Abstract
We read with interest the recent systematic review by Shah et al 4 on the long-term radiographic outcomes of chronically anterior cruciate ligament (ACL)–deficient knees. It is a relevant and well-executed study that addresses a question we frequently encounter in practice: whether ACL reconstruction truly changes the long-term risk of osteoarthritis (OA).
One of the main takeaways is the similar rate of radiographic OA between ACL-deficient and ACL-reconstructed groups. This is consistent with prior reports suggesting that the initial injury may be more important than the treatment itself in terms of driving degeneration. 1,2 Still, we think that a few points deserve more attention.
First, the issue of meniscal status seems central. Although it is mentioned in the article, this issue may actually explain a large part of the findings. Across studies, meniscectomy is repeatedly associated with worse outcomes, 4 which matches what many of us see in daily practice. This finding is also supported by biomechanical evidence showing the key role of the meniscus in stabilizing the ACL-deficient knee. 3 In that sense, differences between treatment strategies could be less about reconstruction itself and more about how often patients end up with secondary meniscal damage over time.
Second, relying on radiographic OA as the main outcome has its limitations. These classifications tend to reflect relatively late disease. Earlier changes—cartilage damage or subchondral alterations—may not be captured, which makes it harder to detect differences between groups, especially in younger patients.
Third, from our experience in a tertiary referral center in a middle-income setting, questions arise about how broadly the results apply. In many cases, patients arrive late, access to early surgery is not always straightforward, and rehabilitation is variable. All of these factors can increase the risk of meniscal injury along the way and may influence long-term outcomes more than the initial treatment decision.
Fourth, the increase in OA after 10 years is a reminder that this is a long process. It probably makes sense to think beyond reconstruction versus nonoperative care and focus more on joint preservation early on—especially protecting the meniscus when possible.
Overall, the study by Shah et al 4 adds valuable data but also highlights that long-term outcomes are shaped by more than a single intervention. Factors such as meniscal integrity, timing of care, and access to treatment likely play a key role and deserve further study.
