A systematic review to evaluate exercise for anterior cruciate ligament injuries: does this approach reduce the incidence of knee osteoarthritis?

A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature

Purpose

The aim of the present systematic review was to quantitatively synthesize the best literature evidence regarding osteoarthritis developing after anterior cruciate ligament reconstruction (ACLR), including only studies with a follow-up duration of at least 20 years.

Material and Methods

A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on four electronic databases (PubMed, Scopus, EMBASE and Cochrane Library). The outcome measures extracted from the studies were failure rate, subsequent knee surgery on the same knee, radiographic development of osteoarthritis measured with Kellgren-Lawrence, International Knee Documentation Committee (IKDC) radiographic score and Ahlbäck classification. The health of both the ACLR knee and the contralateral knee was compared.

Results

A total of 1552 patients were included in the study, of which 1290 (83.11%) were operated on using a patellar tendon graft, 190 (12.24%) with hamstrings, 27 (1.73%) with an iliotibial band and 45 (2.89%) with patellar tendon plus a ligament augmentation device (LAD). The mean age at the time of surgery was 25.18 ± 1.91 years, and the mean follow-up time was 23.34 ± 2.56 years. Analysing IDKC Score at final follow-up, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 33.2% (324/976) of the patients showed a moderate to severe degree (Grade C or D) of osteoarthritis, while for Kellgren-Lawrence, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 28.9% (196/678) of the patients showed a moderate to severe degree (Grade III or IV) of osteoarthritis. In total, 1552 patients were registered, 155 reruptures (9.98%) and a total of 300 (19.3%) new surgeries, of which 228 meniscectomy (14.69%), 21 (1.35%) knee arthroplasty and 17 (1.09%) hardware removal were recorded.

Conclusions

ACL reconstruction appears to result in mild osteoarthritis in the long term in most of the patients and only less than 33.2% develop a moderate to severe degree of knee OA according to IKDC radiographic score. A slight degree of osteoarthritis appears to be present in ACLR knees compared with contralateral healthy knees.

Level of Evidence

Level IV.

Efficacy of the SOAR knee health program: protocol for a two-arm stepped-wedge randomized delayed-controlled trial

BACKGROUND

Knee trauma permanently elevates one's risk for knee osteoarthritis. Despite this, people at-risk of post-traumatic knee osteoarthritis rarely seek or receive care, and accessible and efficacious interventions to promote knee health after injury are lacking. Exercise can ameliorate some mechanisms and independent risk factors for osteoarthritis and, education and action-planning improve adherence to exercise and promote healthy behaviours.

METHODS

To assess the efficacy of a virtually-delivered, physiotherapist-guided exercise-based program (SOAR) to improve knee health in persons discharged from care after an activity-related knee injury, 70 people (16-35 years of age, 12-48 months post-injury) in Vancouver Canada will be recruited for a two-arm step-wedged assessor-blinded delayed-control randomized trial. Participants will be randomly allocated to receive the intervention immediately or after a 10-week delay. The program consists of 1) one-time Knee Camp (group education, 1:1 individualized exercise and activity goal-setting); 2) weekly individualized home-based exercise and activity program with tracking, and; 3) weekly 1:1 physiotherapy-guided action-planning with optional group exercise class. Outcomes will be measured at baseline, 9- (primary endpoint), and 18-weeks. The primary outcome is 9-week change in knee extension strength (normalized peak concentric torque; isokinetic dynamometer). Secondary outcomes include 9-week change in moderate-to-vigorous physical activity (accelerometer) and self-reported knee-related quality-of-life (Knee injury and OA Outcome Score subscale) and self-efficacy (Knee Self Efficacy Scale). Exploratory outcomes include 18-week change in primary and secondary outcomes, and 9- and 18- week change in other components of knee extensor and flexor muscle function, hop function, and self-reported symptoms, function, physical activity, social support, perceived self-care and kinesiophobia. Secondary study objectives will assess the feasibility of a future hybrid effectiveness-implementation trial protocol, determine the optimal intervention length, and explore stakeholder experiences.

DISCUSSION

This study will assess the efficacy of a novel, virtually-delivered, physiotherapist-guided exercise-based program to optimize knee health in persons at increased risk of osteoarthritis due to a past knee injury. Findings will provide valuable information to inform the management of osteoarthritis risk after knee trauma and the conduct of a future effectiveness-implementation trial.

TRIAL REGISTRATION

Clinicaltrials.gov reference: NTC04956393. Registered August 5, 2021, https://clinicaltrials.gov/ct2/show/NCT04956393?term=SOAR&cond=osteoarthritis&cntry=CA&city=Vancouver&draw=2&rank=1.

Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: protocol for a systematic review

INTRODUCTION

Injuries of the anterior cruciate ligament (ACL) are a common musculoskeletal complication and can cause significant reduction in patient function and quality of life. Many undergo ACL reconstruction, with high-quality rehabilitation key to successful outcome. Knowledge of physical prognostic factors, such as quadriceps strength, is crucial to inform rehabilitation and has important implications for outcome following ACL reconstruction. However, these factors predicting outcome are poorly defined. Therefore, the aim of this systematic review is to establish physical prognostic factors predictive of outcome in adults following ACL reconstruction. Outcome will be subdivided into two groups of outcome measures, patient-reported and performance-based. Physical prognostic factors of interest will reflect a range of domains and may be modifiable/non-modifiable. Results will help decide most appropriate management and assist in planning and tailoring preoperative and postoperative rehabilitation.

METHODS AND ANALYSIS

This systematic review protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. MEDLINE, CINAHL and EMBASE databases, key journals and grey literature will be searched from inception to July 2019. Prospective cohort studies including participants aged ≥16 years who have undergone ACL reconstruction will be included, with articles focusing on multi-ligament reconstructions and ACL repair surgery, or not published in English excluded. Two independent reviewers will conduct searches, assess study eligibility, extract data, assess risk of bias (Quality in Prognostic Studies tool) and quantify overall quality of evidence (modified Grading of Recommendations, Assessment, Development and Evaluation guidelines). If possible, a meta-analysis will be conducted, otherwise a narrative synthesis will ensue focusing on prognostic factors, risk of bias of included studies and strength of association with outcomes.

ETHICS AND DISSEMINATION

Findings will be published in a peer-reviewed journal, presented at conferences and locally to physiotherapy departments. Ethical approval is not required for this systematic review.

PROSPERO REGISTRATION NUMBER

CRD42019127732.

The time course and mechanisms of change in biomarkers of joint metabolism in response to acute exercise and chronic training in physiologic and pathological conditions

PURPOSE

The benefits of exercise across the lifespan and for a wide spectrum of health and diseases are well known. However, there remains less clarity as to the effects of both acute and chronic exercise on joint health. Serum biomarkers of joint metabolism are sensitive to change and have the potential to differentiate between normal and adverse adaptations to acute and chronic load. Therefore, the primary objective of this review is to evaluate how serum biomarkers can inform our understanding of how exercise affects joint metabolism.

METHODS

A comprehensive literature search was completed to identify joint biomarkers previously used to investigate acute and chronic exercise training.

RESULTS

Identified biomarkers included those related to joint cartilage, bone, synovium, synovial fluid, and inflammation. However, current research has largely focused on the response of serum cartilage oligomeric matrix protein (COMP) to acute loading in healthy young individuals. Studies demonstrate how acute loading transiently increases serum COMP (i.e., cartilage metabolism), which is mostly dependent on the duration of exercise. This response does not appear to be associated with any lasting deleterious changes, cartilage degradation, or osteoarthritis.

CONCLUSION

Several promising biomarkers for assessing joint metabolism exist and may in future enhance our understanding of the physiological response to acute and chronic exercise. Defining 'normal' and 'abnormal' biomarker responses to exercise and methodological standardisation would greatly improve the potential of research in this area to understand mechanisms and inform practice.