A pragmatic approach to prevent post-traumatic osteoarthritis after sport or exercise-related joint injury

Health And Performance Promotion in Youth (HAPPY) hybrid effectiveness-implementation cluster randomised trial: comparison of two strategies to implement an injury prevention exercise programme in Danish youth handball

OBJECTIVE

To investigate if a combination of an online and onsite implementation strategy was superior to an online-only strategy in enhancing the use of an injury prevention exercise programme (IPEP) and in reducing the risk of shoulder, knee and ankle injuries in youth community handball players (age 11-17) over a handball season.

METHODS

In this 30-week hybrid effectiveness-implementation cluster randomised type 3 study, 20 youth handball clubs were randomly assigned 1:1 to either a combined online and onsite implementation strategy (coach workshop using the health action process approach behaviour change model and health service provider (HSP) support) or an online-only strategy (control group). The primary implementation outcome was coach-reported adherence, measured as the average IPEP exercise usage by the team over 30 weeks. The primary effectiveness outcome was player-reported handball playing time to any new handball-related shoulder, knee and ankle injuries, reported weekly using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems.

RESULTS

We enrolled 63 coaches (27% women) and 945 players (mean age 14.5 years, 55% girls). Intention-to-treat analyses showed no statistically significant difference between implementation strategies in adherence (between-group difference 1.4, 95% CI -0.5 to 3.4) or in cumulative injury risk (between-group difference 5.5% points, 95% CI -2.2 to 13.1).

CONCLUSION

Our findings demonstrate that in youth community handball, a combined online and onsite implementation strategy, including a coach workshop and HSP support, was not superior to an online-only strategy regarding adherence to an IPEP or in reducing shoulder, knee and ankle injury risk.

TRIAL REGISTRATION NUMBER

NCT05294237.

Mechanical loading and orthobiologic therapies in the treatment of post-traumatic osteoarthritis (PTOA): a comprehensive review

The importance of mechanical loading and its relationship to orthobiologic therapies in the treatment of post-traumatic osteoarthritis (PTOA) is beginning to receive attention. This review explores the current efficacy of orthobiologic interventions, notably platelet-rich plasma (PRP), bone marrow aspirate (BMA), and mesenchymal stem/stromal cells (MSCs), in combating PTOA drawing from a comprehensive review of both preclinical animal models and human clinical studies. This review suggests why mechanical joint loading, such as running, might improve outcomes in PTOA management in conjunction with orthiobiologic administration. Accumulating evidence underscores the influence of mechanical loading on chondrocyte behavior and its pivotal role in PTOA pathogenesis. Dynamic loading has been identified as a key factor for optimal articular cartilage (AC) health and function, offering the potential to slow down or even reverse PTOA progression. We hypothesize that integrating the activation of mechanotransduction pathways with orthobiologic treatment strategies may hold a key to mitigating or even preventing PTOA development. Specific loading patterns incorporating exercise and physical activity for optimal joint health remain to be defined, particularly in the clinical setting following joint trauma.

Regulation of Oxygen Tension as a Strategy to Control Chondrocytic Phenotype for Cartilage Tissue Engineering and Regeneration

Cartilage defects and osteoarthritis are health problems which are major burdens on health care systems globally, especially in aging populations. Cartilage is a vulnerable tissue, which generally faces a progressive degenerative process when injured. This makes it the 11th most common cause of global disability. Conservative methods are used to treat the initial phases of the illness, while orthopedic management is the method used for more progressed phases. These include, for instance, arthroscopic shaving, microfracturing and mosaicplasty, and joint replacement as the final treatment. Cell-based implantation methods have also been developed. Despite reports of successful treatments, they often suffer from the non-optimal nature of chondrocyte phenotype in the repair tissue. Thus, improved strategies to control the phenotype of the regenerating cells are needed. Avascular tissue cartilage relies on diffusion for nutrients acquisition and the removal of metabolic waste products. A low oxygen content is also present in cartilage, and the chondrocytes are, in fact, well adapted to it. Therefore, this raises an idea that the regulation of oxygen tension could be a strategy to control the chondrocyte phenotype expression, important in cartilage tissue for regenerative purposes. This narrative review discusses the aspects related to oxygen tension in the metabolism and regulation of articular and growth plate chondrocytes and progenitor cell phenotypes, and the role of some microenvironmental factors as regulators of chondrocytes.

The effect of MSM in the treatment of ankle arthrosis: Is MSM as effective as methylprednisolone or hyaluronic acid?

Posttraumatic ankle osteoarthritis (PTAO) causes severe ankle and adjacent joint morbidity. We aimed to compare the treatment efficacy of previously tried and still applied intra-articular injections and oral methylsulfonylmethane (MSM) at functional and histopathological level in PTAO animal model. Thirty-two adult female Sprague-Dawley rats were divided into four groups (Group 1: Control, Group 2: 0.06 g/kg/day MSM, Group 3: 0.04 mg/µL methylprednisolone [MP], Group 4: 0.04 mg/µL hyaluronic acid [HA]). MSM was started orally between Day 0 to the end of 8 weeks. Intra-articular injections were applied to the right ankles of the subjects after surgery. All subjects were killed after radiological evaluation at the 8th week. Subsequently, functional (range of motion) and histopathological evaluation was performed. Radiological evaluation showed better results of the MP (p < 0.001) and MSM (p < 0.001) groups than the control group. Severity of osteoarthritis (OA) in the MP group was significantly less than in the HA group (p = 0.032). When the total Osteoarthritis Research Society International score was compared, the severity of OA was higher in the KS and HA groups than in the control group (p < 0.001). No significant statistical difference was found in the histopathological comparison of MSM and control group (p = 0.466). There was no difference between the groups in range of motion measurement according to the contralateral ankle joint. The radiological progression of OA was slowed in the MSM and MP groups, but significant histopathological worsening was found in the MP and HA applied groups. We suggest that the treatment methods used in daily practice need to be reviewed.

The effect of attending rehabilitation after traumatic knee joint injury on femoral articular cartilage morphology in collegiate rugby players with a history of intracapsular knee joint injury during two-year consecutive rugby seasons

Introduction

This present study aimed to compare ultrasonographic measures of femoral articular cartilage during two-year seasons between collegiate rugby players who have attended supervised rehabilitation following intracapsular knee joint injury and those without a history of knee injury.

Methods

Using a prospective observational study design, 12 male collegiate rugby players with a previous history of intracapsular knee joint injury who have received and completed supervised rehabilitation following their injury and 44 players without knee joint injury participated in this study. Ultrasonographic images were used to verify changes in femoral articular cartilage thickness and cross-sectional area (CSA) with or without a previous history of knee joint injury over two consecutive rugby seasons.

Results

Significant time main effects were observed for the lateral condylar thickness (p < 0.001), the intercondylar thickness (p = 0.001), the medial condylar thickness (p < 0.001), and CSA (p < 0.001). No significant interactions nor group main effects were identified for all femoral articular cartilage (p < 0.05).

Conclusions

Collegiate rugby players demonstrated a decrease in femoral articular cartilage thickness and CSA over two-year consecutive rugby seasons. These findings indicate that engaging in collegiate rugby induces alterations in femoral articular cartilage structure. Furthermore, there were no differences in all femoral cartilage outcome measures between rugby players with and without a previous history of traumatic knee joint injury. Therefore, attending supervised rehabilitation at the time of their knee joint injury appeared to reduce the impact of a previous history of intracapsular knee joint injury on the change in femoral articular cartilage thickness and CSA among active rugby players.

Post-traumatic osteoarthritis: the worst associated injuries and differences in patients' profile when compared with primary osteoarthritis

BACKGROUND

The estimated prevalence of post-traumatic osteoarthritis (PTOA) is 10-12% and in this study 12.4%. Different knee and hip injuries have been identified as risk factors for PTOA, but there is no consensus regarding the most painful and disabling injuries. Identifying these injuries might help in the prevention of PTOA. Additionally, patients with PTOA have a higher risk for complications after arthroplasty than patients with primary OA, perhaps due to differences in the profile and comorbidity that might help to explain the difference. This work aims 1) to identify the most common past injuries associated with the most painful and disabling PTOA cases in non-athlete patients and 2) to compare the comorbidities and characteristics between PTOA and primary OA.

METHODS

Retrospective hospital-based cohort study with 1290 participants with joint complaints or who received arthroplasty. Medical records included demographic information, diagnosis, medication, smoking, alcohol history and comorbidities. Data from January 2012 orthopaedic consults till December 2019 was reviewed and had the type and date of injury, pain score by the numerical rating scale and walking disability. Odds Ratio (OR) and 95% confidence intervals are presented.

RESULTS

There were 641 cases with primary OA (65% females) and 104 with PTOA (61% males). Patients with PTOA were 7.5 years younger (P < 0.001), reported more alcohol consumption (P = 0.01) and had higher odds of osteoporotic fractures (OP) and psychosis than patients with primary OA (OR = 2.0, CI = 1.06-3.78 and OR = 2.90, CI = -0.91-9.18, respectively). Knee fractures were most common in males and hip fractures in females (31% and 37.5%, respectively, P < 0.005). The PTOA-associated injuries with the highest pain and disability scores were meniscal injuries and hip fractures. Besides, in the group with primary OA, there were more diabetes, hypertension and hypothyroidism cases than in PTOA. However, after adjustment, differences were only significant for diabetes (OR_adj = 1.78, CI = 1.0-3.2).

CONCLUSIONS

Past meniscal injuries and hip fractures were the most relevant PTOA-associated injuries regarding pain and walking disability. This, together with differences in their profile when compared with primary OA, might help to decide the orthopaedic management of these injuries to prevent complications such as PTOA and recurrence, with appropriate preoperative planning, surgery choice and comorbidity treatment.

Healthy and Osteoarthritis-Affected Joints Facing the Cellular Crosstalk

Osteoarthritis (OA) is a chronic, progressive, severely debilitating, and multifactorial joint disease that is recognized as the most common type of arthritis. During the last decade, it shows an incremental global rise in prevalence and incidence. The interaction between etiologic factors that mediate joint degradation has been explored in numerous studies. However, the underlying processes that induce OA remain obscure, largely due to the variety and complexity of these mechanisms. During synovial joint dysfunction, the osteochondral unit undergoes cellular phenotypic and functional alterations. At the cellular level, the synovial membrane is influenced by cartilage and subchondral bone cleavage fragments and extracellular matrix (ECM) degradation products from apoptotic and necrotic cells. These "foreign bodies" serve as danger-associated molecular patterns (DAMPs) that trigger innate immunity, eliciting and sustaining low-grade inflammation in the synovium. In this review, we explore the cellular and molecular communication networks established between the major joint compartments-the synovial membrane, cartilage, and subchondral bone of normal and OA-affected joints.

Post-traumatic osteoarthritis: epidemiology, pathogenesis, clinical picture, approaches to pharmacotherapy

Post-traumatic osteoarthritis (PTOA) is an inflammatory and degenerative disease that occurs as a result of the joint structures injury. It is a common pathology, accounting for approximately 12% of all cases of osteoarthritis (OA). PTOA often occurs in people of young productive age, progresses rapidly, causing chronic pain and increasing dysfunction. Individuals undergoing joint replacement for PTOA are, on average, 10 years younger than those with primary OA. The time interval from the moment of injury to the onset of typical PTOA radiological signs varies widely – from 1 year to 15–20 years.The main injuries that cause PTOA are intra-articular fractures, anterior cruciate ligament injuries, meniscus rupture and dislocation of the patella of the knee joint, joint dislocations with damage to the ligamentous apparatus of the ankle and shoulder joints.The pathogenesis of PTOA is determined by chronic inflammation accompanied by macrophage activation, hyperproduction of cytokines, primarily interleukin (IL) 1â, chemokines and growth factors, progressive destruction of joint tissue and degenerative changes (fibrosis, neoangiogenesis, osteophytosis).Pathogenetic treatment of PTOA, which would stop the progression of the disease, has not been developed. The possibility of using inhibitors of IL1â, IL6, inhibitors of tumor necrosis factor á, glucocorticoids, hyaluronic acid, autologous cell based therapy is under study. The control of pain and inflammation in PTOA requires the prescription of traditional drugs that are widely used in the practice of managing patients with primary OA. In particular, the use of symptomatic delayed-acting agents, such as the injectable form of chondroitin sulfate, seems to be appropriate.

SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) versus minimal intervention for young adults at risk of knee osteoarthritis after ACL reconstruction: SUPER-Knee randomised controlled trial protocol

INTRODUCTION

Anterior cruciate ligament injury and reconstruction (ACLR) is often associated with pain, functional loss, poor quality of life and accelerated knee osteoarthritis development. The effectiveness of interventions to enhance outcomes for those at high risk of early-onset osteoarthritis is unknown. This study will investigate if SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) is superior to a minimal intervention control for improving pain, function and quality of life in young adults with ongoing symptoms following ACLR.

METHODS AND ANALYSIS

The SUPER-Knee Study is a parallel-group, assessor-blinded, randomised controlled trial. Following baseline assessment, 184 participants aged 18-40 years and 9-36 months post-ACLR with ongoing symptoms will be randomly allocated to one of two treatment groups (1:1 ratio). Ongoing symptoms will be defined as a mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score (KOOS₄) subscales covering pain, symptoms, function in sports and recreational activities and knee-related quality of life. Participants randomised to SUPER will receive a 4-month individualised, physiotherapist-supervised strengthening and neuromuscular programme with education. Participants randomised to minimal intervention (ie, control group) will receive a printed best-practice guide for completing neuromuscular and strengthening exercises following ACLR. The primary outcome will be change in the KOOS₄ from baseline to 4 months with a secondary endpoint at 12 months. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, kinesiophobia, physical activity, thigh muscle strength, knee function and knee cartilage morphology (ie, lesions, thickness) and composition (T2 mapping) on MRI. Blinded intention-to-treat analyses will be performed. Findings will also inform cost-effectiveness analyses.

ETHICS AND DISSEMINATION

This study is approved by the La Trobe University and Alfred Hospital Ethics Committees. Results will be presented in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620001164987.

"I feel I'm leading the charge." Experiences of a virtual physiotherapist-guided knee health program for persons at-risk of osteoarthritis after a sport-related knee injury

Objective

Describe participants' perspectives about the feasibility of a virtual, physiotherapist-guided knee health program for people at risk of post-traumatic osteoarthritis after a sport-related knee injury.

Design

Qualitative description study nested within a quasi-experimental study evaluating the feasibility of the Stop OsteoARthritis (SOAR) with persons with sport-related knee injuries. SOAR includes: 1) one-time Knee Camp (group education, 1:1 exercise/activity goal-setting); 2) weekly home-based exercise/activity program with tracking, and; 3) weekly 1:1 physiotherapy-guided action-planning. Upon program completion, semi-structured 1:1 interviews were conducted with participants identified by convenience and maximum variation sampling (age, gender, program satisfaction). Open-ended questions elicited participants' experiences with the program. Content analysis was conducted.

Results

12 women and 4 men [median (min-max) age; 30 (19-46) years] were interviewed. Four categories depicted participants' experiences: 1) 'SOAR satisfies an unmet need' portrayed the perceived relevance and need for a program that promotes knowledge about knee health and self-efficacy for independent exercise behaviour, 2) 'Regaining control of knee health' described how SOAR empowered participants and fostered a sense of 'leading the charge' to their own knee health, 3) 'Social support encourages exercise participation' highlighted that weekly physiotherapy interactions provided accountability for achieving exercise goals, and that relating to other participants was inspirational, 4) 'Program refinements and barriers' suggested enhancements to meet the needs of future participants.

Conclusions

Participants report the SOAR program to be acceptable, relevant, and empowering. Improved knowledge about one's knee health, self-efficacy, autonomy, and social support may encourage exercise adherence and self-management of future knee OA risk.

Osteoarthritis as an Umbrella Term for Different Subsets of Humans Undergoing Joint Degeneration: The Need to Address the Differences to Develop Effective Conservative Treatments and Prevention Strategies

Osteoarthritis (OA) of joints such as the knee and hip are very prevalent, and the number of individuals affected is expected to continue to rise. Currently, conservative treatments after OA diagnosis consist of a series of increasingly invasive interventions as the degeneration and pain increase, leading very often to joint replacement surgery. Most interventions are focused on alleviating pain, and there are no interventions currently available that stop and reverse OA-associated joint damage. For many decades OA was considered a disease of cartilage, but it is now considered a disease of the whole multi-tissue joint. As pain is the usual presenting symptom, for most patients, it is not known when the disease process was initiated and what the basis was for the initiation. The exception is post-traumatic OA which results from an overt injury to the joint that elevates the risk for OA development. This scenario leads to very long wait lists for joint replacement surgery in many jurisdictions. One aspect of why progress has been so slow in addressing the needs of patients is that OA has been used as an umbrella term that does not recognize that joint degeneration may arise from a variety of mechanistic causes that likely need separate analysis to identify interventions unique to each subtype (post-traumatic, metabolic, post-menopausal, growth and maturation associated). A second aspect of the slow pace of progress is that the bulk of research in the area is focused on post-traumatic OA (PTOA) in preclinical models that likely are not clearly relevant to human OA. That is, only ~12% of human OA is due to PTOA, but the bulk of studies investigate PTOA in rodents. Thus, much of the research community is failing the patient population affected by OA. A third aspect is that conservative treatment platforms are not specific to each OA subset, nor are they integrated into a coherent fashion for most patients. This review will discuss the literature relevant to the issues mentioned above and propose some of the directions that will be required going forward to enhance the impact of the research enterprise to affect patient outcomes.

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.

An exploration of the antecedents and mechanisms causing athletes' stress and twisties symptom

Research background

Twisties symptoms have attracted the world's attention in the sports field since the 2020 Tokyo Olympics.

Aim

However, studies on the symptoms and causes, inducing mechanisms, and relationships between DP/DR (Depersonalization/Derealization Disorder) and anxiety and depression for athletes have been sparse for both the general population and athletes. The literature on the twisties issue of athletes is quite scarce in the past.

Research method

Adopting the criteria appealing to PRISMA Items to review the subject twisties in a broader mode and combing with the IPO (Input-Process-Output) model for triangulation testing purpose, this study categorized the literature to explore input variables causing athletes’ twisties and identified process variables in psychological mechanisms bridging suppression and finally discussed the existing possible ways in helping athletes to solve problems caused by twisties.

Results

The authors formed 6 propositions in summarizing twisties' influential factors and mechanisms and tried to propose solutions to reduce the stress and the relevant twisties symptom of athletes. (1) Promotion of Athletes' Mental Toughness to Resist Stressors. (2) Interventions that correct for cognitive misinterpretations and appropriate relaxation and mindfulness practice in correcting a range of attention might reduce DP/DR. (3) Monitoring the athlete's HRV test results to ensure the Athlete's ability to resist pressure. (4) Avoid organizational stressors. (5) Written Emotional Disclosure method. (6) Improve various support systems for athletes: dual career paths. (7) Athletes' Stressful Awareness about the impact of gender, seniority, and environment.

Conclusion

Through the theoretical dialogue on the symptom of twisties, this study helps promote the development of the research of “twisties” and depersonalization-derealization symptoms (DDS); both have been under-researched.

Study on the Role of MicroRNA-214 in the Rehabilitation of Cartilage in Mice with Exercise-Induced Traumatic Osteoarthritis

This study aimed to explore the possible relationship between the expression of Micro RNA-214 (miR-214) and the pathogenesis and recovery in mice with post-traumatic osteoarthritis (PTOA). In this study, 40 male C57BL/6 mice were randomly divided into five groups: model control (MC) group, model (M) group, rehabilitation control (RC) group, model + rehabilitation (M + R) group, and model + convalescent (M + C) group. Four weeks of high-intensity treadmill exercise (HITE) and 4 weeks of moderate-intensity treadmill exercise (MITE) were implemented for PTOA modeling and rehabilitation, respectively. In vitro, 10% elongation mechanical strain was used for IL-1β stimulated chondrocytes. We found that compared with the MC group, there was a significant increase in the aspect of inflammation and catabolism while a dramatic fall in miR-214 expression was observed in the M group. After the 4 weeks of MITE, the level of inflammation and metabolism, as well as miR-214 expression, was partially reversed in the M + R group compared with the M + C group. The expression of miR-214 decreased dramatically after chondrocyte stimulation by IL-1β and then increased significantly after 10% strain was applied to IL-1β-treated cells. These results suggest that a suitable mechanical load can increase the expression of miR-214, and that miR-214 may play a chondroprotective effect in the development of OA.

Risk factors for knee osteoarthritis after traumatic knee injury: a systematic review and meta-analysis of randomised controlled trials and cohort studies for the OPTIKNEE Consensus

Objective

To identify and quantify potential risk factors for osteoarthritis (OA) following traumatic knee injury.

Design

Systematic review and meta-analyses that estimated the odds of OA for individual risk factors assessed in more than four studies using random-effects models. Remaining risk factors underwent semiquantitative synthesis. The modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for prognostic factors guided the assessment.

Data sources

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to 2009–2021.

Eligibility

Randomised controlled trials and cohort studies assessing risk factors for symptomatic or structural OA in persons with a traumatic knee injury, mean injury age ≤30 years and minimum 2-year follow-up.

Results

Across 66 included studies, 81 unique potential risk factors were identified. High risk of bias due to attrition or confounding was present in 64% and 49% of studies, respectively. Ten risk factors for structural OA underwent meta-analysis (sex, rehabilitation for anterior cruciate ligament (ACL) tear, ACL reconstruction (ACLR), ACLR age, ACLR body mass index, ACLR graft source, ACLR graft augmentation, ACLR+cartilage injury, ACLR+partial meniscectomy, ACLR+total medial meniscectomy). Very-low certainty evidence suggests increased odds of structural OA related to ACLR+cartilage injury (OR=2.31; 95% CI 1.35 to 3.94), ACLR+partial meniscectomy (OR=1.87; 1.45 to 2.42) and ACLR+total medial meniscectomy (OR=3.14; 2.20 to 4.48). Semiquantitative syntheses identified moderate-certainty evidence that cruciate ligament, collateral ligament, meniscal, chondral, patellar/tibiofemoral dislocation, fracture and multistructure injuries increase the odds of symptomatic OA.

Conclusion

Moderate-certainty evidence suggests that various single and multistructure knee injuries (beyond ACL tears) increase the odds of symptomatic OA. Risk factor heterogeneity, high risk of bias, and inconsistency in risk factors and OA definition make identifying treatment targets for preventing post-traumatic knee OA challenging.

Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis

OBJECTIVE

Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.

DESIGN

Living systematic review and meta-analysis.

DATA SOURCES

Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.

ELIGIBILITY CRITERIA

Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.

DATA SYNTHESIS

Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.

RESULTS

Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.

CONCLUSIONS

There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.

PROSPERO REGISTRATION NUMBER

CRD42021256537.

New or Recurrent Knee Injury, Physical Activity, and Osteoarthritis Beliefs in a Cohort of Female Athletes 2 to 3 Years After ACL Reconstruction and Matched Healthy Peers

BACKGROUND

At 2 to 3 years after anterior cruciate ligament reconstruction (ACLR), the relationship between known modifiable osteoarthritis (OA) risk factors and recurrent knee injury is unknown. This study aimed to determine the odds of new or recurrent traumatic knee injury in a cohort of young female athletes with ACLR 2 to 3 years postsurgery compared with healthy control participants. Secondary objectives were to explore the relationships of moderate and vigorous physical activity (MVPA) and body mass index (BMI) with knee injury, and to document self-reported MVPA satisfaction and beliefs about OA.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 2.

METHODS

A total of 51 female athletes with unilateral ACLR 1 to 2 years previously and 51 age and sport-matched control participants underwent assessment of MVPA (GT3X accelerometers) and BMI. One year later, participants self-reported knee injuries. Bivariable conditional logistic regression explored the association between knee injury, MVPA, and BMI in each group (injury/control).

RESULTS

At 1-year follow-up (n = 101), 19.6% of the injured cohort and 6.0% of control participants sustained a new or recurrent knee injury. The odds of knee injury for the injury group increased 7-fold over controls [odds ratio (OR) = 7.00 (95% CI = 0.86, 56.90)], although this was not statistically significant. The OR for MVPA was 0.98 (95% CI = 0.93, 1.03) and BMI was OR = 1.24 (95% CI = 0.85, 1.82). Half (56.0%) of injury participants and 66% of controls were satisfied with their MVPA; 81.6% of injury participants believed they had increased knee OA risk compared with someone who had never had a knee injury.

CONCLUSIONS

In the 2 to 3 years after ACLR, 1 in 5 young female athletes had a new or recurrent knee injury. Based on the point estimate, injured participants were more likely to suffer a traumatic knee injury than matched control participants. MVPA and BMI were not associated with increased odds of knee injury.

CLINICAL RELEVANCE

Clinicians should be encouraged to have in-depth conversations with female athletes with previous ACLR regarding enjoyable and sustainable MVPA participation to promote long-term joint health.

Racket or Bat Sports: No Association With Thumb-Base Osteoarthritis

CONTEXT

Repetitive joint use is a risk factor for osteoarthritis, which is a leading cause of disability. Sports requiring a racket or bat to perform repetitive high-velocity impacts may increase the risk of thumb-base osteoarthritis. However, this hypothesis remains untested.

OBJECTIVE

To determine if a history of participation in racket or bat sports was associated with the prevalence of thumb-base osteoarthritis.

DESIGN

Descriptive epidemiologic study.

SETTING

Four US clinical sites associated with the Osteoarthritis Initiative.

PATIENTS OR OTHER PARTICIPANTS

We recruited 2309 men and women from the community. Eligible participants had dominant-hand radiographic readings, hand symptom assessments, and historical physical activity survey data.

MAIN OUTCOME MEASURE(S)

A history of exposure to racket or bat sports (badminton, baseball or softball, racketball or squash, table tennis [or ping pong], tennis [doubles], or tennis [singles]) was based on self-reported recall data covering 3 age ranges (12-18, 19-34, and 35-49 years). Prevalent radiographic thumb-base osteoarthritis was defined as Kellgren-Lawrence grade >2 in the first carpometacarpal joint or scaphotrapezoidal joint at the Osteoarthritis Initiative baseline visit. Symptomatic thumb-base osteoarthritis was defined as radiographic osteoarthritis and hand or finger symptoms.

RESULTS

Radiographic or symptomatic thumb-base osteoarthritis was present in 355 (34%) and 56 (5%), respectively, of men (total = 1049) and 535 (42%) and 170 (13%), respectively, of women (total = 1260). After adjusting for age, race, and education level, we found no significant associations between a history of any racket or bat sport participation and thumb-base osteoarthritis (radiographic or symptomatic; odds ratios ranged from 0.82 to 1.34).

CONCLUSIONS

In a community-based cohort, a self-reported history of participation in racket or bat sports was not associated with increased odds of having radiographic or symptomatic thumb-base osteoarthritis in the dominant hand.

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.

Health-Related Outcomes 3-15 Years Following Ankle Sprain Injury in Youth Sport: What Does the Future Hold?

BACKGROUND

This study examined the association between youth sport-related ankle sprain injury and health-related outcomes, 3-15 years postinjury.

METHODS

A historical cohort study in which uninjured controls were cluster-matched with injured cases. The primary outcome was self-reported Foot and Ankle Outcome Score (FAOS). Secondary outcomes included measures of adiposity, validated questionnaires for physical activity, athletic identity, fear of pain, and tests of strength, balance, and function.

RESULTS

We recruited 86 participants (median age of 23 years; 77% female); 50 with a time-loss ankle sprain, median of 8 years postinjury, and 36 uninjured controls cluster-matched by sex and sport. Based on mixed effects multivariable regression models, previously injured participants demonstrated poorer outcomes than controls on all 5 FAOS subscales regardless of sex and time since injury, with the largest differences observed in symptoms (-20.9, 99% CI: -29.5 to -12.3) and ankle-related quality of life (-25.3, 99% CI: -34.7 to -15.9) subscales. Injured participants also had poorer unipedal dynamic balance (-1.9, 99% CI: 3.5 to -0.2) and greater fear of pain (7.2, 99% CI: 0.9-13.4) compared with controls. No statistically significant differences were found for other secondary outcomes.

CONCLUSION

At 3-15 years following time-loss ankle sprain injury in youth sport, previously injured participants had more pain and symptoms, poorer self-reported function, ankle-related quality of life, reduced sport participation, balance, and greater fear of pain than controls. This underlines the need to promote the primary prevention of ankle sprains and secondary prevention of potential health consequences, including posttraumatic osteoarthritis.

LEVEL OF EVIDENCE

Level III, historical cohort study.

Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury

INTRODUCTION

Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA.

METHODS

We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences.

RESULTS

Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention.

CONCLUSIONS

This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

A lifespan approach to osteoarthritis prevention

Prevention is an attractive solution for the staggering and increasingly unmanageable burden of osteoarthritis. Despite this, the field of osteoarthritis prevention is relatively immature. To date, most of what is known about preventing osteoarthritis and risk factors for osteoarthritis is relative to the disease (underlying biology and pathophysiology) of osteoarthritis, with few studies considering risk factors for osteoarthritis illness, the force driving the personal, financial and societal burden. In this narrative review we will discuss what is known about osteoarthritis prevention, propose actionable prevention strategies related to obesity and joint injury which have emerged as important modifiable risk factors, identify where evidence is lacking, and give insight into what might be possible in terms of prevention by focussing on a lifespan approach to the illness of osteoarthritis, as opposed to a structural disease of the elderly. By targeting a non-specialist audience including scientists, clinicians, students, industry employees and others that are interested in osteoarthritis but who do not necessarily focus on osteoarthritis, the goal is to generate discourse and motivate inquiry which propel the field of osteoarthritis prevention into the mainstream.

Should return to pivoting sport be avoided for the secondary prevention of osteoarthritis after anterior cruciate ligament reconstruction? A prospective cohort study with MRI, radiographic and symptomatic outcomes

OBJECTIVE

To evaluate if returning to pivoting sport following anterior cruciate ligament reconstruction (ACLR) is associated with longitudinal structural and symptomatic osteoarthritis outcomes.

DESIGN

Eighty-one adults aged 18-50 years were followed prospectively 1- to 5-years post-ACLR. Return to pivoting sport was assessed at 1-, 3- and 5-years. Longitudinal changes in osteoarthritis features were evaluated from 1- and 5-year magnetic resonance imaging (MRI)s using MRI Osteoarthritis Knee Score (MOAKS). Radiographic osteoarthritis and self-reported knee symptoms, function and quality of life were assessed using the Osteoarthritis Research Society International (OARSI) atlas and Knee injury Osteoarthritis Outcome Score (KOOS), respectively, at 5 years post-ACLR. Generalised linear models (adjusted for baseline characteristics) assessed whether returning to pivoting sport was associated with risk of worsening osteoarthritis features on MRI, radiographic osteoarthritis and KOOS.

RESULTS

Thirty participants returned to pivoting sport 1-year post-ACLR and 50 returned at any time (i.e., 1-, 3- or 5-years). Returning to pivoting sport was not associated with worsening of any MRI osteoarthritis feature (risk ratio (RR) range: 0.59-2.91) or 5-year KOOS (β range: -2.73-3.69). Returning to pivoting sport at 1-year and up to 5-years post-ACLR was associated with a 50% (RR 0.49, 95%CI 0.10-2.37) and 40% (RR 0.60, 95%CI 0.16-2.17) reduced risk of radiographic osteoarthritis, respectively, but these risk reductions were inconclusive due to wide confidence intervals.

CONCLUSION

After ACLR, returning to pivoting sport was not associated with increased risk of worsening knee osteoarthritis features on MRI, radiographic osteoarthritis or knee symptoms. Participation in pivoting sport need not be avoided as part of osteoarthritis secondary prevention strategies.

Moderate-intensity treadmill running relieves motion-induced post-traumatic osteoarthritis mice by up-regulating the expression of lncRNA H19

BACKGROUND

The purpose of this study was to explore whether moderate-intensity exercise can alleviate motion-induced post-traumatic osteoarthritis (PTOA) and the expression change of lncRNA H19 during this progression.

METHODS

Twenty-week-old male C57BL/6 mice were randomly divided into five groups: model control group (MC group, n = 6), treadmill model group (M group, n = 6), rehabilitation control group (RC group, n = 6), treadmill model + rehabilitation training group (M + R group, n = 6) and treadmill model + convalescent group (M + C group, n = 6). Paraffin sections were used to observe the pathological changes in the mouse knee joint in each group. A micro-CT was used to scan the knee joint to obtain the morphological indexes of the tibial plateau bone. Real-time PCR was used to detect the mRNA levels of inflammatory factors, synthetic and catabolic factors in cartilage.

RESULTS

After high-intensity exercise for 4 weeks, the inflammation and catabolism of the mouse knee cartilage were enhanced, and the anabolism was weakened. Further study showed that these results were partially reversed after 4-week moderate-intensity training. The results of hematoxylin-eosin staining confirmed this finding. Meanwhile, high-intensity exercise reduced the expression of lncRNA H19 in cartilage, while the expression of lncRNA H19 increased after 4 weeks of moderate-intensity exercise.

CONCLUSION

High-intensity treadmill running can cause injury to the knee cartilage in C57BL/6 mice which leads to PTOA and a decrease of lncRNA H19 expression in cartilage. Moderate-intensity exercise can relieve PTOA and partially reverse lncRNA H19 expression.

The Effect of a Single Freeze-Thaw Cycle on Matrix Metalloproteinases in Different Human Platelet-Rich Plasma Formulations

Storing platelet-rich plasma (PRP) for future use is a compelling approach, presuming the retention of biological properties is maintained. However, certain factors in PRP preparations have deleterious effects for the treatment of certain musculoskeletal conditions. The purpose of this study was to measure and compare matrix metalloproteinase protein (MMP) concentrations between fresh and freeze-thawed leukocyte-rich PRP (LR-PRP) inactivated (LR-I) and activated (LR-A) preparations, and leukocyte-poor PRP (LP-PRP) inactivated (LP-I) and activated (LP-A) preparations. A volume of 60 mL of whole blood was drawn from 19 healthy donors. LP-I and LR-I samples were processed using a manual extraction and centrifugation methodology. LP-A and LR-A products were activated with 10% CaCl2 and recombinant thrombin. Blood fractions were either immediately assayed and analyzed or stored at -80 °C for 24, 72 and 160 h. Multiplex immunoassay was used to measure MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, and MMP-12. MMP-1 concentrations increased in LR-A (p < 0.05) and MMP-9 significantly increased in LR-I (p < 0.05), while MMP-2 significantly decreased in LR-I (p < 0.05) and MMP-3 concentrations significantly decreased in LR-A (p < 0.05). MMP-12 concentrations also significantly decreased in LR-I (p < 0.05) from baseline concentrations. There were no significant differences between LP-A and LP-I preparations and MMP concentrations. MMP-10 concentrations in all PRP samples compared to each freezing time point were also not significantly different. MMPs regulate components of the extracellular matrix (ECM) in the remodeling phase of musculoskeletal injury. In this study, we observed a significant increase and decrease in MMP concentrations in response to a single freeze-thaw cycle in inactivated PRP and activated PRP preparations. This evidence contributes to the growing body of literature on the optimization of PRP preparation and storage strategies prior to delivery. Our findings suggest that specific PRP preparations after a single freeze-thaw may be more advantageous for certain musculoskeletal applications based on the presence of MMP concentrations.

Cartilage articulation exacerbates chondrocyte damage and death after impact injury

Posttraumatic osteoarthritis (PTOA) is typically initiated by momentary supraphysiologic shear and compressive forces delivered to articular cartilage during acute joint injury and develops through subsequent degradation of cartilage matrix components and tissue remodeling. PTOA affects 12% of the population who experience osteoarthritis and is attributed to over $3 billion dollars annually in healthcare costs. It is currently unknown whether articulation of the joint post-injury helps tissue healing or exacerbates cellular dysfunction and eventual death. We hypothesize that post-injury cartilage articulation will lead to increased cartilage damage. Our objective was to test this hypothesis by mimicking the mechanical environment of the joint during and post-injury and determining if subsequent joint articulation exacerbates damage produced by initial injury. We use a model of PTOA that combines impact injury and repetitive sliding with confocal microscopy to quantify and track chondrocyte viability, apoptosis, and mitochondrial depolarization in a depth-dependent manner. Cartilage explants were harvested from neonatal bovine knee joints and subjected to either rapid impact injury (17.34 ± 0.99 MPa, 21.6 ± 2.45 GPa/s), sliding (60 min at 1 mm/s, under 15% axial compression), or rapid impact injury followed by sliding. Explants were then bisected and fluorescently stained for cell viability, caspase activity (apoptosis), and mitochondria polarization. Results show that compared to either impact or sliding alone, explants that were both impacted and slid experienced higher magnitudes of damage spanning greater tissue depths.

Pharmacopuncture and joint movement manual therapy for post-traumatic phalangeal osteoarthritis: A case report

INTRODUCTION

Post-traumatic osteoarthritis (PTOA) is a type of osteoarthritis that develops after ligament injury, meniscus injury, or fracture. Currently, there is no specific treatment approved for PTOA. This report describes the case of a 38-year-old man who suffered from PTOA of the right second distal interphalangeal (DIP) joint after practicing judo.

PATIENT CONCERNS

He visited the author's clinic at 3 months after the onset of symptoms. Symptoms included pain, limited motion, and joint enlargement of the right second DIP joint.

DIAGNOSIS

Partial tear of the ulnar collateral ligament of the DIP was revealed by magnetic resonance imaging. As the symptoms appeared after the traumatic event, PTOA was diagnosed.

INTERVENTIONS

Intra-articular hominis placenta pharmacopuncture and joint movement manual therapy were performed on each visit. Altogether, 10 sessions were performed until the symptoms improved remarkably.

OUTCOMES

Visual analogue scale score (VAS) for pain; Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH); joint circumference; and range of motion showed improvements at the end of the treatment. VAS decreased from 8.4 to 0.4, QuickDASH decreased from 44 to 13, joint circumference decreased from 5.5 to 5.4 cm, and range of motion was almost recovered, which was measured by the photographs.

LESSONS

There are not enough studies on phalangeal joint PTOA and its treatment. This case suggests pharmacopuncture and joint movement manual therapy as treatment options for phalangeal PTOA.

SCIENTIFIC PHYSICAL EXERCISE TO PREVENT MUSCLE INJURY IN COMPETITIVE SPORTS

ABSTRACT Introduction: Various factors cause many sports traumas in groups engaged in mass sports activities, amateur sports training, and professional sports training in China that must be called to our attention. Objective: Scientific Sports Therapy is a scientific and reasonable systemic sports training program formulated for competitive athletes based on their physical and disease characteristics. Methods: This article conducted scientific sports therapy interventions on tennis elbow patients and analyzed multiple physiological indicators such as muscle endurance before and after the intervention. Results: There are significant differences in the athletes’ muscle strength and muscle endurance data after physical exercise therapy. Conclusion: We analyzed the causes of muscle damage and adopted scientific and practical sports therapy. In this way, coaches and athletes can find effective ways to prevent and manage muscle injuries, thereby improving competitive sports training. Level of evidence II; Therapeutic studies - investigation of treatment results.

A Cross-Sectional Study of Retired Great British Olympians (Berlin 1936-Sochi 2014): Olympic Career Injuries, Joint Health in Later Life, and Reasons for Retirement from Olympic Sport

Background

The relationship between Olympic career sport injury and the long-term musculoskeletal health of the elite athlete remains unclear. This study describes the lifetime prevalence of medical attention injuries that occurred during training and/or competition as part of the athlete’s Olympic career, reasons for retirement from Olympic sport, and the point prevalence of pain and osteoarthritis (OA) among retired Great Britain’s (GB) Olympians.

Methods

This cross-sectional study involved distributing a questionnaire to retired GB Olympians who had competed at 36 Olympic Games between Berlin 1936 and Sochi 2014. The questionnaire captured Olympic career injury history (lasting ≥ 1 month), sport exposure, musculoskeletal pain (last 4 weeks), physician-diagnosed OA, and joint replacement. Injury prevalence was calculated for sports with a minimal of 15 respondents. Adjusted odds ratios (aOR) were estimated in logistic regression for pain, OA, and joint replacement. Models were adjusted for age, sex, BMI, and career duration.

Results

Six hundred fifty (57.8% male; 42.2% female) retired athletes representing 40 sports (29 summer; 11 winter), aged 60.5 years (range 23–97), completed the questionnaire. Overall, 721 injuries (368 athletes) were self-reported equating to a lifetime Olympic career injury prevalence of 56.6%. Injury prevalence was highest in field athletics (81.0%), gymnastics (75.0%), and track athletics (67.7%). Injuries most frequently occurred at the knee (19.0%), lower back (15.4%), and shoulder (11.5%). Of those injured, 19.5% retired from sport due to injury. Pain was most prevalent at the lumbar spine (32.8%), knee (25.3%), and hip (22.5%), and OA at the knee (13.4%), hip (10.4%), and lumbar spine (4.6%). Injury was associated with pain at the hip (aOR 4.88; 95% CI, 1.87–12.72, p = 0.001), knee (aOR 2.35; 95% CI, 1.45–3.81, p = 0.001), and lumbar spine (aOR 2.53; 95% CI, 1.63–3.92, p < 0.001); OA at the hip (aOR 5.97; 95% CI, 1.59–22.47, p = 0.008) and knee (aOR 3.91; 95% CI, 2.21–6.94, p < 0.001); and joint replacement at the hip (aOR 8.71; 95% CI, 2.13–35.63, p = 0.003) and knee (aOR 5.29; 95% CI, 2.39–11.74, p < 0.001).

Conclusion

The lifetime prevalence of Olympic career injury was 56.6%, with those injured more likely to self-report current pain and/or OA at the hip, knee, and lumbar spine and joint replacement at the hip and knee.

Anti-Inflammatory Therapeutic Approaches to Prevent or Delay Post-Traumatic Osteoarthritis (PTOA) of the Knee Joint with a Focus on Sustained Delivery Approaches

Inflammation plays a central role in the pathogenesis of knee PTOA after knee trauma. While a comprehensive therapy capable of preventing or delaying post-traumatic osteoarthritis (PTOA) progression after knee joint injury does not yet clinically exist, current literature suggests that certain aspects of early post-traumatic pathology of the knee joint may be prevented or delayed by anti-inflammatory therapeutic interventions. We discuss multifaceted therapeutic approaches that may be capable of effectively reducing the continuous cycle of inflammation and concomitant processes that lead to cartilage degradation as well as those that can simultaneously promote intrinsic repair processes. Within this context, we focus on early disease prevention, the optimal timeframe of treatment and possible long-lasting sustained delivery local modes of treatments that could prevent knee joint-associated PTOA symptoms. Specifically, we identify anti-inflammatory candidates that are not only anti-inflammatory but also anti-degenerative, anti-apoptotic and pro-regenerative.

Pre-Operative Femoral Cartilage Ultrasound Characteristics Are Altered in People Who Report Symptoms at 1 year After Anterior Cruciate Ligament Reconstruction

We assessed whether pre-operative femoral cartilage thickness and echo intensity on ultrasound are different between individuals who are symptomatic (n = 6) and asymptomatic (n = 7) at 1 year after a primary unilateral anterior cruciate ligament (ACL) reconstruction (age, 23 ± 4 y; 31% women, 69% men; body mass index, 24.9 ± 3.7 kg/m²). A pre-operative, bilateral ultrasound assessment was used to quantify average thickness and echo intensity in the medial, middle and lateral femoral trochlear regions. An inter-limb ratio (ACL/contralateral limb) was calculated for average thickness and echo intensity. At 1 y after ACL reconstruction, we operationally defined the presence of symptoms as scoring ≤85% on at least two Knee Injury and Osteoarthritis Outcome Score subscales. Independent-sample t-tests and Cohen's d effect sizes were used to compare ultrasound pre-operative inter-limb ratios between participants with and without symptoms at 1 y after ACL reconstruction. For medial femoral cartilage, symptomatic participants had significantly greater average cartilage thickness inter-limb ratios (p = 0.01, d = -1.65) and significantly lower echo intensity inter-limb ratios (p = 0.01, d = 1.72) compared with asymptomatic participants. Middle and lateral femoral cartilage average thickness and echo intensity were not different between symptomatic and asymptomatic participants. These findings provide preliminary evidence that a clinically feasible ultrasound assessment of the femoral trochlear cartilage may be prognostic of self-reported symptoms at 1 y after ACL reconstruction.

Prevention of posttraumatic osteoarthritis at the time of injury: Where are we now, and where are we going?

This overview of progress made in preventing post-traumatic osteoarthritis (PTOA) was delivered in a workshop at the Orthopaedics Research Society Annual Conference in 2019. As joint trauma is a major risk factor for OA, defining the molecular changes within the joint at the time of injury may enable the targeting of biological processes to prevent later disease. Animal models have been used to test therapeutic targets to prevent PTOA. A review of drug treatments for PTOA in rodents and rabbits between 2016 and 2018 revealed 11 systemic interventions, 5 repeated intra-articular or topical interventions, and 5 short-term intra-articular interventions, which reduced total Osteoarthritis Research Society International scores by 30%-50%, 20%-70%, and 0%-40%, respectively. Standardized study design, reporting of effect size, and quality metrics, alongside a "whole joint" approach to assessing efficacy, would improve the translation of promising new drugs. A roadblock to translating preclinical discoveries has been the lack of guidelines on the design and conduct of human trials to prevent PTOA. An international workshop addressing this in 2016 considered inclusion criteria and study design, and advocated the use of experimental medicine studies to triage candidate treatments and the development of early biological and imaging biomarkers. Human trials for the prevention of PTOA have tested anakinra after anterior cruciate ligament rupture and dexamethasone after radiocarpal injury. PTOA offers a unique opportunity for defining early mechanisms of OA to target therapeutically. Progress in trial design and high-quality preclinical research, and allegiance with patients, regulatory bodies, and the pharmaceutical industry, will advance this field.

Does sex affect second ACL injury risk? A systematic review with meta-analysis

OBJECTIVE

To determine sex-based differences in risk of a second ACL injury (overall and by laterality) following primary ACL reconstruction in athletes who are attempting to return to sport.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Systematic search of five databases conducted in August 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting sex-based differences in the incidence of second ACL injury in athletes attempting to return-to-sports and who were followed for at least 1 year following primary ACL reconstruction.

RESULTS

Nineteen studies were included in this review, with seven studies excluded from the primary meta-analysis due to high risk of bias. The remaining 12 studies (n=1431 females, n=1513 males) underwent meta-analysis, with all 19 studies included in a sensitivity analysis. Total second ACL injury risk was 21.9% (females: 22.8%, males: 20.3%). Females were found to have 10.7% risk of an ipsilateral ACL injury and 11.8% risk of a contralateral ACL injury. Males were found to have 12.0% risk of an ipsilateral ACL injury and 8.7% risk of a contralateral ACL injury. No statistically significant differences were observed for total second ACL injury risk (risk difference=-0.6%, 95% CI -4.9 to 3.7, p=0.783, I²=41%) or contralateral ACL injury risk (risk difference=1.9%, 95% CI -0.5% to 4.4%, p=0.113, I²=15%) between sexes. Females were found to have a 3.4% absolute risk reduction in subsequent ipsilateral ACL injury risk compared with males (risk difference=-3.4%, 95% CI -6.7% to -0.02%, p=0.037, I²=35%).

CONCLUSION

Both sexes have >20% increased risk of experiencing a second ACL injury. Any difference in the absolute risk of either a subsequent ipsilateral or contralateral ACL injury between sexes appears to be small.

REGISTRATION

PROSPERO (CRD42020148369).

Neuromuscular Function of the Knee Joint Following Knee Injuries: Does It Ever Get Back to Normal? A Systematic Review with Meta-Analyses

BACKGROUND

Neuromuscular deficits are common following knee injuries and may contribute to early-onset post-traumatic osteoarthritis, likely mediated through quadriceps dysfunction.

OBJECTIVE

To identify how peri-articular neuromuscular function changes over time after knee injury and surgery.

DESIGN

Systematic review with meta-analyses.

DATA SOURCES

PubMed, Web of Science, Embase, Scopus, CENTRAL (Trials).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Moderate and high-quality studies comparing neuromuscular function of muscles crossing the knee joint between a knee-injured population (ligamentous, meniscal, osteochondral lesions) and healthy controls. Outcomes included normalized isokinetic strength, muscle size, voluntary activation, cortical and spinal-reflex excitability, and other torque related outcomes.

RESULTS

A total of 46 studies of anterior cruciate ligament (ACL) and five of meniscal injury were included. For ACL injury, strength and voluntary activation deficits were evident (moderate to strong evidence). Cortical excitability was not affected at < 6 months (moderate evidence) but decreased at 24+ months (moderate evidence). Spinal-reflex excitability did not change at < 6 months (moderate evidence) but increased at 24+ months (strong evidence). We also found deficits in torque variability, rate of torque development, and electromechanical delay (very limited to moderate evidence). For meniscus injury, strength deficits were evident only in the short-term. No studies reported gastrocnemius, soleus or popliteus muscle outcomes for either injury. No studies were found for other ligamentous or chondral injuries.

CONCLUSIONS

Neuromuscular deficits persist for years post-injury/surgery, though the majority of evidence is from ACL injured populations. Muscle strength deficits are accompanied by neural alterations and changes in control and timing of muscle force, but more studies are needed to fill the evidence gaps we have identified. Better characterisation and therapeutic strategies addressing these deficits could improve rehabilitation outcomes, and potentially prevent PTOA.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42019141850.

Exercise-therapy and education for individuals one year after anterior cruciate ligament reconstruction: a pilot randomised controlled trial

BACKGROUND

Guided rehabilitation beyond 6-months is rare following anterior cruciate ligament reconstruction (ACLR), despite high prevalence of unacceptable symptoms and quality of life (QoL). Our primary aim was to determine the feasibility of a randomised controlled trial (RCT) evaluating a physiotherapist-guided intervention for individuals 1-year post-ACLR with persistent symptoms. Our secondary aim was to determine if a worthwhile treatment effect could be observed for the lower-limb focussed intervention (compared to the trunk-focussed intervention), for improvement in knee-related QoL, symptoms, and function.

DESIGN

Participant- and assessor-blinded, pilot feasibility RCT.

METHODS

Participant eligibility criteria: i) 12-15 months post-ACLR; ii) < 87.5/100 on the Knee injury and Osteoarthritis Outcome Score (KOOS) QoL subscale; and either a one-leg rise test < 22 repetitions, single-hop < 90% limb symmetry; or Anterior Knee Pain Scale < 87/100. Participants were randomised to lower-limb or trunk-focussed focussed exercise and education. Both interventions involved 8 face-to-face physiotherapy sessions over 16-weeks. Feasibility was assessed by eligibility rate (> 1 in 3 screened), recruitment rate (> 4 participants/month), retention (< 20% drop-out), physiotherapy attendance and unsupervised exercise adherence (> 80%). Between-group differences for knee-related QoL (KOOS-QoL, ACL-QoL), symptoms (KOOS-Pain, KOOS-Symptoms), and function (KOOS-Sport, functional performance tests) were used to verify that the worthwhile effect (greater than the minimal detectable change for each measure) was contained within the 95% confidence interval.

RESULTS

47% of those screened were eligible, and 27 participants (3 participants/month; 48% men, 34±12 years) were randomised. Two did not commence treatment, and two were lost to follow-up (16% drop-out). Physiotherapy attendance was > 80% for both groups but reported adherence to unsupervised exercise was low (< 55%). Both interventions had potentially worthwhile effects for KOOS-QoL and ACL-QoL, while the lower-limb focussed intervention had potentially greater effects for KOOS-Sport, KOOS-Pain, and functional performance.

CONCLUSIONS

A larger-scale RCT is warranted. All feasibility criteria were met, or reasonable recommendations could be made to achieve the criteria in future trials. Strategies to increase recruitment rate and exercise adherence are required. The potential worthwhile effects for knee-related QoL, symptoms, and function indicates a fully-powered RCT may detect a clinically meaningful effect.

TRIAL REGISTRATION

Prospectively registered ( ACTRN12616000564459 ).

"I think we need to empower people to manage it better themselves": A qualitative interview study exploring UK healthcare practitioners' perspectives on treating young adults following a sport-related knee injury

OBJECTIVES

To elicit healthcare practitioners' views on treatment following sport-related knee injury in young adults (18-35) and the potential for individuals to self-manage joint health.

DESIGN

Semi-structured interviews were audio-recorded, transcribed and analysed systematically using an inductive approach.

SETTING

South West UK.

PARTICIPANTS

Twelve healthcare practitioners with experience of treating young adults.

MAIN OUTCOME MEASURES

Understanding how healthcare practitioners treat young adults following knee injury and to what extent individuals may be able to self-manage knee health.

RESULTS

Participants' perceptions were encapsulated in three consistent themes: [1] Treating patients; [2] Maintaining physical activity; and [3] Education and support. All participants described how staying physically active and maintaining a healthy weight were integral to conserving knee health, and that post-injury education was necessary to "empower" patients to self-manage knee health. A need for greater access to support, advice and guidance for patients was also articulated.

CONCLUSIONS

Healthcare practitioners should tailor their treatment to young adults to account for individual characteristics, aspirations for sport and exercise participation, and their emotional wellbeing. Fulfilment of individuals' educational and supportive needs is key to the establishment of self-management behaviours that may help to conserve knee health.

Level of pain, muscle strength and posture: effects of PBM on an exercise program in women with knee osteoarthritis - a randomized controlled trial

To evaluate the effectiveness of an exercise program associated to photobiomodulation (PBM) on pain, postural changes, functionally, and muscular strength in women, one of the risk factors, with knee osteoarthritis (OA). A randomized controlled trial, with a blinded assessor and intention-to-treat analysis and placebo control. Sixty-two participants with knee OA (with confirmed radiological diagnosis) were evaluated for this study. However, 34 were considered eligible and were randomized into two groups: EPPG - exercise and PBM placebo group (n = 17) and EPAG - exercise and PBM active group (n = 16), but one participant was excluded of EPAG. The exercise program and PBM (808 nm, 100 mW/point, 4 J/point, 56 J total, 91 J/cm2) were realized twice a week, during 8 weeks. West Ontario and the McMaster University Osteoarthritis Index (WOMAC) and Lequesne questionnaires, 1-repetition maximum test (1-RM) and posture evaluation software (SAPO) were used to analyze the effects of the therapies. In intragroup analysis, a significant improvement in pain WOMAC (p < 0.001), stiffness (p < 0.001), function (p < 0.001), Lequesne (p < 0.001), and 1-RM (all muscle groups) (p < 0.001) were observed. In this study, the exercise program improved pain, function, and muscle strength of all the participants. However, PBM, in the parameters used, did not optimize the effects of the exercise program in women with knee OA.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

OBJECTIVE

To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk.

METHODS

An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated.

RESULTS

A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information.

CONCLUSION

HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.

Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression

Background

Not meeting functional performance criteria increases reinjury risk after ACL reconstruction (ACLR), but the implications for osteoarthritis are not well known.

Objective

To determine if poor functional performance post-ACLR is associated with risk of worsening early osteoarthritis features, knee symptoms, function and quality of life (QoL).

Methods

Seventy-eight participants (48 men) aged 28±15 years completed a functional performance test battery (three hop tests, one-leg-rise) 1 year post-ACLR. Poor functional performance was defined as <90% limb symmetry index (LSI) on each test. At 1 and 5 years, MRI, Knee injury Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective form were completed. Primary outcomes were: (i) worsening patellofemoral and tibiofemoral MRI-osteoarthritis features (cartilage, bone marrow lesions (BMLs) and meniscus) and (ii) change in KOOS and IKDC scores, between 1 and 5 years.

Results

Only 14 (18%) passed (≥90% LSI on all tests) the functional test battery. Poor functional performance on the battery (all four tests <90% LSI) 1 year post-ACLR was associated with 3.66 times (95% CI 1.12 to 12.01) greater risk of worsening patellofemoral BMLs. A triple-crossover hop <90% LSI was associated with 2.09 (95% CI 1.15 to 3.81) times greater risk of worsening patellofemoral cartilage. There was generally no association between functional performance and tibiofemoral MRI-osteoarthritis features, or KOOS/IKDC scores.

Conclusion

Only one in five participants met common functional performance criteria (≥90% LSI all four tests) 1 year post-ACLR. Poor function on all four tests was associated with a 3.66 times increased risk of worsening patellofemoral BMLs, and generally not associated with decline in self-reported outcomes.