Anterior Cruciate Ligament Tears: Impact of Delayed Presentation on Intra-Articular Injuries

Abstract

Objectives:Chronic anterior cruciate ligament (ACL) injury is associated with increased risk for meniscal and chondral injuries. The purpose of this study was to examine what intra-articular injuries occur related to the cartilage and meniscus in the setting of chronic ACL deficiency.Methods:A cross-sectional cohort study was conducted using a retrospective chart review for all patients who sustained an ACL injury and underwent reconstruction from January 1, 2009 to May 14, 2015. Demographic variables were age, gender, and BMI (Body Mass Index). Additionally, days from injury to surgery, presence of meniscus tears and presence of articular cartilage injury were recorded. Data was analyzed to determine the association between delay of surgery and cartilage or meniscus injury as well as gender, BMI and age at the time of surgery.Results:410 patients were included in this study. The average age was 27 ± 8.8 years (range of 14-59 years). 58.5% of patients had a BMI >25. 70.5% of the patients were male. 27.3% of patients were treated within 3 months of injury, 23.6% between 3-6 months, 18% between 6-12 months, 24.1% between 12-60 months, and 6.9% >60 months (Table 1). Male gender and older age were significant predictive factors for delaying ACL surgery (P < .01). Male gender was significantly associated with presence of lateral meniscus tear (LMT) (P < .001) and lateral femoral condyle (LFC) injury (P< .01). The 40+ age group was significantly more likely to have an medial femoral condyle (MFC) injury (P < .01), medial tibial plateau (MTP) injury (P < .001), lateral tibial plateau (LTP) injury (P < .01), and patellofemoral (PF) injury (P < .001) as compared to those <20 years old. Patients with BMI >25 were significantly more likely to have an MFC injury (P< .05). There was a significant correlation of medial meniscus tear (MMT) with MFC and MTP injury (P < .001, OR 4.8; P < .05, OR 2.6). There was also a significant correlation of LMT and LTP injury (P < .05, OR 2.0). An increase in the presence of MMT was seen in longer delay to time of surgery (P < .001). When compared to the < 3 months group, the 6 to < 12 months group (OR 2.1), the 12 to < 60 months group (OR 4.2) and the 60 months or greater group (OR 6.2) were more likely to have a MMT. A similar trend was seen with MFC injury (P < .001) in the 6 to < 12 months group (OR 2.7), the 12 to < 60 months group (OR 3.1), and the 60 months or greater group (OR 8.3). Presence of LTP injury and LFC injury was also significantly increased with surgical delay, but this association did not occur until 12 to < 60 months (P < .05; OR 5.6) and 60 months or greater (P < .001; OR 21.5) (Figure 1).Conclusion:Delaying ACL surgery for 6 months or longer is associated with an increased presence of medial meniscus tears and chondral injury (MFC, LFC, and LTP), with increased incidence in longer delays. This data supports not delaying surgery more than 6 months following an ACL tear to prevent the incidence of secondary meniscus tears and articular cartilage injury. In addition, particular attention should be paid to those who are older age and male gender as they are at increased risk for more severe cartilage and meniscal injuries.Table 1.Demographic Factors and Associated Meniscal and Chondral Injuries Identified in Surgerya BMIAge (years)Gender <2525 to <3030+<2020 to <3030 to <4040+MaleFemale MMT 69/138 (50.0)98/167 (58.7)46/73 (63.0)39/77 (50.6)101/187 (54.0)64/104 (61.5)27/40 (67.5) P=NS166/288 (57.6)66/121 (54.5) P=NS LMT 75/138 (54.3)98/167 (58.7)49/73 (67.1) P=NS49/77 (63.6)119/188 (63.3)58/104 (55.8)15/40 (37.5) OR, 0.3 P < 0.5187/289 (64.7) OR, 2.354/121 (44.6) P < .001 MFC Injury 25/138 (18.1)53/167 (31.7) OR, 2.122/73 (30.1) OR, 1.9 P < .0512/77 (15.6)47/188 (25.0)33/104 (31.7) OR, 2.519/40 (47.5) OR, 4.9 P < .0172/289 (24.9)40/121 (33) P=NS LFC Injury 8/138 (5.8)22/167 (13.2)9/73 (12.3) P=NS1/76 (1.3)26/188 (13.8)11/104 (10.6)2/40 (5.0) P=NS35/288 (12.1) OR, 3.25/121 (4.1) P < .05 MTP Injury 2/137 (1.5)12/167 (7.2)5/72 (6.9) P=NS1/76 (1.3)4/187 (2.1)6/104 (5.8)10/40 (25.0) OR, 25.0 P < .00119/288 (6.6)2/118 (1.7) P=NS LTP Injury 13/138 (9.4)20/167 (12.0)11/73 (15.1) P=NS2/76 (2.6)18/188 (9.6)19/104 (18.3) OR, 8.38/40 (20.0) OR, 9.2 P < .0131/288 (10.8)16/121 (13.2) P = NS PF Injury 22/138 (15.9)35/167 (21.0)21/73 (28.8) P=NS5/77 (6.5)17/188 (9.0)35/104 (33.7) OR, 7.325/40 (62.5) OR, 24.0 P < .00155/289 (19)27/121 (22.3) P=NS aValues are expressed as n (%). P < .05 considered statistically significant, OR, odds ratio; NS, not significant, OR listed for groups significantly different from comparison group. Female gender was used as the comparison group for gender.