Patient Reported Outcomes 1 to 5 years After ACL Reconstruction: Effect of Combined Injury, and Associations with MRI-Defined Osteoarthritis Features
Patterson BE, Culvenor AG, Barton CJ, Guermazi A, Stefanick JJ, & Crossley KM. Arthritis Care Res. 2019; Published online ahead of print February 14, 2019. DOI:10.1002/acr.23854
Take Home Message: Patients with an isolated anterior cruciate ligament reconstruction have better patient-reported outcomes at 1 and 5 years after surgery compared with patients who have other combined injuries. At 1 and 5 years after surgery, a patient with a patellofemoral cartilage defect or meniscal tear may be more likely to have poor patient-reported outcomes compared with their peers.
People who suffer an anterior cruciate ligament (ACL) injury often have symptoms that will gradually improve up to one year after surgical reconstruction. However, these symptoms can persist beyond that one-year mark and cause significant limitations and comorbidities. Persistent symptoms may be linked with concomitant injuries and other structural or degenerative changes. Therefore, the authors aimed to test this hypothesis by determining the relationship between concomitant injuries and other structural findings at 1 and 5 years post surgery to patient-reported outcomes 1 and 5 years after an ACL reconstruction. These researchers followed 81 participants who had an ACL reconstruction a year prior to the study and no new injury during that year. The authors defined a “combined injury” as a knee with a concomitant meniscectomy or cartilage defect at the time of an ACL reconstruction. Researchers evaluated patient-reported outcomes (KOOS & IKDC), activity levels, and structural changes or secondary injuries (via MRI) at 1 and 5 years after surgery. Participants who had an ACL reconstruction with a combined injury reported worse KOOS sport and IKDC scores at 1 year. On average, patients improved in all knee outcomes, except KOOS Symptoms, between 1 and 5 years after surgery. The presence of a patellofemoral cartilage defect at 1 year after surgery was associated with worse patient-reported outcomes at 5 years after surgery. Furthermore, a person with a meniscal lesion at 1 year was more likely to have worse KOOS symptoms at 5 years after surgery. At 5 years after surgery, a person with a patellofemoral cartilage defect or meniscal tear was more likely to have worse outcomes while someone with a tibiofemoral bone marrow lesion was more likely to have better patient-reported outcomes.
A patient with a secondary or concomitant injury is at a greater risk for poor outcomes than those who have an isolated ACL reconstruction. This agrees with Claes and colleagues who showed that a person who had a meniscectomy at the time of an ACL reconstruction was 3.5 times more likely to develop osteoarthritis within the first decade after injury than someone with an isolated ACL reconstruction. Interestingly, most of the imaging findings were not associated with worse patient-reported outcomes, except for the presence of patellofemoral cartilage defects and meniscal lesions. This makes clinical sense, yet the question becomes whether the injury or secondary injury caused these structural changes, or if they developed after mal-adaptations in gait or rehabilitation post-surgery. Interestingly, bone marrow lesions at 5 years post reconstruction were associated with better patient-reported outcomes. Post-traumatic bone marrow lesions (bone bruises) are often seen on imaging shortly after an injury, and they tend to resolve within the first year. In other patient populations, bone marrow lesions are often associated with overloading a region of a bone. It would be interesting to see if the new bone marrow lesions at 5 years post-surgery appear where the original lesions were located. This may be something to further investigate to see if these individuals are participating in more physical activity and their knee is not responding well to the loading activities. Researchers should also follow these patients to track their progression or rate of deterioration. As clinicians, we should pay attention to patients with concomitant injuries and patellofemoral pain and try to emphasize patient education about committing to long-term management of this injury to prevent or delay long-term issues. One to 5 years after surgery may serve as a critical time to emphasize and target interventions for these patients. Unfortunately, these patients often are not evaluated at these time points because they are no longer under the care of the sports medicine team. It may be important to educate patients to seek an evaluation at 1 and 5 years after surgery if they experience any knee symptoms.
Questions for Discussion: Do you follow up with patients after the first year after an ACL reconstruction? What things do you tell your patients as they are nearing the 1-year post-surgery milestone?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban