Knee Osteoarthritis Following Anterior Cruciate Ligament Reconstruction: Frequency, Contributory Elements, and Recent Interventions to Modify the Route of Degeneration



Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain


Half of the individuals who experience an anterior cruciate ligament reconstruction (ACLR) suffer from knee
osteoarthritis (OA) 12–14 years later. Elements that make a contribution to the appearance of OA following ACLR
are anomalous anterior tibial displacement and anomalous tibial rotation in the course of the stance phase of walking
(exhibited in 85% of operated knees). Individuals who undergo an early ACLR (5 days on average following anterior
cruciate ligament [ACL] breakage) have an inferior frequency of radiographically apparent tibiofemoral OA at 32–37
years of follow-up than individuals with ACL who did not experience the procedure. Nevertheless, the percentage of
symptomatic OA, radiographically apparent patellofemoral OA and knee symptoms are alike in both groups. At 15
years of follow-up, 23% of knees that experienced an anatomic ACLR suffer from OA, while this percentage augments
to 44% if the ACLR was non-anatomic. Knees of individuals who experience ACLR need total knee arthroplasty at an
earlier age than healthy knees. Intra-articular injections of interleukin-1 receptor antagonist and corticosteroids may
reduce the peril of OA after ACLR.
Level of evidence: III


  1. Cheung EC, DiLallo M, Feeley BT, Lansdown DA. Osteoarthritis and ACL reconstruction—myths and risks. Curr Rev Musculoskelet Med .2020; 13(1):115-22. doi: 10.1007/s12178-019-09596-w.
  2. Carbone A, Rodeo S. Review of current understanding of posttraumatic osteoarthritis resulting from sports injuries. J Orthop Res. 2017; 35(3):397-405. doi: 10.1002/jor.23341.
  3. Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee. 2006; 13(3):184-88. doi: 10.1016/j.knee.2006.01.005.
  4. Haddad F, Oussedik S. Cruciate ligament reconstruction. Hosp Med. 2004; 65(7):412-7. doi: 10.12968/hosp.2004.65.7.15459.
  5. Lohmander LS, Östenberg A, Englund M, Ross H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004; 50(10):3145-52. doi: 10.1002/art.20589.
  6. Barenius B, Ponzer S, Shalabi A, Bujak R, Norlén L, Eriksson K. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: A 14-year follow-up study of a randomized controlled trial. Am J Sports Med. 2014; 42(5):1049-57. doi: 10.1177/0363546514526139.
  7. Rodriguez-Merchan EC, Duran D, Revilla C, Gomez-Cardero P, Martinez-Lloreda A, Bello S. Arthroscopic BPTB graft reconstruction in ACL ruptures: 15-year results and survival. Knee. 2014; 21(5):902-5. doi: 10.1016/j.knee.2014.07.004.
  8. Rodriguez-Merchan EC. Evidence-based ACL reconstruction. Arch Bone Jt Surg. 2015; 3(1):9-12.
  9. Samitier G, Marcano AI, Alentorn-Geli E, Cugat R, Farmer KW, Moser MW. Failure of anterior cruciate ligament reconstruction. Arch Bone Jt Surg. 2015; 3(4):220-40.
  10. Tahami SM, Rad SM. Outcome of ACL reconstruction and concomitant articular injury treatment. Arch Bone Jt Surg. 2015; 3(4):260-3.
  11. Shervegar S, Nagaraj P, Grover A, Dj NG, Ravoof A. Functional outcome following arthroscopic ACL reconstruction with rigid fix: A retrospective observational study. Arch Bone Jt Surg. 2015; 3(4):264-8.
  12. Rahnemai-Azar AA, Sabzevari S, Irarrázaval S, Chao T, Fu FH. Restoring nature through individualized anatomic anterior cruciate ligament reconstruction surgery. Arch Bone Jt Surg. 2016; 4(4):289-90.
  13. Rahnemai-Azar AA, Sabzevari S, Irarrázaval S, Chao T, Fu FH. Anatomical individualized ACL reconstruction. Arch Bone Jt Surg. 2016; 4(4):291-7.
  14. Kazemi SM, Abbasian MR, Esmailijah AA, et al. Comparison of clinical outcomes between different femoral tunnel positions after anterior cruciate ligament reconstruction surgery. Arch Bone Jt Surg. 2017; 5(6):419-25.
  15. Mousavi H, Mohammadi M, Aghdam HA. Injury to the infrapatellar branch of the saphenous nerve during ACL reconstruction with hamstring tendon autograft: A comparison between oblique and vertical incisions. Arch Bone Jt Surg. 2018; 6(1):52-6.
  16. Shahpari O, FallahKezabi M, Kalati HH, Bagheri F, Ebrahimzadeh MH. Clinical Outcome of anatomical transportal arthroscopic anterior cruciate ligament reconstruction with hamstring tendon autograft. Arch Bone Jt Surg. 2018; 6(2):130-9.
  17. Yazdi H, Yousof Gomrokchi A, Nazarian A, Lechtig A, Hanna P, Ghorbanhoseini M. The effect of gentamycin in the irrigating solution to prevent joint infection after anterior cruciate ligament (ACL) reconstruction. Arch Bone Jt Surg. 2019; 7(1):67-74.
  18. Hadi H, Bagherifar A, Tayebi F, et al. Anterior cruciate ligament reconstruction with hamstring tendons has no deleterious effect on hip extension strength. Arch Bone Jt Surg. 2019; 7(3):278-83.
  19. Keyhani S, Esmailiejah AA, Mirhoseini MS, Hosseininejad SM, Ghanbari N. the prevalence, zone, and type of the meniscus tear in patients with anterior cruciate ligament (ACL) injury: Does delayed ACL reconstruction affects the meniscal injury? Arch Bone Jt Surg. 2020; 8(3):432-8. doi: 10.22038/abjs.2019.39084.2076.
  20. Suomalainen P, Järvelä S, Paakkala A, Kannus P, Järvinen M. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective randomized study with 5-year results. Am J Sports Med. 2012; 40(7):1511-8. doi: 10.1177/0363546512448177.
  21. Louboutin H, Debarge R, Richou J, et al. Osteoarthritis in patients with anterior cruciate ligament rupture: A review of risk factors. Knee. 2009; 16(4):239-244. doi: 10.1016/j.knee.2008.11.004.
  22. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010; 363(4):331-342. doi: 10.1056/NEJMoa0907797.
  23. Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: A systematic review. Am J Sports Med. 2009; 37(7):1434-43. doi: 10.1177/0363546509338827.
  24. Kumar D, Su F, Wu D, et al. Frontal plane knee mechanics and early cartilage degeneration in people with anterior cruciate ligament reconstruction: a longitudinal study. Am J Sports Med. 2018; 46(2):387-78. doi: 10.1177/0363546517739605.
  25. Seon JK, Song EK, Park SJ. Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop. 2006; 30(2):94-8. doi: 10.1007/s00264-005-0036-0.
  26. Hannan MT, Felson DT, Pincus T. Analysis of the discordance between radiographic changes and knee pain in osteoarthritis of the knee. J Rheumatol. 2000; 27(6):1513-7.
  27. Barker K, Lamb SE, Toye F, Jackson S, Barrington S. Association between radiographic joint space narrowing, function, pain and muscle power in severe osteoarthritis of the knee. Clin Rehabil. 2004; 18(7):793-800. doi: 10.1191/0269215504cr754oa.
  28. Szebenyi B, Hollander AP, Dieppe P, et al. Associations between pain, function, and radiographic features in osteoarthritis of the knee. Arthritis Rheum. 2006; 54(1):230-5. doi: 10.1002/art.21534.
  29. Øiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med. 2011; 45(7):583-8. doi: 10.1136/bjsm.2010.073130.
  30. Brophy RH, Gray BL, Nunley RM, Barrack RL, Clohisy JC. Total knee arthroplasty after previous knee surgery: expected interval and the effect on patient age. J Bone Jt Surg. 2014; 96(10):801-5. doi: 10.2106/JBJS.M.00105.
  31. Zaid M, Lansdown D, Su F, et al. Abnormal tibial position is correlated to early degenerative changes one year following ACL reconstruction. J Orthop Res. 2015; 33(7):1079-86. doi: 10.1002/jor.22867.
  32. Scanlan SF, Chaudhari AMW, Dyrby CO, Andriacchi TP. Differences in tibial rotation during walking in ACL reconstructed and healthy contralateral knees. J Biomech. 2010; 43(9):1817-22. doi: 10.1016/j.jbiomech.2010.02.010.
  33. Reider B, Arcand MA, Diehl LH, et al. Proprioception of the knee before and after anterior cruciate ligament reconstruction. Arthroscopy 2003; 19(1):2–12. doi: 10.1053/jars.2003.50006.
  34. Ageberg E, Thomeé R, Neeter C, Silbernagel KS, Roos EM. Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year followup. Arthritis Rheum. 2008; 59(12):1773-9. doi: 10.1002/art.24066.
  35. Brewer BW, Cornelius AE, Sklar JH, et al. Pain and negative mood during rehabilitation after anterior cruciate ligament reconstruction: a daily process analysis. Scand J Med Sci Sport. 2007; 17(5):520-9. doi: 10.1111/j.1600-0838.2006.00601.x.
  36. Di Stasi SL, Logerstedt D, Gardinier ES, Snyder-Mackler L. Gait patterns differ between ACL-reconstructed athletes who pass return-to-sport criteria and those who fail. Am J Sports Med. 2013; 41(6):1310-8. doi: 10.1177/0363546513482718.
  37. Kramer WC, Hendricks KJ, Wang J. Pathogenetic mechanisms of posttraumatic osteoarthritis: opportunities for early intervention. Int J Clin Exp Med. 2011; 4(4):285-98.
  38. Irie K, Uchiyama E, Iwaso H. Intraarticular inflammatory cytokines in acute anterior cruciate ligament injured knee. Knee. 2003; 10(1): 93-6. doi: 10.1016/s0968-0160(02)00083-2.
  39. Haslauer CM, Elsaid KA, Fleming BC, Proffen BL, Johnson VM, Murray MM. Loss of extracellular matrix from articular cartilage is mediated by the synovium and ligament after anterior cruciate ligament injury. Osteoarthritis Cartilage 2013; 21(12):1950-7. doi: 10.1016/j.joca.2013.09.003.
  40. D’Lima DD, Hashimoto S, Chen PC, Colwell Jr CW, Lotz MK. Human chondrocyte apoptosis in response to mechanical injury. Osteoarthritis Cartilage 2001; 9(8):712-9. doi: 10.1053/joca.2001.0468.
  41. Edd SN, Giori NJ, Andriacchi TP. The role of inflammation in the initiation of osteoarthritis after meniscal damage. J Biomech. 2015; 48(8):1420-6. doi: 10.1016/j.jbiomech.2015.02.035.
  42. Harkey MS, Luc BA, Golightly YM, et al. Osteoarthritis-related biomarkers following anterior cruciate ligament injury and reconstruction: a systematic review. Osteoarthritis Cartilage 2015; 23(1):1-12. doi: 10.1016/j.joca.2014.09.004.
  43. Wei L, Fleming BC, Sun X, et al. Comparison of differential biomarkers of osteoarthritis with and without posttraumatic injury in the Hartley guinea pig model. J Orthop Res. 2010; 28(7):900-6. doi: 10.1002/jor.21093.
  44. Yang KGA, Saris DBF, Verbout AJ, Creemers LB, Dhert WJA. The effect of synovial fluid from injured knee joints on in vitro chondrogenesis. Tissue Eng. 2006; 12(10):2957-64. doi: 10.1089/ten.2006.12.2957.
  45. Marks PH, Donaldson MLC. Inflammatory cytokine profiles associated with chondral damage in the anterior cruciate ligament deficient knee. Arthroscopy 2005; 21(11):1342-7. doi: 10.1016/j.arthro.2005.08.034.
  46. Kraus VB, Birmingham J, Stabler TV, et al. Effects of intraarticular IL1-Ra for acute anterior cruciate ligament knee injury: a randomized controlled pilot trial (NCT00332254). Osteoarthritis Cartilage 2012; 20(4):271-8. doi: 10.1016/j.joca.2011.
  47. Lattermann C, Jacobs CA, Bunnell MP, et al. A multicenter study of early anti-inflammatory treatment in patients with acute anterior cruciate ligament tear. Am J SportsMed. 2016; 45(2):325-33. doi: 10.1177/0363546516666818.
  48. Falah M, Nierenberg G, Soudry M, Hayden M, Volpin G. Treatment of articular cartilage lesions of the knee. Int Orthop. 2010; 35(5):621-30. doi: 10.1007/s00264-010-0959-y.
  49. Ichiba A, Kishimoto I. Effects of articular cartilage and meniscus injuries at the time of surgery on osteoarthritic changes after anterior cruciate ligament reconstruction in patients under 40 years old. Arch Orthop Trauma Surg. 2009; 129(3):409-15. doi: 10.1007/s00402-008-0786-4.
  50. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med. 2010; 38(3):455-63. doi: 10.1177/0363546509350914.
  51. Brophy RH, Zeltser D, Wright RW, Flanigan D. Anterior cruciate ligament reconstruction and concomitant articular cartilage injury: incidence and treatment. Arthroscopy 2010; 26(1):112-20. doi: 10.1016/j.arthro.2009.09.002.
  52. Potter HG, Jain SK, Ma Y, Black BR, Fung S, Lyman S. Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up. Am J Sports Med. 2012; 40(2):276-85. doi: 10.1177/0363546511423380.
  53. Granan LP, Inacio MCS, Maletis GB, Funahashi TT, Engebretsen L. Intraoperative findings and procedures in culturally and geographically different patient and surgeon populations: an anterior cruciate ligament reconstruction registry comparison between Norway and the USA. Acta Orthop. 2012; 83(6):577-82. doi: 10.3109/17453674.2012.741451.
  54. Ahldén M, Samuelsson K, Sernert N, M Forssblad, Karlsson J, Kartus J. The Swedish national anterior cruciate ligament register: a report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med. 2012; 40(10):2230-5. doi: 10.1177/0363546512457348.
  55. Hagino T, Ochiai S, Senga S, et al. Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg. 2015; 135(12):1701-6. doi: 10.1007/s00402-015-2309-4.
  56. Kamatsuki Y, Furumatsu T, Fujii M, et al. Complete tear of the lateral meniscus posterior root is associated with meniscal extrusion in anterior cruciate ligament deficient knees. J Orthop Res. 2018; 36(7):1894-900. doi: 10.1002/jor.23861.
  57. Chung KS, Ha JK, Yeom CH, et al. Comparison of clinical and radiologic results between partial meniscectomy and refixation of medial meniscus posterior root tears: a minimum 5-year follow-up. Arthroscopy 2015; 31(10):1941-50. doi: 10.1016/j.arthro.2015.03.035.
  58. Starman JS, Vanbeek C, Armfield DR, et al. Assessment of normal ACL double bundle anatomy in standard viewing planes by magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):493-9. doi: 10.1007/s00167-006-0266-8.
  59. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA, LaPrade RF. Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored with in situ pull-out suture repairs. J Bone Jt Surg. 2014; 96(6):471-9. doi: 10.2106/JBJS.L.01252.
  60. Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17-20 years. Int Orthop. 2011; 35(7):1093-7. doi: 10.1007/s00264-011-1206-x.
  61. Meuffels DE, FavejeeMM, VissersMM, Heijboer MP, Reijman M, Verhaar JAN. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sport Med. 2009; 43(5):347-51. doi: 10.1136/bjsm.2008.049403.
  62. Chalmers PN, Mall NA, Moric M, et al. Does ACL reconstruction alter natural history? A systematic literature review of long-term outcomes. J Bone Jt Surg. 2014; 96(4):292-300. doi: 10.2106/JBJS.L.01713.
  63. Jomha NM, Borton DC, Clingeleffer AJ, Pinczewski LA. Long-term osteoarthritic changes in anterior cruciate ligament reconstructed knees. Clin Orthop Relat Res. 1999 ;( 358):188-93.
  64. Harris K, Driban JB, Sitler MR, Cattano NM, Hootman JM. Five year clinical outcomes of a randomized trial of anterior cruciate ligament treatment strategies: an evidence-based practice paper. J Athl Train. 2015; 50(1):110-2. doi: 10.4085/1062-6050-49.3.53.
  65. Sanders TL, Kremers HM, Bryan AJ, et al. Is anterior cruciate ligament reconstruction effective in preventing secondary meniscal tears and osteoarthritis? Am J Sports Med. 2016; 44(7):1699-707. doi: 10.1177/0363546516634325.
  66. de Campos GC, NeryW, Teixeira PEP, Araujo PH, de Mello Alves Jr W. Association between meniscal and chondral lesions and timing of anterior cruciate ligament reconstruction. Orthop J Sport Med. 2016; 4(10):2325967116669309. doi: 10.1177/ 2325967116669309.
  67. Patterson B, Culvenor AG, Barton CJ, et al. Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression. Br J Sports Med 2020; 54(9):546-55. doi: 10.1136/bjsports-2019-101503.
  68. Kvist J, Filbay S, Andersson C, Ardern CL, Gauffin H. Radiographic and symptomatic knee osteoarthritis 32 to 37 years after acute anterior cruciate ligament rupture. Am J Sports Med. 2020; 48(10):2387-94. doi: 10.1177/0363546520939897.
  69. Rothrauff BB, Jorge A, de Sa D, Kay J, Fu FH, Musahl V. Anatomic ACL reconstruction reduces risk of post-traumatic osteoarthritis: A systematic review with minimum 10-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2020; 28(4):1072-84. doi: 10.1007/s00167-019-05665-2.
  70. Söderman T, Wretling ML, Hänni M, et al. Higher frequency of osteoarthritis in patients with ACL graft rupture than in those with intact ACL grafts 30 years after reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020; 28(7):2139-46. doi: 10.1007/s00167-019-05726-6.
  71. Bodkin SG, Werner BC, Slater LV, Hart JM. Post-traumatic osteoarthritis diagnosed within 5 years following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020; 28(3):790-6. doi: 10.1007/s00167-019-05461-y.
  72. Curado J, Hulet C, Hardy P, et al. Very long-term osteoarthritis rate after anterior cruciate ligament reconstruction: 182 cases with 22-year’follow- Orthopaedics & Traumatology: Surgery & Research. 2020; 106(3):459-63. doi: 10.1016/j.otsr.2019.09.034.