Sports Medicine Research: In the Lab & In the Field: Cartilage Degradation After ACL Altered by Early Injection (Sports Med Res)


Wednesday, March 8, 2017

Cartilage Degradation After ACL Altered by Early Injection

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

Related Posts:

Lattermann, C., Jacobs, C., Proffitt Bunnell, M., Huston, L., Gammon, L., Johnson, D., Reinke, E., Huebner, J., Kraus, V., & Spindler, K. (2017). A Multicenter Study of Early Anti-inflammatory Treatment in Patients With Acute Anterior Cruciate Ligament Tear The American Journal of Sports Medicine, 45 (2), 325-333 DOI: 10.1177/0363546516666818


Ryan Duffy said...

This is a very fascinating article. The unfortunate long-term outcomes after ACL-R are well documented, with osteoarthritis at the forefront. While the findings in this study are certainly important, only time will tell if these short-term effects have an impact in the long term. I think doctors, patients, and insurance companies will absolutely be on board with prophylactic injections if proven to prevent knee OA down the road. The consequences and cost of OA management are boundless and if a simple injection can prevent it, it will change the future of ACL management.

Going off of this study, I would be interested to see the effects of other anti-inflammatory agents such as NSAID's, cannabichromene, etc. would have similar effects to the injections along with long term effects. I hope to continue to see research on OA prevention, specifically post ACL-R. It's a very interesting and important topic in sports medicine.

Nicole Cattano said...

Thanks for your comment Ryan. I agree that there's so much more we need to see...and interestingly only time will tell. It would be interesting to see a long term cost benefit analysis of injections early vs. Long term care and TKR.

Catherine Hess said...

The perspective of this study is very interesting – to look at the biochemical aspect rather than the biomechanical aspect. It seems to be something that is somewhat more easily influenced through medical interventions. Osteoarthritis is a prevalent problem with those who have undergone surgeries such as ACL reconstruction and if this method helps to reduce that risk, it has clinical value. I am curious, however, about the long term results. It would be valuable to check in with the patients further on down the line. I think at those time points further out, there would be differences with the patient-reported outcomes. The more research on this intervention, the greater the chance that it gains a place in the clinical treatment of ACL injuries.

I think that the Sports Medicine world could really get behind the concept of prophylactic injections once more research is available. As with many other facets of research, there is still so much yet to become known. It would be very interesting to see optimal times to complete the injections in addition to the potential long term effects of this type of treatment. I think this is definitely a promising direction for research and there may even be potential applications for other injuries or surgical interventions. I would be interested to see if there are other benefits associated with the injection or even different ‘cocktails’ that could be utilized for further benefits. Of course, this type of research is tricky too because it is utilizing human subjects and if this intervention improves quality of life significantly then it wouldn’t be ethical to withhold that from others.

Jeffrey Driban said...

Catherine, thanks for the great comments. To address your last concern I think we would need to use comparative effectiveness trials to see if the injections are better than other treatment strategies. This way we don't run into the ethical issues of failing to provide a treatment to a population that needs care.

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