of arthritis may be substantially decreased. Therefore, patients should be counseled regarding articular injury and its effect on outcome. As research continues and longer follow-up is available, we should be able to provide our patients with alternative treatments that will improve the functional outcome.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Drongowski RA, Coran AG, Wojtys EM. Predictive value of meniscal and chondral injuries in conservatively treated anterior cruciate ligament injuries. Arthroscopy. 1994;10:97-102.
2. McDaniel WJ Jr, Dameron TB JR. The untreated anterior cruciate ligament rupture. Clin Orthop. 1983;172:158-63.
3. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983;65:163-74.
4. Williams RJ 3rd, Kelly BT, Wickiewicz TL, Altchek DW, Warren RF. The short-term outcome of surgical treatment for painful varus arthritis in association with chronic ACL deficiency. J Knee Surg. 2003;16:9-16.
5. Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ. Joint injury in young adults and risk for subsequent knee and hip osteoarthitis. Ann Intern Med. 2000;133:321-8.