Multicenter Study of Early Anti-inflammatory Treatment I Patients with Acute
Anterior Cruciate Ligament Tear
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
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.
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.
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.
for Discussion: What are your thoughts
on injections prophylactically? What other
options do you think might help in delaying early onset of OA?
by: Nicole Cattano
by: Jeffrey Driban
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