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If you have a torn ACL and damage to the joint cartilage, should you have both repaired at the same time? Or do one and then have the other fixed later?

You have asked the very same question that has come to light recently in a study from Poland. When surgeons are reconstructing the anterior cruciate ligament (ACL) of the knee, they often see damage to the joint surface. The area affected is called the articular cartilage. This is the cartilage that covers the joint and makes it possible for the two sides of the joint to slide and glide smoothly across each other. There is a question about whether or not surgeons should go ahead and repair these cartilage (chondral) lesions. Does it make a difference in the results of the ACL repair? Maybe it doesn't matter and it's best to leave these defects alone. We just don't know yet which approach is best. In this study, surgeons compared results between two groups of ACL patients: those with a chondral defect and those without. The patients with just an ACL rupture but no chondral damage were considered the control group. Patients in the two groups were matched by age, sex, and type of chondral injury. In terms of the cartilage injury, each patient had one defect rated as a grade 3 or 4 -- that's moderate-to-severe. Everyone in both groups was treated the same way. First they saw a physical therapist for a preoperative program of rehabilitation. Then, the surgeon reconstructed the ruptured ligament using a bone-tendon-bone graft. This means they took a piece of tendon from some other area of the leg and used it to replace the damaged ACL. Then everyone went back to rehab after surgery. They all completed the same program of exercises. The cartilage lesion was not repaired and no special measures were taken to rehab differently because of the chondral lesion. Everyone was followed for 10 to 15 years to see what the long-term differences might be between the two groups. The authors were unable to see a measurable difference between the two groups. The location of the lesion didn't seem to change anyones' function after surgery. X-ray findings weren't significantly different between the two groups. And tests of function using the International Knee Documentation Committee (IKDC) scores showed no major differences from one group to the other. They concluded that deep cartilage defects that occur along with ACL rupture can be left alone. Treating them or not treating them does not give better results. And these lesions don't seem to contribute to further joint damage or degeneration. The authors did say they would like to see more studies in this area before throwing the towel in on chondral lesions. It's possible that some other (as yet unidentified) factor is important in the treatment decision about chondral lesions. Perhaps if we found a better way to treat the chondral lesions, the results would be improved.


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