Impact of Anterior Cruciate Ligament Status on Early Satisfaction and Clinical Outcomes Following Total Knee Arthroplasty
While total knee arthroplasty (TKA) is a successful treatment for debilitating arthritis, up to 20% of patients may be dissatisfied with their outcome. One hypothesis for dissatisfaction is the distortion of native knee kinematics following sacrifice of the anterior cruciate ligament (ACL) during TKA. The purpose of this study was to determine the impact of ACL status at the time of surgery in patients undergoing Posterior Stabilized (PS) TKA for osteoarthritis (OA).
A consecutive prospective series of patients undergoing TKA by a single surgeon underwent prospective intraoperative assessment of their ACL status divided into three different groups:1) intact, 2) attenuated, or 3) deficient. Demographic, preoperative, intraoperative, and postoperative data were collected for each patient by two blinded, independent observers. Outcomes included patient satisfaction and Knee Society Score for Pain (KSS) and Function (KSF), Kellgren and Lawrence (K&L), UCLA Activity Score (UCLA), Short Form-12 (SF12), EuroQol (EQ5D) and patient satisfaction.
Of 116 patients, 33 (28.4%) patients had an ACL deficient knee, 40 (34.5%) patients had an attenuated ACL, and 43 (37.1%) patients had an intact ACL. Those with absent ACL were significantly more likely to have a higher BMI (p=.007) and be male (p=.003). Patient with a deficient ACL had significantly lower preoperative KSF and higher K&L scores (p=.009, p=1.26 x 10-7). Attenuated and deficient groups had the greatest change in SF12PCS scores at their one-year follow-up with increases of 9.9 (±10.0) and 10.8 (±8.0), respectively (p=.037). No significant differences in overall postoperative KSS, KSF and satisfaction scores based on ACL status (p=.574 and p=.529, respectively) were found.
In a relatively large series, patient with ACL deficiency were more likely to have worse pre-operative outcome scores and similar or better post-operative outcome scores. This suggests that those with ACL insufficiency may experience more subjective improvement from TKA. ACL status can be used as an additional surgical marker to help orthopaedic surgeons identify which patients would most benefit from TKA.
Argenson JN, Boisgard S, Parratte S, et al. Survival analysis of total knee arthroplasty at a minimum 10 years’ follow-up: a multicenter French nationwide study including 846 cases. Orthop Traumatol Surg Res 2013;99(4):385.
Barrington JW, Sah A, Malchau H, et al. Contemporary cruciate-retaining total knee arthroplasty with a pegged tibial baseplate results at a minimum of ten years. J Bone Joint Surg Am 2009;91(4):874.
Berend, ME. ACL damage and deficiency is associated with more severe preoperative deformity, lower range of motion at the time of TKA. 2016; 12(3): 235-239.
Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010;468(1):57.
Cushner FD, La Rosa DF, Vigorita VJ, et al. A quantitative histologic comparison: ACL degeneration in the osteoarthritic knee. J Arthroplasty. 2003; 18(6): 687-92.
Hill CL, Seo GS, Gale D, et al. Cruciate ligament integrity in osteoarthritis of the knee. Arthritis Rheum. 2005; 52(3): 794-9.
Johnson AJ, Howell SM, Costa CR, et al. The ACL in the arthritic knee: how often is it present and can preoperative tests predict its presence? Clin Orthop Relat Res. 2013; 471(1): 181-8.
Komistek RD, Allain J, Anderson DT, Dennis DA, Goutallier D. In vivo kinematics for subjects with and without an anterior cruciate ligament. Clin Orthop Relat Res. 2002;404:315–325.
Lee GC, Cushner FD, Vigoritta V, et al. Evaluation of the anterior cruciate ligament integrity and degenerative arthritic patterns in patients undergoing total knee arthroplasty. J Arthroplasty. 2005; 20(1): 59-65.
Metsovitis SR, Ploumis AL, Chantzidis PT, et al. Rotaglide total knee arthroplasty: a long- term follow-up study. J Bone Joint Surg Am 2011;93(9):878.
Mont MA, Elmallah, RK, Cherian JJ, et al. Histopathological Evaluation of Anterior Cruciate Ligament in Patients Undergoing Primary Total Knee Arthroplasty. The Journal of Arthroplasty 2015pii: S0883-5403(15)00610-5
Mullaji AB, Marawar SV, Luthra M. Tibial articular cartilage wear in varus osteoarthritic knees: correlation with anterior cruciate ligament integrity and severity of deformity. J Arthroplasty. 2008; 23(1): 128-35.
NRJ. National Joint Registry. National Joint Registry for England and Wales: 11th Annual Report; 2017.
Sabouret P, Lavoie F, Cloutier JM. Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study. The Bone & Joint Journal 2013;95-B(7):917-922.
Schmidt R, Komistek RD, Blaha JD, Penenberg BL, Maloney WJ. Fluoroscopic analyses of cruciate-retaining and medial pivot knee implants. Clin Orthop Relat Res. 2003;410:139–147.
Stiehl JB, Komistek RD, Cloutier JM, Dennis DA. The cruciate ligaments in total knee arthroplasty: a kinematic analysis of 2 total knee arthroplasties. Journal of Arthroplasty 2000 Aug;15(5):545-550
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