and meniscal injuries increase the risk of primary total knee replacement for
osteoarthritis: a matched case–control study using the Clinical Practice Research
Datalink (CPRD)
T, Alvand A, Prieto-Alhambra D, Culliford DJ, Judge A, Jackson WF, Scammell BE,
Arden NK, & Price AJ. Br J Sports Med.
2017; Online Ahead of Print December 21, 2017.  
Take Home Message: A patient with
a knee injury is more likely to get a knee replacement and be younger when
getting it than someone without a history of injury.
A knee injury, such as an anterior
cruciate ligament (ACL) injury or meniscal injury, is a major risk factor for
the early development of knee osteoarthritis within 10 to 20 years after injury.  However, it remains unknown if a patient with
a history of knee injury is likely to progress to end-state OA, which often
requires a total knee replacement (TKR). 
These authors used a case-control study to investigate the chance of
having a TKR surgery within 20 years among patients with a history of ACL or
meniscal injury compared to healthy controls.  The authors identified patients who received a primary TKR between 1991
to 2011 from a United Kingdom clinical practice database. They then matched
those patients with a TKR to two controls by age, gender, and same practice
(about 50,000 cases and 100,000 controls). 
A person with a history of an ACL injury was ~7 times more likely to receive
a TKR than someone without an ACL injury. 
Someone with a meniscal injury was ~15 times more likely to have a TKR
than a person without a meniscal injury history.  A patient with an ACL and meniscal injury was
4 times more likely to receive a TKR compared with someone with an isolated ACL
injury.  Patients with an ACL injury were
also ~13 years younger at the time of TKR than patients with no history of
This large-scale case-control study
demonstrates that ACL or meniscal injuries are linked to a higher risk of knee
OA that results in needing TKR at much younger ages than those without a knee
injury.  These findings confirm previous
research about higher knee OA risks within 10 years of an injury.  Patients with an ACL and meniscal injury were
4 times more likely to undergo TKR in comparison to patients with an isolated
ACL injury.  The authors identified that
they were unable to compare surgical to non-surgical management of knee
injuries.  Claes
and colleagues
estimated that a person with an ACL
injury and meniscectomy were 3.5 times more likely to have osteoarthritis at 10
years after an injury than people who had an isolated ACL injury or an ACL
injury with meniscal repair. Hence, it would be interesting to see which patients
were handled surgically versus non-surgically and which surgery was performed.  ACL reconstruction fails to protect against
OA, as supported by the findings presented in a previous Sports Med Res post on the work by Luc and colleagues, and may possibly increase OA risk as a second
macro-traumatic event.  The longer-term
problem is that the number of ACL and meniscal knee injuries are increasing,
which will have major implications to the number of people who will get an OA
diagnoses and a potential TKR.  As
clinicians and researchers, we need to determine what we can do to help relieve
the impending burden on the health care system. For example, we should take
steps to implement injury prevention programs and re-evaluate how we manage knee
injuries, with a focus on not just short-term benefits but also long-term
Questions for Discussion:  Are
you currently incorporating any long-term secondary prevention strategies with
knee injury patients?  What is the advice
that you give patients who have suffered a knee injury to help prolong their
knee health?
by: Nicole Cattano
by: Jeffrey Driban