Sports Medicine Research: In the Lab & In the Field: Time Doesn’t Heal All Wounds, Specifically Post ACL (Sports Med Res)

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Wednesday, July 11, 2018

Time Doesn’t Heal All Wounds, Specifically Post ACL

Changes in KOOS and WOMAC Scores in a Young Athletic Populations With and Without Anterior Cruciate Ligament Injury

Antosh I, Svoboda SJ, Peck KY, Garcia EG, & Cameron KL. Am J Sports Med. 2018; 46(7): 1606-1616.  DOI: 10.1177/0363546518768753
           
Take Home Message: Students at a US service academy with an anterior cruciate ligament (ACL) reconstruction tend to report poorer patient-reported outcomes at 2 years post reconstruction than healthy uninjured peers. 

https://www.flickr.com/photos/west_point/4751423269
Most patients after an anterior cruciate ligament (ACL) reconstruction experience a near-full recovery of functional outcomes. However, many of these patients fail to return to preinjury activity levels and report lingering knee symptoms.  It is challenging to interpret these lingering symptoms without knowing how patients were doing prior to injury.  Hence, these authors conducted a prospective study to compare patient-reported outcomes between students at a US service academy with and without an ACL injury.  Researchers assessed patient-reported outcomes of all incoming cadets with the Knee Osteoarthritis Outcome Score (KOOS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Physical Activity Rating Scale (MARS).  Through the four-year study period, 30 students out of ~1000 students with no previous injury suffered an ACL injury (without multi-ligamentous injury requiring surgical care) and were enrolled in the study for a 2-year follow-up period.  Three healthy controls were matched to every 1 participant with an ACL injury by age, sex, and activity level.  Follow-up assessments were completed in the ACL group prior to surgical reconstruction, and then again after surgery, 6 months, 1 year, and 2 years post-surgery. Healthy controls were contacted and re-assessed within 1 year of graduation – about 4 years after their baseline assessments.  Patient-reported outcomes were comparable at preinjury assessment. However, 2 years after an ACL injury students reported worse knee pain, symptoms, quality of life, sports function, and stiffness than their peers. These differences met the criteria for being clinically meaningful.  Compared to pre-injury scores, the students with an ACL injury tended to report meaningful worsening in knee symptoms, sports function, quality of life, and activity levels at 2 years after an injury. In contrast, the healthy uninjured students showed similar patient-reported outcomes between entering the academy and after graduation.

These researchers were the first to prospectively demonstrate differences in patient-reported outcomes between students with and without an ACL injury.  This is very interesting because it is in a relatively homogenous group of military cadets who are experiencing similar physical activity demands. This helps us infer that the ACL injury is likely the cause of these deficits.  ACL injured participants showed improvements in patient-reported outcomes post-surgery, but these improvements plateaued and failed to return to their pre-injury levels. These poor patient-reported outcomes may be part of the reason that we are seeing the general population fail to return to preinjury levels of activity. More informatively, in this military cohort, we are seeing that their physical activity levels are remaining relatively consistent with healthy controls despite poorer patient-reported outcomes. It would be interesting to see if and how the patient-reported outcomes change over the next few years and how this influences their ability to remain in active service.  In the meantime, this is another reminder to clinicians that it may be valuable to assess patient-reported outcomes over time after an ACL reconstruction to get a better sense of the patient’s symptoms and how they perceive their function. 

Questions for Discussion:  What patient-reported outcomes do you currently use after ACL injury?  Are there any other factors that you think would be valuable to include in trying to assess long-term joint health?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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