Ioannis Kostogiannis

Prevalence of Tibiofemoral Osteoarthritis 15 Years After Nonoperative Treatment of Anterior Cruciate Ligament Injury: A Prospective Cohort Study

Background The occurrence of osteoarthritis (OA), associated meniscal injuries, meniscectomy, and patient-related measures for patients treated nonoperatively after anterior cruciate ligament (ACL) injuries have not been well described in the literature in terms of natural history. Hypothesis Patients with ACL injury can achieve a low occurrence of tibiofemoral OA and good knee function when treated without ACL reconstruction. Study Design Cohort study (prognosis); Level of evidence, 2. Methods One hundred consecutive patients with an acute, complete ACL injury were observed for 15 years. All patients were primarily treated with activity modification and without ACL reconstruction. To achieve improved functional stability, supervised physical therapy was initiated early after injury. The patients were examined using anteroposterior weightbearing radiography. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms and knee function. Results Seventy-nine patients consented to radiographic examination and 93 completed the KOOS questionnaire. Thirteen patients (16%), all of whom were among the 35 patients whose knees were meniscectomized, developed radiographic tibiofemoral OA. In contrast, none of the remaining nonmeniscectomized and radiographed knees developed OA (n = 44) (P < .0001). Sixty-three patients (68%) had an asymptomatic knee. Twenty-two patients (23%) had undergone ACL reconstruction with a mean time of 4 years after injury. Conclusion The study had a favorable long-term outcome regarding incidence of radiographic knee OA, knee function and symptoms, and need for ACL reconstruction. Although risk factors for posttraumatic OA are multifactorial, the primary risk factor that stood out in this study was if a meniscectomy had been performed. Early activity modification and neuromuscular knee rehabilitation might also have been related to the low prevalence of radiographic knee OA. In patients with ACL injury willing to moderate activity level to avoid reinjury, initial treatment without ACL reconstruction should be considered.

Activity Level and Subjective Knee Function 15 Years After Anterior Cruciate Ligament Injury A Prospective, Longitudinal Study of Nonreconstructed Patients

Background The activity level and subjective knee function after an anterior cruciate ligament (ACL) injury treated without reconstruction have not been well elucidated. Hypothesis Patients with ACL injury can achieve good knee function and satisfactory long-term activity level when treated by early activity modification combined with rehabilitation. Study Design Cohort study (prognosis); Level of evidence, 2. Materials and Methods One hundred patients with an acute total ACL injury were observed for 15 years. All patients initially underwent arthroscopic surgery and a rehabilitation program. They were advised to modify their activity level, especially by avoiding contact sports. Patients with recurrent giving-way episodes and/or secondary meniscal injuries that required fixation (n = 6) were subsequently excluded and underwent reconstruction (n = 22). Sixty-seven patients with unilateral nonreconstructed ACL injury remained at the 15-year follow-up. The Lysholm knee score, Tegner activity level, and a visual analog score for global knee function were recorded at regular intervals. At the final follow-up, patients were further evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective knee evaluation form. Results Forty patients resumed their preinjury activity level or higher within 3 years. The median activity level 15 years after injury had decreased from 7 to 4 according to Tegner activity scale (P < .001). The mean Lysholm knee score was 96 and 95, 1 and 3 years after injury, respectively, but declined to 86 after 15 years (P < .001). Forty-nine patients had good/excellent results, and 14 had fair (n = 6) or poor function (n = 8) at 15 years. Patients injured in contact sports scored lower in the quality of life sub-scale of KOOS than those injured in noncontact sports (P < .05). Thirteen of the 67 patients (19%) were reoperated with an arthroscopic procedure because of knee symptoms. Conclusion Early activity modification and neuromuscular rehabilitation resulted in a good knee function and an acceptable activity level in the majority of the nonreconstructed patients. The decline in activity level of patients engaged in contact sports at the time of injury affected their subjective quality of life more than patients involved in noncontact sports.

Risk factors for a contralateral anterior cruciate ligament injury.

Contralateral anterior cruciate ligament (ACL) injuries are together with the risk of developing osteoarthritis of the knee and the risk of re-rupture/graft failure important aspects to consider after an ACL injury. The aim of this review was to perform a critical analysis of the literature on the risk factors associated with a contralateral ACL injury. A better understanding of these risk factors will help in the treatment of patients with unilateral ACL injuries and in the development of interventions designed to prevent contralateral ACL injuries. A Medline search was conducted to find studies investigating risk factors for a contralateral ACL injury, as well as studies where a contralateral ACL injury was the outcome of the study. Twenty studies describing the risk of a contralateral ACL rupture, or specific risk factors for a contralateral ACL injury, were found and systematically reviewed. In 13 of these studies, patients were followed prospectively after a unilateral ACL injury. The evidence presented in the literature shows that the risk of sustaining a contralateral ACL injury is greater than the risk of sustaining a first time ACL injury. Return to a high activity level after a unilateral ACL injury was the most important risk factor of sustaining a contralateral ACL injury. There was inconclusive evidence of the relevance of factors such as female gender, family history of ACL injuries, and a narrow intercondylar notch, as risk factors for a contralateral ACL injury. Risk factors acquired secondary to the ACL injury, such as altered biomechanics and altered neuromuscular function, affecting both the injured and the contralateral leg, most likely, further increase the risk of a contralateral ACL injury. This literature review indicates that the increased risk of sustaining a contralateral ACL injury should be contemplated, when considering the return to a high level of activity after an ACL injury.

Clinically Assessed Knee Joint Laxity as a Predictor for Reconstruction After an Anterior Cruciate Ligament Injury A Prospective Study of 100 Patients Treated With Activity Modification and Rehabilitation

Background The association of early knee joint laxity with the need for later reconstruction of the anterior cruciate ligament has not been extensively studied. Hypothesis The grade of knee laxity can be used as an early predictor of the need for later reconstruction. Study Design Cohort study (prognosis); Level of evidence, 2. Methods One hundred consecutive patients with an acute arthroscopically verified total anterior cruciate ligament rupture were followed prospectively for 15 years. Lachman and pivot-shift tests were performed with the patient under general anesthesia before arthroscopy. After 3 months, the tests were repeated in an ordinary clinical setting. All patients underwent rehabilitation as the first choice of treatment. Anterior cruciate ligament reconstruction was performed only in cases of significant reinjuries (n = 16) or reparable meniscal lesions (n = 6) at a mean of 4 years after injury (range, 4 months-11 years). After 15 years, 94 patients were available for follow-up. Results Of the later reconstructed patients (n = 18), 82% had a high-grade Lachman test under anesthesia compared with 63% of the nonreconstructed patients (n = 45; P = .048). At 3 months, 44% of the nonreconstructed patients (n = 32) had a high-grade Lachman test compared with 82% of the reconstructed patients (n = 18; P = .007). Twenty-five patients displayed a normal pivot-shift test at 3 months, of whom 1 underwent later reconstruction (P = .009). A high-grade pivot-shift test at 3 months was associated with an 11.4 relative risk for reconstruction. Conclusion A positive pivot-shift test at 3 months after injury in an awake patient is the strongest predictor for the future need for reconstruction. Furthermore, a normal pivot-shift test at 3 months indicates a low risk for reconstruction and is characteristic for copers.

Differences in the radiological characteristics between post‐traumatic and non‐traumatic knee osteoarthritis

Osteoarthritis (OA) of the knee can be defined as primary (non‐traumatic) or secondary (post‐traumatic). Both non‐traumatic OA and post‐traumatic OA have been described predominantly in the medial compartment of the knee. The objective of this study was to compare the location of structural radiographic changes in non‐traumatic OA and post‐traumatic OA. A non‐traumatic cohort, consisting of 155 patients suffering from chronic knee pain without known major injuries, was compared with a post‐traumatic cohort, consisting of 176 patients, all of whom had sustained an anterior cruciate ligament injury while playing soccer. A standardized weight‐bearing knee radiography of the tibiofemoral joint was performed. Joint space narrowing (JSN) and osteophytes were graded according to the radiographic atlas of the Osteoarthritis Research Society International. JSN and osteophytes were located predominantly in the medial compartment in the non‐traumatic cohort. In the post‐traumatic cohort, structural changes were evenly distributed between the lateral and the medial compartments. We were thus able to demonstrate radiological differences between post‐traumatic and non‐traumatic OA.

Knee laxity after complete anterior cruciate ligament tear: a prospective study over 15 years.

There is limited knowledge of knee laxity in the long term after a complete anterior cruciate ligament (ACL) tear treated without ACL reconstruction. The aim of this study was (1) to describe the clinical course of knee laxity after a complete ACL tear over 15 years, and (2) to study the association between knee laxity and meniscal injuries and the development of knee osteoarthritis (OA). We studied 100 consecutive subjects [mean (SD) age 26 (8) years] presenting with acute ACL injury prospectively. The initial treatment in all subjects was knee rehabilitation without reconstructive surgery. The subjects were examined with Lachmans and pivot‐shift tests at baseline, 6 weeks, 3 months, 1 year, 3 years and 15 years after the injury. Sagittal knee laxity was also evaluated with the KT‐1000 arthrometer at the 15‐year follow‐up. During follow‐up, 22 subjects were ACL reconstructed due to unacceptable knee instability. There was only a mild remaining knee laxity [median Lachman grade and pivot‐shift test value of 1 on a 4‐grade scale (0–3)] after 15 years in subjects treated without primary ACL reconstruction. Knees with higher anterior sagittal knee laxity 3 months after the injury had a worse long‐term outcome with respect to meniscal injuries and knee OA development.

Arthroscopic Surgical Procedures Versus Sham Surgery for Patients With Femoroacetabular Impingement and/or Labral Tears: Study Protocol for a Randomized Controlled Trial (HIPARTI) and a Prospective Cohort Study (HARP)

•STUDY DESIGN: Study protocol for a randomized controlled trial and a prospective cohort. •BACKGROUND: The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high‐quality evidence of the effect of such interventions is lacking. •OBJECTIVES: The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient‐reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long‐term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). •METHODS: The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool‐33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self‐Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient‐Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. •CONCLUSION: To determine the true effect of surgery, beyond that of placebo, double‐blinded placebo‐controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence‐based treatment of FAIS. Predictors for long‐term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined.