Osteoarthritis prevalence ‘highly concerning’ in younger patients with ACL rupture
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The prevalence of osteoarthritis among younger patients with ACL rupture is “high concerning,” with 30% of the youngest cohort — at a median age of 22 years — having involved knee OA within 5 years of their injury, according to researchers.
“Anterior cruciate ligament (ACL) ruptures are one of the most common traumatic knee joint injuries in adolescents and young adults,” Elanna K. Arhos, PT, DPT, PhD, of the University of Delaware, and colleagues wrote in Arthritis Care & Research. “Post-traumatic osteoarthritis (PTOA) in the knee joint is one of many concerning long-term outcomes facing individuals who have torn their ACL.”
To examine and categorize subgroups of patients with ruptured ACL, and to assess their long-term outcomes following injury, Arhos and colleagues analyzed data from the Delaware-Oslo ACL prospective cohort study. Patients eligible for the analysis were recruited between 2006 and 2016 from Delaware and Oslo, Norway. Eligible patients were those who experienced an ACL rupture, achieved minimal knee pain or effusion, were aged 13 to 60 years, and had participated in level 1 and 2 intensity sports — defined via actions such as running, jumping, pivoting and cutting — for at least 50 hours per week prior to injury.
Previous ACL ruptures did not exclude patients, but other injuries, including those to the knee, bilateral injuries, concomitant grade III injuries, full-thickness cartilage damage or fractures were grounds for exclusion.
The researchers categorized patients into subgroups using probabilistic assignment modeling. The primary outcome was the presence of OA in the impacted knee within 5 years of ACL rupture, as discerned through radiographic evidence. Secondary endpoints included OA presence in the knee with no ACL rupture, return to preinjury sport within 2 years of injury, surgery and OA status at 5 years.
The researchers identified four subgroups of younger and older patients among the 293 total participants, with each group self-reporting good and poor outcomes. According to the researchers, all four subgroups demonstrated an OA prevalence of at least 30%, with the highest experiencing a prevalence of 53%.
Among the "young, good self-reporting” subgroup, the youngest of the four groups, 30% demonstrated involved knee OA. Meanwhile, prevalence figures for the “younger, poor self-report,” “older, poor self-report,” and “older, good self-report” subgroups were 31%, 47%, and 53% respectively. Patients in the two older subgroups were at an average age of 38 and 43 years, respectively, at 5 years following ALC rupture. The differences in prevalence between the groups were not significant (P = .059), according to the researchers.
“Though it may be expected that the oldest subgroup had the highest percentage of individuals with radiographic changes in both the involved and uninvolved knees, the percentages of individuals meeting our definition of knee OA in the younger subgroups is highly concerning,” Arhos and colleagues wrote. “At a mean age of 22 years old, our youngest subgroup, the Younger good self-report group, demonstrated radiographic changes in 30% of ipsilateral and 17% of contralateral knees at 5 years after ACL rupture.
“The results of our study suggest that there are subgroupings of individuals that may guide treatment after ACL rupture and reconstruction by providing support for developing a patient-centered approach,” they added. “While returning to preinjury sport level may be a goal for some individuals, symptom management and returning a generally active lifestyle may be the goal for others as they transition away from previous sport participation. This analysis provides support for developing an individual-based approach, where all aspects of baseline evaluation are incorporated to inform treatment decisions.”
Perspective
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Anterior cruciate ligament (ACL) tear remains one of the most devastating injuries in all age groups both in competitive and recreational sports. This is among the most common injury in sports that may result from pivoting forces on the knees and sudden deceleration or change of direction. It can result in significant disability, pain and swelling of the knee, and loss of ability to participate in competitive sports.
The risk factors leading to post-traumatic osteoarthritis (PTOA) following ACL tear include female gender, high BMI, smoking and age. However, since the starting point of PTOA is known there may be some utility in grouping patients based on their self-reported outcomes to tailor their rehabilitation.
The paper alludes to, but does not elaborate on, the psychological aspects of poor and good self-report outcomes, as that is not the scope of this paper. However, it merits further study in preparing and overcoming kinesiophobia after an injury. Organizing patients into groups based on their self-reported outcomes may also tailor additional physical therapy and re-education towards gait biomechanics and re-injury prevention. Superiority of ACL repair over conservative treatments has not been clearly established.
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