Preventing post-ACLR osteoarthritis: The overlooked role of scheduled radiographs

Dear Editor, Anterior Cruciate Ligament Reconstruction (ACLR) is routinely performed to restore knee joint stability, particularly in athletes and active individuals. However, despite satisfactory surgical repair and structured rehabilitation, numerous studies have highlighted a strong association between ACLR and the onset of knee osteoarthritis (OA) within the first decade after surgery.[1,2] This elevated risk exists even when patients do not present the clinical symptoms in the early stages. The integration of periodic radiographic screening into the long-term ACLR follow-up offers the opportunity for the early detection of joint degeneration. Research has demonstrated that structural changes in the knee joint, including joint space narrowing and osteophyte development, can occur silently before clinical symptoms emerge.[3] Guidelines from global rheumatology societies suggest imaging-based surveillance in populations at risk of OA to facilitate early interventions.[4] Performing weight-bearing radiographs at biennial intervals could help monitor these changes, providing clinicians with critical information to adjust rehabilitation or modify physical activity before irreversible joint deterioration develops. While regular imaging may raise concerns over cumulative radiation exposure, the diagnostic dose from conventional digital radiographs remains extremely low. A typical bilateral knee radiograph examination involves a radiation dose of approximately 0.005–0.015 mSv, well below the levels associated with health risk.[5] Economically, the cost of imaging is also reasonable in the Indian healthcare setting. A full bilateral knee assessment, which generally includes standing anteroposterior, lateral, and skyline (patellofemoral) views, requires six images per session. Depending on the location and facility, costs per view range from ₹100 to ₹150, leading to a total estimated cost of ₹600–₹900 per follow-up, making it a financially accessible preventive tool.[6] When weighed against the expenses of surgical interventions like total knee arthroplasty, this modest investment in the early detection could offer substantial long-term savings for both healthcare systems and patients. Further clinical research is warranted to validate the effectiveness of scheduled imaging in altering the trajectory of post-ACLR joint degeneration. Prospective longitudinal studies could help clarify the relationship between early radiographic changes and functional decline. In addition, comparative trials investigating whether imaging-guided modifications to rehabilitation can improve joint outcomes could strengthen the case for standardized imaging protocols post-ACLR.[7] Implementing biennial radiographic assessments in ACLR follow-up programs promotes a proactive rather than reactive approach to joint health. Such surveillance has the potential to delay or prevent the progression of OA, particularly in young and active populations who rely on joint integrity for the quality of life and athletic performance. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.