Patient Acceptable Symptom State Thresholds for IKDC-SKF and KOOS at the 10-Year Follow-up After Anterior Cruciate Ligament Injury: A Study From the Delaware-Oslo ACL Cohort.

Background: Clinicians need thresholds for the Patient Acceptable Symptom State (PASS) and Treatment Failure to interpret group-based patient-reported outcome measures after anterior cruciate ligament (ACL) injury. Validated thresholds that are crucial for accurately discerning patient symptom state and facilitating effective interpretation have not been determined for long-term follow-up after ACL injury. Purpose: To calculate and validate thresholds for PASS and Treatment Failure for the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales at the 10-year follow-up after ACL injury. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 163 participants with unilateral ACL injury (treated with reconstruction or rehabilitation alone) from the Delaware-Oslo ACL Cohort were included. Thresholds for PASS were calculated for IKDC-SKF and KOOS subscales using anchor-based predictive modeling and receiver operating characteristic (ROC) analysis. Too few participants had self-reported Treatment Failure to calculate thresholds for that outcome. Nonparametric bootstrapping was used to derive 95% CIs. The criterion validity of the predictive modeling and ROC-derived thresholds were assessed by comparing actual patient-reported PASS outcome with the calculated PASS outcome for each method of calculation and calculating their positive and negative predictive values with respect to the anchor questions. Results: A total of 127 (78%) participants reported satisfactory symptom state. Predictive modeling PASS thresholds (95% CIs) were 76.2 points (72.1-79.4 points) for IKDC-SKF, 85.4 points (80.9-89.2 points) for KOOS Pain, 76.5 points (67.8-84.7 points) for KOOS Symptoms, 93.8 points (90.1-96.9 points) for KOOS activities of daily living, 71.6 points (63.4-77.7 points) for KOOS Sports, and 59.0 points (53.7-63.9 points) for KOOS quality of life (QoL). Predictive modeling thresholds classified 81% to 93% of the participants as having satisfactory symptom state, whereas ROC-derived thresholds classified >50% as unsatisfied. The thresholds for IKDC-SKF, KOOS Sports, and KOOS QoL resulted in the most accurate percentages of PASS among all identified thresholds and therefore demonstrate the highest validity. Conclusion: Predictive modeling provided valid PASS thresholds for IKDC-SKF and KOOS at the 10-year follow-up after ACL injury. The thresholds for IKDC-SKF, KOOS Sports, and KOOS QoL should be used when determining satisfactory outcomes. ROC-derived thresholds result in substantial misclassification rates of the participants who reported satisfactory symptom state.

Cost-effectiveness of strength exercise or aerobic exercise compared with usual care for patients with knee osteoarthritis: secondary results from a multiarm randomised controlled trial in Norway.

OBJECTIVES: To evaluate the 1-year cost-effectiveness of strength exercise or aerobic exercise compared with usual care for patients with symptomatic knee osteoarthritis (OA), from a societal and healthcare perspective. DESIGN: Cost-effectiveness analysis embedded in a three-arm randomised controlled trial. PARTICIPANTS AND SETTING: A total of 161 people with symptomatic knee OA seeking Norwegian primary or secondary care were included in the analyses. INTERVENTIONS: Participants were randomised to either 12 weeks of strength exercise (n=54), 12 weeks of aerobic exercise (n=53) or usual care (n=54). OUTCOME MEASURES: Quality-adjusted life-years (QALYs) estimated by the EuroQol-5 Dimensions-5 Levels, and costs related to healthcare utilisation and productivity loss estimated in euros (€), aggregated for 1 year of follow-up. Cost-effectiveness was expressed with mean incremental cost-effectiveness ratios (ICERs). Bootstrapping was used to estimate ICER uncertainty. RESULTS: From a 1-year societal perspective, the mean cost per patient was €7954, €8101 and €17 398 in the strength exercise, aerobic exercise and usual care group, respectively. From a 1-year healthcare perspective, the mean cost per patient was €848, €2003 and €1654 in the strength exercise, aerobic exercise and usual care group, respectively. Mean differences in costs significantly favoured strength exercise and aerobic exercise from a 1-year societal perspective and strength exercise from a 1-year healthcare perspective. There were no significant differences in mean QALYs between groups. From a 1-year societal perspective, at a willingness-to-pay threshold of €27 500, the probability of strength exercise or aerobic exercise being cost-effective was ≥98%. From a 1-year healthcare perspective, the probability of strength exercise or aerobic exercise being cost-effective was ≥97% and ≥76%, respectively. CONCLUSION: From a 1-year societal and healthcare perspective, a 12-week strength exercise or aerobic exercise programme is cost-effective compared with usual care in patients with symptomatic knee OA. TRIAL REGISTRATION NUMBER: NCT01682980.

Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop.

Objective: The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies. Design: An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward. Results: Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population. Conclusions: Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction.

PURPOSE: Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR). METHODS: Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated. RESULTS: Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.). CONCLUSION: Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care. LEVEL OF EVIDENCE: Level II.

Body Mass Index, Quality of Life and Activity Limitation Trajectories over 2 Years in Patients with Knee or Hip Osteoarthritis: A Dual Trajectory Approach Based on 4265 Patients Included in the AktivA Quality Register.

(1) Background: Recent studies claim that weight-neutral approaches emphasizing physical activity might be as effective as weight-loss-centered approaches for improving pain and physical function in patients with knee and hip osteoarthritis. The objectives were to identify distinctive groups of individuals with similar BMI, quality of life and activity limitation trajectories over two years, to compare the overall differences between BMI trajectory groups for baseline variables and to explore the probabilities of the quality of life and activity limitation trajectory groups conditional on the BMI group. (2) Methods: Baseline data for age, gender, BMI, quality of life, activity limitations, pain, general health, knee or hip osteoarthritis and follow-up data on BMI, quality of life and activity limitations at 3, 12 and 24 months were retrieved from the "Active with osteoarthritis" (AktivA) electronic quality register. Group-based trajectory modeling was used to identify distinct trajectories for BMI, quality of life and activity limitations. (3) Results: 4265 patients were included in the study. Four distinct BMI trajectories were identified, normal weight (31%), slightly overweight (43%), overweight (20%) and obese (6%). At baseline, there were highly significant differences between all BMI groups, pain increased and age and general health decreased with higher BMI. Irrespective of weight category, minimal changes in BMI were found over the two-year follow-up period. Over 80% of the participants showed moderate-to-considerable improvements both in quality of life and activity limitations. (4) Conclusions: Almost 70% of the participants belonged to the overweight trajectories. Despite no significant weight reduction over the two years, eight in every 10 participants improved their quality of life and reduced their activity limitations after participating in the AktivA program.

The efficacy of strength or aerobic exercise on quality of life and knee function in patients with knee osteoarthritis. A multi-arm randomized controlled trial with 1-year follow-up.

OBJECTIVE: To evaluate the efficacy of strength exercise or aerobic exercise compared to usual care on knee-related quality of life (QoL) and knee function at 4 months and 1 year in individuals with knee osteoarthritis. METHODS: A three-arm randomized controlled trial (RCT) compared 12 weeks of strength exercise or aerobic exercise (stationary cycling) to usual care supervised by physiotherapists in primary care. We recruited 168 participants aged 35-70 years with symptomatic knee osteoarthritis. The primary outcome was The Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL at 1 year. Secondary outcomes were self-reported function, pain, and self-efficacy, muscle strength and maximal oxygen uptake (VO2max) at 4 months and 1 year. RESULTS: There were no differences between strength exercise and usual care on KOOS QoL (6.5, 95% CI -0.9 to 14), or for aerobic exercise and usual care (5.0, 95% CI -2.7 to 12.8), at 1 year. The two exercise groups showed better quadriceps muscle strength, and VO2max at 4 months, compared to usual care. CONCLUSION: This trial found no statistically significant effects of two exercise programs compared to usual care on KOOS QoL at 1 year in individuals with symptomatic and radiographic knee osteoarthritis, but an underpowered sample size may explain lack of efficacy between the intervention groups and the usual care group. GOV IDENTIFIER: NCT01682980.

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

OBJECTIVE: To identify subgroups of individuals with anterior cruciate ligament (ACL) injuries based on patient characteristics, self-reported outcomes, and functional performance at baseline, and to associate subgroups with long-term outcomes after ACL rupture. METHODS: A total of 293 participants (45.7% male, mean ± SD age 26.2 ± 9.4 years, days from injury 58 ± 35) were enrolled after effusion, pain, and range of motion impairments were resolved and quadriceps strength was at least 70% of the uninvolved limb. Mixture modeling was used to uncover latent subgroups without a prior group classification using probabilistic assignment. Variables include demographics, functional testing, and self-reported outcome measures. Radiographic evidence of osteoarthritis (OA; i.e., Kellgren/Lawrence grade of ≥1) in the involved knee at 5 years after injury was the primary outcome of interest. Chi-square tests assessed differences in the presence of radiographic OA in the involved knee between subgroups at 5 years after ACL rupture. Secondary outcomes of interest included radiographic OA in the uninvolved knee, return to preinjury sport by 2 years, operative status, and clinical OA (classified using Luyten et al criteria) at 5 years. RESULTS: Four distinct subgroups exist after ACL rupture (younger good self-report, younger poor self-report, older poor self-report, older good self-report) with 30%, 31%, 47%, and 53%, respectively, having involved knee OA. The percentage of radiographic OA was not significantly different between the groups (P = 0.059). CONCLUSION: The prevalence of OA in all subgroups is highly concerning. These results suggest there are unique subgroupings of individuals that may guide treatment after ACL rupture and reconstruction by providing support for developing a patient-centered approach.

OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis.

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7-9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5-5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.

Measurement properties for muscle strength tests following anterior cruciate ligament and/or meniscus injury: What tests to use and where do we need to go? A systematic review with meta-analyses for the OPTIKNEE consensus.

OBJECTIVES: Critically appraise and summarise the measurement properties of knee muscle strength tests after anterior cruciate ligament (ACL) and/or meniscus injury using the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist. DESIGN: Systematic review with meta-analyses. The modified Grading of Recommendations Assessment, Development and Evaluation-guided assessment of evidence quality. DATA SOURCES: Medline, Embase, CINAHL and SPORTSDiscus searched from inception to 5 May 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies evaluating knee extensor or flexor strength test reliability, measurement error, validity, responsiveness or interpretability in individuals with ACL and/or meniscus injuries with a mean injury age of ≤30 years. RESULTS: Thirty-six studies were included involving 31 different muscle strength tests (mode and equipment) in individuals following an ACL injury and/or an isolated meniscus injury. Strength tests were assessed for reliability (n=8), measurement error (n=7), construct validity (n=27) and criterion validity (n=7). Isokinetic concentric extensor and flexor strength tests were the best rated with sufficient intrarater reliability (very low evidence quality) and construct validity (moderate evidence quality). Isotonic extensor and flexor strength tests showed sufficient criterion validity, while isometric extensor strength tests had insufficient construct and criterion validity (high evidence quality). CONCLUSION: Knee extensor and flexor strength tests of individuals with ACL and/or meniscus injury lack evidence supporting their measurement properties. There is an urgent need for high-quality studies on these measurement properties. Until then, isokinetic concentric strength tests are most recommended, with isotonic strength tests a good alternative.

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

BACKGROUND: Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist. PURPOSE: (1) 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 ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (<6 months after the 5-week program), 11% delayed ACLR (>6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation. RESULTS: Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory. CONCLUSION: We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories' validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

What tests should be used to assess functional performance in youth and young adults following anterior cruciate ligament or meniscal injury? A systematic review of measurement properties for the OPTIKNEE consensus.

OBJECTIVES: To critically appraise and summarise measurement properties of functional performance tests in individuals following anterior cruciate ligament (ACL) or meniscal injury. DESIGN: Systematic review. DATA SOURCES: Systematic searches were performed in Medline (Ovid), Embase (Ovid), CINAHL (EBSCO) and SPORTSDiscus (EBSCO) on 7 July 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies evaluating at least one measurement property of a functional performance test including individuals following an ACL tear or meniscal injury with a mean injury age of ≤30 years. The COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist was used to assess methodological quality. A modified Grading of Recommendations Assessment, Development and Evaluation assessed evidence quality. RESULTS: Thirty studies evaluating 26 functional performance tests following ACL injury were included. No studies were found in individuals with an isolated meniscal injury. Included studies evaluated reliability (n=5), measurement error (n=3), construct validity (n=26), structural validity (n=1) and responsiveness (n=1). The Single Leg Hop and Crossover Hop tests showed sufficient intrarater reliability (high and moderate quality evidence, respectively), construct validity (low-quality and moderate-quality evidence, respectively) and responsiveness (low-quality evidence). CONCLUSION: Frequently used functional performance tests for individuals with ACL or meniscal injury lack evidence supporting their measurement properties. The Single Leg Hop and Crossover Hop are currently the most promising tests following ACL injury. High-quality studies are required to facilitate stronger recommendations of performance-based outcomes following ACL or meniscal injury.

A Framework to Guide the Development of Health Care Professional Education and Training in Best Evidence Osteoarthritis Care.

Osteoarthritis (OA) is a leading cause of disability. Clinical practice guidelines recommend education on OA management, exercise, and weight control. However, many people with OA do not receive this recommended OA care. Some health care professionals (HCPs) lack the knowledge and skills to deliver recommended OA care. This article presents a framework to guide the development and evaluation of education and training for HCPs in the delivery of evidence-based OA care including: (1) Overarching principles for education and training; (2) Core capabilities for the delivery of best evidence OA care; (3) Theories of learning and preferences for delivery; (4) Evaluation of education and training.

Creating Crosswalks for Knee Outcomes After ACL Reconstruction Between the KOOS and the IKDC-SKF.

BACKGROUND: Anterior cruciate ligament (ACL) registries do not all use the same patient-reported outcome measures, limiting comparisons and preventing pooling of data for meta-analysis. Our objective was to create a statistical crosswalk to convert cohort and registry mean Knee Injury and Osteoarthritis Outcome Scores (KOOS) to International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores and vice versa to allow these comparisons. METHODS: Data from 3 ACL registries were pooled (n = 14,412) and were separated into a training data set (70% of the sample) or a validation data set (30% of the sample). The KOOS and the IKDC-SKF scores were available prior to the operation and at 1, 2, and 5 or 6 years postoperatively. We used equipercentile equating methods to create crosswalks in the training data set and examined accuracy in the validation data set as well as bootstrapping analyses to assess the impact of sample size on accuracy. RESULTS: Preliminary analyses suggested that crosswalks could be attempted: large correlations between scores on the 2 measures (r = 0.84 to 0.94), unidimensionality of scores, and subpopulation invariance were deemed sufficient. When comparing actual scores with crosswalked scores in the validation data set, negligible bias was observed at the group level; however, individual score deviations were variable. The crosswalks are successful for the group level only. CONCLUSIONS: Our crosswalks successfully convert between the KOOS and the IKDC-SKF scores to allow for a group-level comparison of registry and other cohort data. CLINICAL RELEVANCE: These crosswalks allow comparisons among different national ligament registries as well as other research cohorts and studies; they also allow data from different patient-reported outcome measures to be pooled for meta-analysis. These crosswalks have great potential to improve our understanding of recovery after ACL reconstruction and aid in our ongoing efforts to improve outcomes and patient satisfaction, as well as to allow the continued analysis of historical data.

Association of Quadriceps Strength Symmetry and Surgical Status With Clinical Osteoarthritis Five Years After Anterior Cruciate Ligament Rupture.

OBJECTIVE: The objective of this study was to examine the association of quadriceps strength symmetry and surgical status (anterior cruciate ligament [ACL] reconstruction or nonoperative management) with early clinical knee osteoarthritis (OA) 5 years after ACL injury or reconstruction. METHODS: In total, 204 of 300 athletes were analyzed 5 years after ACL injury or reconstruction. Quadriceps strength was measured and reported as a limb symmetry index. We identified participants with early clinical knee OA using the criteria that 2 of 4 Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales score ≤85%. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression and adjusted for age, sex, meniscal injury, and body mass index to examine the associations of quadriceps strength and surgical status with clinical knee OA. RESULTS: In all, 21% of participants met the KOOS criteria for clinical knee OA. For every 1% increase in quadriceps limb symmetry index, there was a 4% lower odds of clinical OA (adjusted OR [ORadj ] 0.96 [95% CI 0.93-0.99]) at 5 years. Surgical status was not associated with clinical knee OA (ORadj 0.58 [95% CI 0.23-1.50]). CONCLUSION: More symmetric quadriceps strength, but not surgical status, 5 years after ACL injury or reconstruction was associated with lower odds of clinical knee OA.

Muscle Strength and Osteoarthritis Progression After Surgery or Exercise for Degenerative Meniscal Tears: Secondary Analyses of a Randomized Trial.

OBJECTIVE: To evaluate muscle strength changes following partial meniscectomy or exercise therapy for degenerative meniscal tears and the relationship between baseline muscle strength and osteoarthritis progression. METHODS: Secondary analysis of a randomized trial (n = 140 participants). Isokinetic quadriceps and hamstrings strength (peak torque [Nm/kg] and total work [J/kg]) were assessed at baseline, 3-month, 12-month, and 5-year follow-up. Between-group differences were analyzed using intent-to-treat linear mixed models. The relationship between baseline muscle strength and osteoarthritis progression (Kellgren/Lawrence ≥1 grade increase) were assessed using logistic regression models. RESULTS: We found statistically significant between-group differences favoring exercise therapy at 3 months (quadriceps -0.30 Nm/kg [95% confidence interval (95% CI) -0.40, -0.20]; hamstrings -0.10 Nm/kg [95% CI -0.15, -0.04]) and 12 months (quadriceps -0.13 Nm/kg [95% CI -0.23, -0.03]; hamstrings -0.08 Nm/kg [95% CI -0.14, -0.03]). At 5 years, between-group differences were -0.10 Nm/kg (95% CI -0.21, 0.01) for quadriceps and -0.07 Nm/kg (95% CI -0.13, -0.01) for hamstrings. Quadriceps muscle weakness at baseline was associated with knee osteoarthritis progression over 5 years, with adjusted odds ratio of 1.40 for every 0.2 Nm/kg decrease (95% CI 1.15, 1.71). The adjusted odds ratio for hamstrings was 1.14 (95% CI 0.97, 1.35) for every 0.1 Nm/kg decrease. CONCLUSION: Exercise therapy was effective in improving muscle strength at 3- and 12-month follow-up compared to partial meniscectomy, but the effect was attenuated at 5 years. Quadriceps muscle weakness at baseline was associated with higher odds of osteoarthritis progression over 5 years.

Assessing implementation, limited efficacy, and acceptability of the BEAST tool: A rehabilitation and return-to-sport decision tool for nonprofessional athletes with anterior cruciate ligament reconstruction.

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

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

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.

On a Trajectory for Success-9 in Every 10 People With a Degenerative Meniscus Tear Have Improved Knee Function Within 2 Years After Treatment: A Secondary Exploratory Analysis of a Randomized Controlled Trial.

OBJECTIVE: To identify trajectories of patient-reported knee function over 5 years in patients with degenerative meniscal tears, and to explore whether baseline characteristics were associated with trajectories of sport and recreational function. DESIGN: Prospective cohort study. METHODS: We conducted a secondary exploratory analysis of the Odense-Oslo Meniscectomy Versus Exercise randomized controlled trial. Patient-reported knee function was assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 3 months, 1 year, 2 years, and 5 years. We used group-based trajectory modeling to identify subgroups of patients who followed distinctive patterns of change. Multinomial logistic regression was used to examine the associations of patient demographics, knee function, and disease-related factors with KOOS sport and recreational function subscale trajectories. RESULTS: The analysis of data from a sample of 140 participants identified 3 trajectories for all KOOS subscales: (1) low, minimal improvement (10%-12% of the participants), (2) moderate, gradual improvement (20%-36%), and (3) high, early improvement (53%-70%). Baseline prognostic factors for deteriorating function in sport and recreational activities were higher body mass index, poorer mental health, greater knee pain, lower perceived knee function, poorer quadriceps and hamstrings muscle strength, poorer functional performance, more meniscal extrusion, and radiographic signs of knee osteoarthritis. CONCLUSION: We found 3 distinct trajectories of patient-reported knee function over 5 years: (1) low, minimal improvement, (2) moderate, gradual improvement, and (3) high, early improvement. Nine in every 10 participants improved at least gradually over 2 years after diagnosis of a degenerative meniscal tear. J Orthop Sports Phys Ther 2021;51(6):289-297. Epub 10 May 2021. doi:10.2519/jospt.2021.10025.

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

BACKGROUND: Anterior cruciate ligament (ACL) injuries can be treated with or without ACL reconstruction (ACLR), and more high-quality studies evaluating outcomes after the different treatment courses are needed. The purpose of the present study was to describe and compare 5-year clinical, functional, and physical activity outcomes for patients who followed our decision-making and treatment algorithm and chose (1) early ACLR with preoperative and postoperative rehabilitation, (2) delayed ACLR with preoperative and postoperative rehabilitation, or (3) progressive rehabilitation alone. Early ACLR was defined as that performed ≤6 months after the preoperative rehabilitation program, and late ACLR was defined as that performed >6 months after the preoperative rehabilitation program. METHODS: We included 276 patients from a prospective cohort study. The patients had been active in jumping, pivoting, and cutting sports before the injury and sustained a unilateral ACL injury without substantial concomitant knee injuries. The patients chose their treatment through a shared decision-making process. At 5 years, we assessed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, sports participation, quadriceps muscle strength, single-legged hop performance, and new ipsilateral and contralateral knee injuries. RESULTS: The 5-year follow-up rate was 80%. At 5 years, 64% of the patients had undergone early ACLR, 11% had undergone delayed ACLR, and 25% had had progressive rehabilitation alone. Understandably, the choices that participants made differed by age, concomitant injuries, symptoms, and predominantly level-I versus level-II preinjury activity level. There were no significant differences in any clinical, functional, or physical activity outcomes among the treatment groups. Across treatment groups, 95% to 100% of patients were still active in some kind of sports and 65% to 88% had IKDC-SKF and KOOS scores above the threshold for a patient acceptable symptom state. CONCLUSIONS: Patients with ACL injury who were active in jumping, pivoting, and cutting sports prior to injury; who had no substantial concomitant knee injuries; and who followed our decision-making and treatment algorithm had good 5-year knee function and high sport participation rates. Three of 4 patients had undergone ACLR within 5 years. There were no significant differences in any outcomes among patients treated with early ACLR, delayed ACLR, or progressive rehabilitation alone. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.