Patient-Reported Outcomes One to Five Years After Anterior Cruciate Ligament Reconstruction: The Effect of Combined Injury and Associations With Osteoarthritis Features Defined on Magnetic Resonance Imaging

Abstract

Objective: Persistent symptoms and poor quality of life (QoL) are common following anterior cruciate ligament reconstruction (ACLR). We aimed to determine the influence of a combined ACL injury (i.e., concomitant meniscectomy and/or arthroscopic chondral defect at the time of ACLR and/or secondary injury/surgery to ACLR knee) and cartilage defects defined on magnetic resonance imaging (MRI), bone marrow lesions (BMLs), and meniscal lesions on patient-reported outcomes 1 to 5 years after ACLR.

Methods: A total of 80 participants (50 men; mean ± SD age 32 ± 14 years) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) questionnaires as well as a 3T MRI assessment at 1 and 5 years after ACLR. Median patient-reported outcome scores were compared between isolated and combined ACL injuries and with published normative values. Using multivariate regression, we evaluated the association between compartment-specific MRI cartilage, BMLs, and meniscal lesions and patient-reported outcomes at 1 and 5 years.

Results: Individuals with a combined injury had significantly worse scores in the KOOS subscale of function in sport and recreation (KOOS sport/rec) and in the IKDC questionnaire at 1 year, and worse scores in the KOOS subscales of pain (KOOS pain), symptoms (KOOS symptoms), and QoL (KOOS QoL) and in the IKDC questionnaire at 5 years compared to those with an isolated injury. Although no feature on MRI was associated with patient-reported outcomes cross-sectionally at 1 year, patellofemoral cartilage defects at 1 year were significantly associated with worse 5-year KOOS symptoms (β = -9.79, 95% confidence interval [95% CI] -16.67, -2.91), KOOS sport/rec (β = -7.94, 95% CI -15.27, -0.61), KOOS QoL (β = -8.29, 95% CI -15.28, -1.29), and IKDC (β = -4.79, 95% CI -9.34, -0.24) scores. Patellofemoral cartilage defects at 5 years were also significantly associated with worse 5-year KOOS symptoms (β = -6.86, 95% CI -13.49, -0.24) and KOOS QoL (β = -11.71, 95% CI -19.08, -4.33) scores.

Conclusion: Combined injury and patellofemoral cartilage defects shown on MRI are associated with poorer long-term outcomes. Clinicians should be vigilant and aware of individuals with these injuries, as such individuals may benefit from targeted interventions to improve QoL and optimize symptoms.

Figure 1.. Flowchart of participant recruitment into the study

PROs = patient-reported outcomes; MRI = magnetic resonance imaging ~Clinical assessment was also performed on a subset of the cohort at 1- and 5-years. Body mass index from the clinical assessment was required for the regression analysis, resulting in n=6 not included in the analysis for 5-years MRI: 5-year PROs. *Participant at 1-year was involved in the research team at 5-years

Figure 2

A. Comparison between isolated and combined ALCR groups, non-injured and general population medians, and acceptable cut-off scores in ACLR individuals for the KOOS^{^} B. Comparison between isolated and combined ALCR groups, non-injured median values and acceptable cut-off scores in ACLR individuals for the IKDC^{^ ^}All values are presented as medians at 1-year and 5-years. Supplementary File 2 presents interquartile range values and scores for the entire group (n=81). At 1-year; n=40 combined, n=41 isolated. At 5-years; n=46 combined, n=35 isolated. KOOS=Knee Osteoarthritis Outcome Score, IKDC=International Knee Documentation Committee knee evaluation *Indicates median value at 1-year or 5-years is ≥minimal detectable change (MDC) [26, 31] below the general population (age-matched, non-injured) normative medians for the KOOS [32] and IKDC [34] **Represents statistically significant difference (p<0.05) between combined and isolated injury groups at 1- or 5-years. ~ Weighted average median values for the KOOS and IKDC were calculated using respective healthy non-injured (no history of knee pain) data [32], general population (may have history of knee pain) age and sex-matched data [33, 34] and “acceptable” cut-off scores in ACLR individuals [6, 35].

Figure 2

A. Comparison between isolated and combined ALCR groups, non-injured and general population medians, and acceptable cut-off scores in ACLR individuals for the KOOS^{^} B. Comparison between isolated and combined ALCR groups, non-injured median values and acceptable cut-off scores in ACLR individuals for the IKDC^{^ ^}All values are presented as medians at 1-year and 5-years. Supplementary File 2 presents interquartile range values and scores for the entire group (n=81). At 1-year; n=40 combined, n=41 isolated. At 5-years; n=46 combined, n=35 isolated. KOOS=Knee Osteoarthritis Outcome Score, IKDC=International Knee Documentation Committee knee evaluation *Indicates median value at 1-year or 5-years is ≥minimal detectable change (MDC) [26, 31] below the general population (age-matched, non-injured) normative medians for the KOOS [32] and IKDC [34] **Represents statistically significant difference (p<0.05) between combined and isolated injury groups at 1- or 5-years. ~ Weighted average median values for the KOOS and IKDC were calculated using respective healthy non-injured (no history of knee pain) data [32], general population (may have history of knee pain) age and sex-matched data [33, 34] and “acceptable” cut-off scores in ACLR individuals [6, 35].