The purpose of this systematic review and meta-analysis was to analyze and compare the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction.
Materials and methods
A systematic search for articles comparing the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction was performed. PubMed central was the database used for the literature review.
Forty articles out of 1836 were included. In 35 trials (88%), there was evidence of a positive correlation between the rate of meniscus and/or cartilage lesions and the time since ACL injury. This correlation was more evident for the medial meniscus in comparison with the lateral meniscus. In particular, a delay of more than 6 months was critical for secondary medial meniscus injuries [risk ratio 0.58 (95% CI 0.44–0.79)] and a delay of more than 12 months was critical for cartilage injuries [risk ratio 0.42 (95% CI 0.29–0.59)]. Additionally, there is evidence that the chance for meniscal repair decreases as the time since ACL rupture increases.
Chronic instability in the ACL-deficient knee is associated with a significant increase of medial meniscus injuries after 6 months followed by a significant increase of cartilage lesions after 12 months.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Ahlen M, Liden M (2011) A comparison of the clinical outcome after anterior cruciate ligament reconstruction using a hamstring tendon autograft with special emphasis on the timing of the reconstruction. Knee Surg Sports Traumatol Arthrosc 19:488–494
Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, Davies A (2014) Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med 42:2242–2252
Anstey DE, Heyworth BE, Price MD, Gill TJ (2012) Effect of timing of ACL reconstruction in surgery and development of meniscal and chondral lesions. Phys Sportsmed 40:36–40
Arastu MH, Grange S, Twyman R (2015) Prevalence and consequences of delayed diagnosis of anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc 23:1201–1205
Atarod M, Frank CB, Shrive NG (2015) Increased meniscal loading after anterior cruciate ligament transection in vivo: a longitudinal study in sheep. Knee 22:11–17
Balasingam S, Sernert N, Magnusson H, Kartus J (2018) Patients with concomitant intra-articular lesions at index surgery deteriorate in their knee injury and osteoarthritis outcome score in the long term more than patients with isolated anterior cruciate ligament rupture: a study from the swedish national anterior cruciate ligament register. Arthroscopy 34:1520–1529
Barenius B, Forssblad M, Engstrom B, Eriksson K (2013) Functional recovery after anterior cruciate ligament reconstruction, a study of health-related quality of life based on the Swedish national knee ligament register. Knee Surg Sports Traumatol Arthrosc 21:914–927
Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA, Pearle AD, Altchek DW (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27:380–390
Brambilla L, Pulici L, Carimati G, Quaglia A, Prospero E, Bait C, Morenghi E, Portinaro N, Denti M, Volpi P (2015) Prevalence of associated lesions in anterior cruciate ligament reconstruction: correlation with surgical timing and with patient age, sex, and body mass index. Am J Sports Med 43:2966–2973
Cartwright N, Munro E (2010) The limitations of randomized controlled trials in predicting effectiveness. J Eval Clin Pract 16:260–266
Chalmers PN, Mall NA, Moric M, Sherman SL, Paletta GP, Cole BJ, Bach BR Jr (2014) Does ACL reconstruction alter natural history?: A systematic literature review of long-term outcomes. J Bone Joint Surg Am 96:292–300
Chen G, Tang X, Li Q, Zheng G, Yang T, Li J (2015) The evaluation of patient-specific factors associated with meniscal and chondral injuries accompanying ACL rupture in young adult patients. Knee Surg Sports Traumatol Arthrosc 23:792–798
Chhadia AM, Inacio MC, Maletis GB, Csintalan RP, Davis BR, Funahashi TT (2011) Are meniscus and cartilage injuries related to time to anterior cruciate ligament reconstruction? Am J Sports Med 39:1894–1899
Church S, Keating JF (2005) Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br 87:1639–1642
Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P (2013) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc 21:1967–1976
Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, Mccarty EC, Spindler KP (2014) Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 42:1058–1067
De Campos GC, Nery W Jr, Teixeira PE, Araujo PH, Alves WM Jr (2016) Association between meniscal and chondral lesions and timing of anterior cruciate ligament reconstruction. Orthop J Sports Med 4:2325967116669309. (eCollection 2325967116662016 Oct)
Domnick C, Garcia P, Raschke MJ, Glasbrenner J, Lodde G, Fink C, Herbort M (2017) Trends and incidences of ligament-surgeries and osteotomies of the knee: an analysis of German inpatient records 2005–2013. Arch Orthop Trauma Surg 137:989–995. d
Edwards DJ, Brown JN, Roberts SN, Paterson RS (2000) Long-term results of anterior cruciate ligament reconstruction using ilio-tibial tract and semitendinosis tendon. Knee 7:87–93
Ercin E, Gokhan Bilgili M, Atbasi Z, Tanriverdi B, Hakan Basaran S, Kural C (2015) Importance of restricting sportive activity and time from injury to surgery in anterior cruciate ligament reconstruction. Open Orthop J 9:427–431. https://doi.org/10.2174/1874325001509010427. (eCollection 1874325001509012015)
Filbay SR, Ackerman IN, Dhupelia S, Arden NK, Crossley KM (2018) Quality of life in symptomatic individuals after anterior cruciate ligament reconstruction, with and without radiographic knee osteoarthritis. J Orthop Sports Phys Ther 48:398–408
Fok AW, Yau WP (2013) Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries. Knee Surg Sports Traumatol Arthrosc 21:928–933
Forkel P, Von Deimling C, Lacheta L, Imhoff FB, Foehr P, Willinger L, Dyrna F, Petersen W, Imhoff AB, Burgkart R (2018) Repair of the lateral posterior meniscal root improves stability in an ACL-deficient knee. Knee Surg Sports Traumatol Arthrosc:4949–4948
Foster A, Butcher C, Turner PG (2005) Changes in arthroscopic findings in the anterior cruciate ligament deficient knee prior to reconstructive surgery. Knee 12:33–35
Frobell RB, Le Graverand MP, Buck R, Roos EM, Roos HP, Tamez-Pena J, Totterman S, Lohmander LS (2009) The acutely ACL injured knee assessed by MRI: changes in joint fluid, bone marrow lesions, and cartilage during the first year. Osteoarthr Cartilage 17:161–167
Frobell RB, Roos HP, Roos EM, Hellio Le Graverand MP, Buck R, Tamez-Pena J, Totterman S, Boegard T, Lohmander LS (2008) The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury? Osteoarthr Cartilage 16:829–836
Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS (2013) Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 346:f232. https://doi.org/10.1136/bmj.f1232
Ghodadra N, Mall NA, Karas V, Grumet RC, Kirk S, Mcnickle AG, Garrido CP, Cole BJ, Bach BR Jr (2013) Articular and meniscal pathology associated with primary anterior cruciate ligament reconstruction. J Knee Surg 26:185–193
Goradia VK, Grana WA (2001) A comparison of outcomes at 2–6 years after acute and chronic anterior cruciate ligament reconstructions using hamstring tendon grafts. Arthroscopy 17:383–392
Granan LP, Bahr R, Lie SA, Engebretsen L (2009) Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the norwegian national knee ligament registry. Am J Sports Med 37:955–961
Gupta R, Masih GD, Chander G, Bachhal V (2016) Delay in surgery predisposes to meniscal and chondral injuries in anterior cruciate ligament deficient knees. Indian J Orthop 50:492–498
Hagino T, Ochiai S, Senga S, Yamashita T, Wako M, Ando T, Haro H (2015) Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg 135:1701–1706
Hollis JM, Pearsall AWT, Niciforos PG (2000) Change in meniscal strain with anterior cruciate ligament injury and after reconstruction. Am J Sports Med 28:700–704
Hur CI, Song EK, Kim SK, Lee SH, Seon JK (2017) Early anterior cruciate ligament reconstruction can save meniscus without any complications. Indian J Orthop 51:168–173
Jacob KM, Oommen AT (2012) A retrospective analysis of risk factors for meniscal co-morbidities in anterior cruciate ligament injuries. Indian J Orthop 46:566–569
Joseph C, Pathak SS, Aravinda M, Rajan D (2008) Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL-deficient athlete and non-athlete population: an Indian experience. Int Orthop 32:57–61
Kennedy J, Jackson MP, O’kelly P, Moran R (2010) Timing of reconstruction of the anterior cruciate ligament in athletes and the incidence of secondary pathology within the knee. J Bone Joint Surg Br 92:362–366
Kluczynski MA, Marzo JM, Bisson LJ (2013) Factors associated with meniscal tears and chondral lesions in patients undergoing anterior cruciate ligament reconstruction: a prospective study. Am J Sports Med 41:2759–2765
Kluczynski MA, Marzo JM, Rauh MA, Bernas GA, Bisson LJ (2015) Sex-specific predictors of intra-articular injuries observed during anterior cruciate ligament reconstruction. Orthop J Sports Med 3:2325967115571300
Krutsch W, Zellner J, Baumann F, Pfeifer C, Nerlich M, Angele P (2017) Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology. Knee Surg Sports Traumatol Arthrosc 25:418–425
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–e34
Luc B, Gribble PA, Pietrosimone BG (2014) Osteoarthritis prevalence following anterior cruciate ligament reconstruction: a systematic review and numbers-needed-to-treat analysis. J Athl Train 49:806–819
Maffulli N, Binfield PM, King JB (2003) Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee. Arthroscopy 19:685–690
Magnussen RA, Pedroza AD, Donaldson CT, Flanigan DC, Kaeding CC (2013) Time from ACL injury to reconstruction and the prevalence of additional intra-articular pathology: is patient age an important factor? Knee Surg Sports Traumatol Arthrosc 21:2029–2034
Mehl J, Diermeier T, Herbst E, Imhoff AB, Stoffels T, Zantop T, Petersen W, Achtnich A (2018) Evidence-based concepts for prevention of knee and ACL injuries. 2017 guidelines of the ligament committee of the German Knee Society (DKG). Arch Orthop Trauma Surg 138:51–61
Michalitsis S, Vlychou M, Malizos KN, Thriskos P, Hantes ME (2015) Meniscal and articular cartilage lesions in the anterior cruciate ligament-deficient knee: correlation between time from injury and knee scores. Knee Surg Sports Traumatol Arthrosc 23:232–239
Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012
Murrell GA, Maddali S, Horovitz L, Oakley SP, Warren RF (2001) The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage loss. Am J Sports Med 29:9–14
O’connor DP, Laughlin MS, Woods GW (2005) Factors related to additional knee injuries after anterior cruciate ligament injury. Arthroscopy 21:431–438
Oiestad BE, Engebretsen L, Storheim K, Risberg MA (2009) Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med 37:1434–1443
Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos H (2007) Meniscal tears in the ACL-deficient knee: correlation between meniscal tears and the timing of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 15:1438–1444
Petersen W (2012) Does ACL reconstruction lead to degenerative joint disease or does it prevent osteoarthritis? How to read science. Arthroscopy 28:448–450
Petrigliano FA, Musahl V, Suero EM, Citak M, Pearle AD (2011) Effect of meniscal loss on knee stability after single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19:S86–S93
Ralles S, Agel J, Obermeier M, Tompkins M (2015) Incidence of Secondary Intra-articular Injuries With Time to Anterior Cruciate Ligament Reconstruction. Am J Sports Med 43:1373–1379
Razi M, Salehi S, Dadgostar H, Cherati AS, Moghaddam AB, Tabatabaiand SM, Dodaran MS (2013) Timing of anterior cruciate ligament reconstruction and incidence of meniscal and chondral injury within the knee. Int J Prev Med 4:S98–S103
Ro KH, Kim HJ, Lee DH (2017) The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26(8):2371–2380. https://doi.org/10.1007/s00167-017-4786-1
Rotterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Aroen A (2011) Effect of gender and sports on the risk of full-thickness articular cartilage lesions in anterior cruciate ligament-injured knees: a nationwide cohort study from Sweden and Norway of 15 783 patients. Am J Sports Med 39:1387–1394
Seon JK, Gadikota HR, Kozanek M, Oh LS, Gill TJ, Li G (2009) The effect of anterior cruciate ligament reconstruction on kinematics of the knee with combined anterior cruciate ligament injury and subtotal medial meniscectomy: an in vitro robotic investigation. Arthroscopy 25:123–130
Slauterbeck JR, Kousa P, Clifton BC, Naud S, Tourville TW, Johnson RJ, Beynnon BD (2009) Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries. J Bone Joint Surg Am 91:2094–2103
Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716
Sri-Ram K, Salmon LJ, Pinczewski LA, Roe JP (2013) The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction. Bone Joint J 95-B:59–64
Tandogan RN, Taser O, Kayaalp A, Taskiran E, Pinar H, Alparslan B, Alturfan A (2004) Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 12:262–270
Tayton E, Verma R, Higgins B, Gosal H (2009) A correlation of time with meniscal tears in anterior cruciate ligament deficiency: stratifying the risk of surgical delay. Knee Surg Sports Traumatol Arthrosc 17:30–34
Worrall J (2002) What evidence in evidence-based medicine? PhiloSci 69:316–330
Yan F, Xie F, Gong X, Wang F, Yang L (2016) Effect of anterior cruciate ligament rupture on secondary damage to menisci and articular cartilage. Knee 23:102–105
Yoo JC, Ahn JH, Lee SH, Yoon YC (2009) Increasing incidence of medial meniscal tears in nonoperatively treated anterior cruciate ligament insufficiency patients documented by serial magnetic resonance imaging studies. Am J Sports Med 37:1478–1483
Zantop T, Herbort M, Raschke MJ, Fu FH, Petersen W (2007) The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am J Sports Med 35:223–227
There is no funding source.
Conflict of interest
JM, AA, RA, ABI, SS and WP are members of the ligament committee of the German knee society (DKG). ABI receives royalties from Arthrex and consultant fees from Arthrosurface and Medi Bayreuth outside the submitted work. SS receives personal fees from Smith & Nephew, Arthrex and Conmed/Linvatec outside the submitted work. WP receives consultant fees from Karl Storz endoscopy, AAP implants and Otto Bock health care. All other authors declare that they have no conflicts of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Mehl, J., Otto, A., Baldino, J.B. et al. The ACL-deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta-analysis (CRD42017076897). Arch Orthop Trauma Surg 139, 819–841 (2019). https://doi.org/10.1007/s00402-019-03128-4
- Anterior cruciate ligament
- Partial meniscectomy