2025 ISAKOS Biennial Congress ePoster
Elevated Risk of Patellofemoral Osteoarthritis Following ACL Reconstruction in Overweight Patients: A Systematic Review and Meta-Analysis of Surgical versus Contralateral Knees and Healthy Controls
Domenico Franco, MD, Altomonte, Cosenza ITALY
Alexander Bumberger , MD, Ottensheim AUSTRIA
Chilan Leite, MD, PhD, Boston, MA UNITED STATES
Sebastian Schmidt, MD, Mannheim GERMANY
Cale A. Jacobs, PhD, Lexington, KY UNITED STATES
Rocco Papalia, Prof, Rome ITALY
Vincenzo Denaro, Rome ITALY
Christian Lattermann, MD, Foxborough, MA UNITED STATES
Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 20 Patriot Place Foxboro, Boston, Massachusetts, UNITED STATES
FDA Status Not Applicable
Summary
Patients undergoing ACL reconstruction (ACL-R) are significantly more likely to develop patellofemoral osteoarthritis particularly if their BMI exceeds 25 kg/m², while graft choice (BPTB vs. Hamstring) shows no significant impact; these findings underscore the need for tailored strategies to reduce PFOA risk in overweight patients after ACL-R.
ePosters will be available shortly before Congress
Abstract
Background
Patellofemoral osteoarthritis (PFOA) is a debilitating condition that is frequently observed in patients after anterior cruciate ligament reconstruction (ACL-R). However, the literature on the association of ACL-R and PFOA has been inconclusive overall. A comprehensive understanding of this relationship is crucial for improving individual clinical decision-making following ACL injury, particularly considering the potential detrimental effects on patellofemoral joint degeneration.
Objective
to evaluate the association between ACL-R and PFOA. We hypothesized that patients who underwent ACL-R are more likely to develop PFOA than those in control groups. Additionally, we examined the role of body mass index (BMI) in PFOA following ACL-R and whether graft choice affects PFOA progression.
Methods
A systematic literature search including PubMed/MEDLINE, Embase, and Scopus was performed on July 1st, 2024. Controlled studies reporting on radiographic or magnetic resonance imaging (MRI) outcomes of the patellofemoral joint following primary ACL-R vs contralateral knees and healthy controls were considered for inclusion. Studies were excluded if patients had concomitant ligamentous or chondral injuries requiring surgical treatment due to their potential confounding effect on postoperative outcomes. Random effects model meta-analysis was performed to assess if primary ACL-R was associated with a higher likelihood of PFOA compared to control knees. The chi-square was used to analyze if a BMI exceeding 25 kg/m2 significantly increased the risk of developing PFOA in the operated knee. A Sub-analysis was performed to assess if bone patellar tendon bone (BPTB) autograft was associated with an higher chance of PFOA than hamstring (HT) autografts. A meta-regression was used to determine if the sample size, mean time of follow-up and population ages confounded the results. The Modified Coleman Methodology Score was used to assess the internal validity of the included studies. The study protocol was registered in the PROSPERO database (ID: CRD42024571939).
Results
A total of 12 studies met the inclusion criteria and were included in this review. Seven studies compared ACL-R to contralateral knees and 1 study compared ACL-R against healthy controls. Three studies considered both contralateral knees and healthy patients as control groups. Moreover, 1 article has included both ACL injury patients and contralateral knee as controls. The pooled follow-up period was 5.3 years (range: 1 to 17.8 years). Nine studies comparing the radiographic or MRI outcomes of ACL-R with a control population were included in the meta-analysis. Patients undergoing ACL-R demonstrated a significantly higher likelihood of PFOA compared to contralateral knees (OR = 5.60; 95% CI: 2.67 - 11.75; p=0.01). Interestingly, a BMI > 25kg/m2 was significantly associated with PFOA (p=0.009). The use of BPTB or HT autografts did not show statistically significant differences in the likelihood of PFOA after ACL-R (p=0.77). The meta-regression revealed a statistically significant association with sample size. Conversely, follow-up time and mean age did not appear to have an influential effect.
Conclusions
This study demonstrated that patients undergoing ACL-R have a higher likelihood of PFOA than control knees. Notably, the analysis showed that BMI greater than 25kg/m2 was a significant modifiable risk factor in the development of PFOA after ACL-R. Finally, the sub-analysis comparing BPTB and HT autografts highlights no significant difference. These findings raise concerns about a potential detrimental effect of ACL-R regarding patellofemoral joint degeneration, especially in overweight patients. Future strategies are essential to mitigate the individual risk of PFOA following ACL-R.
Level of evidence: Systematic review and meta-analysis of level II and III studies.