A Multicenter Study of Early Anti-inflammatory Treatment I Patients with Acute Anterior Cruciate Ligament Tear
Latterman C, Jacobs CA, Bunnell MP, Huston LJ, Gammon LG, Johnson DL, Reinke EK, Huebner JL, Kraus VB, & Spindler KP. Am J Sports Med. 45:325-333. doi: 10.1177/0363546516666818
Take Home Message: A corticosteroid injection performed within the first 5 weeks after anterior cruciate ligament injury resulted in significantly less of an increase in cartilage degradation markers in comparison to placebo injections.
An anterior cruciate ligament (ACL) injury can cause short-term limitations and increase the risk of osteoarthritis, a chronic painful and disabling disorder. There are biomechanical and biochemical changes that occur after a knee injury. Unfortunately, surgical reconstruction fails to prevent the development of osteoarthritis. Therefore, we may need to focus on the biochemical changes. The authors of this triple blind randomized clinical trial investigated the use of early corticosteroid injections in 49 patients post ACL tear. Injections were performed twice (4 days and 2 weeks post injury). Participants were randomized to receive injections based on 4 groupings: 1) corticosteroid then saline, 2) saline then corticosteroid, 3) corticosteroid at both time points, or 4) saline at both time points. Participants were assessed at 4 and 37 days post-injury, on average. The participant underwent an ACL reconstruction after they finished the study. The authors assessed patient reported outcomes, as well as biomarkers in blood, synovial fluid, and urine. Typically, patient-reported outcomes improved over the 5 weeks, while the markers of inflammation and cartilage degradation increased. A measure of collagen breakdown was on average higher in the placebo group than the 2 groups that received the corticosteroid injection at 4 days. The placebo group also had drastic increases in this marker over 5 weeks compared with participants who received a corticosteroid injection. There were no differences in patient-reported outcomes between groups.
These findings highlight that a corticosteroid injection performed early after a knee injury is associated with less collagen breakdown. However, it remains unclear as to whether this will result in any clinically meaningful changes, since participants did not report any differences in symptoms. It would be interesting to continue to follow these participants out long-term to see if they develop differences in patient-reported or radiographic outcomes. This study shows that a simple intervention could potentially modify the biochemical environment post-injury in a population highly susceptible to osteoarthritis. Since all the groups that received corticosteroid injections responded similarly it may be that only 1 injection is needed to calm the biochemical environment down. It would be interesting to see what a repeat injection would do a couple of months after injury, perhaps during the rehabilitation process. However, insurance companies today may be unwilling to pay the costs for an injection used prophylactically. However, this may change if future studies show that these early injections can save long-term healthcare costs. Early use seems to be promising, because once structural changes occur it may be too late to make any modifications. Bottom line is that there is potential for early injection use, but more research is needed looking at the possible longer-term effects. This study also highlights that early interventions while a patient is still under the care of sports medicine clinicians may be key to inducing changes that will offer long-term benefits.
Questions for Discussion: What are your thoughts on injections prophylactically? What other options do you think might help in delaying early onset of OA?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban