Low Rates of Radiographic Knee Osteoarthritis 5 Years After ACL Reconstruction or Rehabilitation Alone: The Delaware-Oslo ACL Cohort Study

Abstract

Background: Patients and clinicians often struggle to choose the optimal management strategy for posttraumatic knee osteoarthritis (OA) after an anterior cruciate ligament (ACL) injury. An evaluation of radiographic outcomes after a decision-making and treatment algorithm applicable in clinical practice can help to inform future recommendations and treatment choices. Purpose: To describe and compare 5-year radiographic outcomes and knee pain in individuals who had gone through our decision-making and treatment algorithm and chosen (1) early (<6 months) ACL reconstruction (ACLR) with pre- and postoperative rehabilitation, (2) delayed (>6 months) ACLR with pre- and postoperative rehabilitation, or (3) progressive rehabilitation alone. Study Design: Cohort study; Level of evidence, 2. Methods: We included 276 patients with unilateral ACL injury from a prospective cohort study. Patients chose management using a shared decision-making process and treatment algorithm, and 5-year postoperative radiographs of the index and contralateral knees were assessed using the Kellgren and Lawrence (K&L) classification and minimum joint space width measurements. We defined radiographic tibiofemoral OA as K&L grade ≥2 and knee pain as a Knee injury and Osteoarthritis Outcome Score for Pain ≤72. To further explore early radiographic changes, we included alternative cutoffs for radiographic knee OA using K&L grade ≥2/osteophyte (definite osteophyte without joint space narrowing) and K&L grade ≥1. Results: At 5 years, 64% had undergone early ACLR; 11%, delayed ACLR; and 25%, progressive rehabilitation alone. Radiographic examination was attended by 187 patients (68%). Six percent of the cohort had radiographic tibiofemoral OA (K&L grade ≥2) in the index knee; 4%, in the contralateral knee. Using the alternative cutoffs at K&L grade ≥2/osteophyte and K&L grade ≥1, the corresponding numbers were 20% and 33% in the index knee and 18% and 29% in the contralateral knee. Six percent had a painful index knee. There were no statistically significant differences in any radiographic outcomes or knee pain among the 3 management groups. Conclusion: There were no statistically significant differences in any 5-year radiographic outcomes or knee pain among the 3 management groups. Very few of the patients who participated in our decision-making and treatment algorithm had knee OA or knee pain at 5 years.

Clinical, Functional, and Physical Activity Outcomes 5 Years Following the Treatment Algorithm of the Delaware-Oslo ACL Cohort Study

“…Based on subgroups of the present cohort, we previously reported (1) large improvement in knee function after preoperative rehabilitation 13 and argued that knee function should be emphasized in treatment choices 15 , (2) that a number of factors are prognostic for successful outcome 16,17 , (3) that coper classification may change after preoperative rehabilitation and affect 2-year outcomes 18,19 , (4) that 2-year outcomes after progressive rehabilitation alone are equivalent to those after ACLR 14 , and (5) that 2-year outcomes in our surgically treated patients are superior to those after usual care in the United States 20 and Norway 21 . We have yet to report the long-term clinical, functional, physical activity, and radiographic 22 outcomes for the whole cohort.…”

Clinically Relevant Subgroups Among Athletes Who Have Ruptured Their Anterior Cruciate Ligaments: A Delaware‐Oslo Cohort Study

“…This study was an analysis of 293 patients (Figure 1) enrolled in the Delaware-Oslo ACL prospective cohort study. Patients included were recruited between 2006 and 2012 from both the University of Delaware in Newark, Delaware, and the Norwegian Sports Medicine Clinic in Oslo, Norway, with outcomes previously reported in the 5 past years (13,14). Individuals were screened for outliers among all variables using histograms and boxplots, and 7 individuals were removed (2 based on days from surgery, and 5 based on age).…”

Four Distinct 5-Year Trajectories of Knee Function Emerge in Patients Who Followed the Delaware-Oslo ACL Cohort Treatment Algorithm

“…The previous publications from our cohort, showing equivalent 2-year and 5-year clinical, functional, physical activity, and radiographic outcomes after progressive rehabilitation alone, early ACLR, and delayed ACLR after our treatment algorithm, 13,33,34 form the basis for combining the treatment groups in one analysis.…”

“…We included patients early after injury, before a 5-week rehabilitation program and shared decision-making process about treatment. Following our treatment algorithm, we have previously reported equivalent 2-year and 5-year clinical, functional, physical activity, and radiographic outcomes after progressive rehabilitation alone, early ACL reconstruction (ACLR), and delayed ACLR 13 , 33 , 34 and assessed prognostic factors for short-term outcomes. 15 , 26 , 27 , 37 …”

“…We included patients early after injury, before a 5-week rehabilitation program and shared decision-making process about treatment. Following our treatment algorithm, we have previously reported equivalent 2-year and 5-year clinical, functional, physical activity, and radiographic outcomes after progressive rehabilitation alone, early ACL reconstruction (ACLR), and delayed ACLR 13,33,34 and assessed prognostic factors for short-term outcomes. 15,26,27,37 We, therefore, aimed to identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACLR plus rehabilitation or rehabilitation alone.…”