ACL reconstruction and treating with exercise therapy alone may alter
prognostic factors for 5-year outcome: an exploratory analysis of the KANON
Filbay SR, Roos EW, Frobell
RB, Roemer, Ranstam J, Lohmander LS. Br J
Sports Med
. 2017. [Epub ahead of print].

Home Message: Patients who are active and present with both an anterior
cruciate ligament (ACL) rupture and meniscal injury or more severe knee
pain/symptoms should consider starting exercise therapy before an ACL
After an ACL injury, many patients fail
to return to the same level of activity, develop early-onset osteoarthritis, or
have a fear of reinjury – all of which could contribute to a decreased quality
of life years after an injury. If clinicians knew which factors predicted long-term
outcomes then they could develop best practices for selecting an optimal treatment
strategy for certain patients. Therefore, Filbay and colleagues completed an
exploratory analysis of data from the KANON randomized controlled trial to identify
factors that may predict 5-year outcomes among 118 people with an acute ACL
injury who were treated with 1) an early reconstruction (59 people), 1) supervised
exercise therapy with a delayed ACL reconstruction (30 people), or 3) exercise
therapy alone (29 people). The outcome of interest was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 5 years post injury.  The authors explored if injury-related (e.g.,
meniscal damage, osteochondral lesions), patient-reported (i.e., baseline KOOS
scores and mental health score), or treatment-related (e.g., number of
surgeries, graft rupture, number of rehab visits) factors were related to
outcomes at 5 years. Among all 118 participants, the best predictor of a poor
outcome was sustaining an ACL graft rupture or an ACL injury in the
contralateral joint during the 5-year follow-up period. Furthermore, having at
least one knee surgery (besides an ACL reconstruction/revision) during the
follow-up period was related to poor outcomes at 5 years. For participants in
the early reconstruction group, worse baseline KOOS scores were related to poorer
outcomes. Furthermore, among people who had an early ACL reconstruction meniscal
damage or an osteochondral lesion at baseline were more likely to have lower
sport and recreation function or lower quality of life at 5 years,
respectively. Conversely, baseline meniscal damage was related to less pain at
follow-up among participants in the exercise therapy with a delayed
reconstruction group. Among people who only received exercise therapy, there
was a trend that suggested that the presence of a cartilage defect at baseline
may predict poor outcomes.
These results should be interesting to
clinicians because they suggest that patients who present with meniscal damage
or more knee pain/symptoms/dysfunction at baseline may benefit from starting exercise
therapy before an ACL reconstruction. This may seem contrary to clinicians’
inclinations as much of the literature on long-term joint health suggests that
meniscal damage results in joint degeneration and that ACL reconstructions may be associated with delaying/preventing osteoarthritis among people with meniscal pathology. It’s important to keep in mind that this strategy still
allows a patient to opt for an ACL reconstruction. This study is also
interesting because the authors help explain why some patients may respond well
to a treatment strategy while another does not. Clinicians should consider
multiple factors when exploring the best treatment option for patients who have
sustained an ACL injury and may wish to begin with an exercise therapy
regiment. For example, a patient with a cartilage defect may be more likely to
have a poor outcome after exercise therapy alone. Ultimately, more long-term
follow-up studies should be completed to better understand how the clinical
decisions made in the first 5 years post-injury will impact the joint over a
longer period. It would also be interesting to see if these results are the
same with 10-year outcomes. Based on these results, clinicians should be aware
that some baseline factor may be related to 5-year outcomes. This information
could be helpful when teaching patients about the possible long-term outcomes
after an ACL injury.
Questions for Discussion: Do you feel this study will
impact your current counseling and education approach to athletes who sustain
and ACL rupture? When considering exercise therapy before ACL reconstruction,
what factors do you look for in your patients?
Written by: Kyle Harris
Reviewed by:  Jeffrey Driban
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