Dear Editor:
We read with great interest the article by Øiestad et al, ‘‘Knee Function and Prevalence of Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Prospective Study With 10 to 15 Years of Follow-up’’ in the November 2010 issue.4 The authors did a commendable job presenting data on 221 patients over a period of 10 to 15 years with an 82% follow up rate. This is no small effort, and we recognize their hard work and contribution to our current knowledge in the field of ACL reconstruction (ACLR) surgery. However, we would like to bring up 2 points that we feel would have been a valuable addition to this study.

First, the authors reported a higher prevalence of radiographic, but not symptomatic, knee osteoarthritis in those with combined injury compared with those with an isolated ACL injury. Two significant contributors to this finding could be (1) nonanatomic ACLR and (2) time delay to ACLR in the combined injury group. There exists a large difference in the average time from injury to surgery for the 2 groups (isolated ACL, 7.1 months; combined injury 42.4, months) (Table 1). This delay in treatment in patients could have contributed to the higher prevalence of radiographic knee osteoarthritis (due to continued joint laxity and abnormal knee kinematics).

Although the authors make the point that there was no statistically significant difference in symptomatic knee osteoarthritis in the 2 groups, 10 to 15 years may still not be enough time to realize that difference (especially in the younger cohort). While we appreciate that the authors’ conclusions do not outreach the data, the dissimilarity in time to treatment introduces a study design flaw that is inadequately addressed.

Secondly, the authors’ use of the ‘‘transtibial technique’’ for ACL tunnel placement has previously been shown to create tunnel mismatch and nonanatomic graft position.3 The subsequent tunnel placement tends to be outside the native insertion site of the ACL bundles, and it can result in abnormal knee kinematics.5 In ACLR, anatomy and tunnel placement are critical to clinical outcomes, with nonanatomic tunnels resulting in limitation in knee range of motion, supraphysiologic graft tension, and potential graft failure. Also, the authors’ use of the ‘‘clock face’’ in describing femoral tunnel position is a poor reference marker and no longer has a role in anatomic ACLR.1,6 It is important to eliminate nonanatomic ACLR as a source of abnormal knee kinematics and as a contributor to progressive cartilage degeneration.5

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