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

Abstract

ObjectiveTo identify and quantify potential risk factors for osteoarthritis (OA) following traumatic knee injury.DesignSystematic 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 sourcesMEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to 2009–2021.EligibilityRandomised 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.ResultsAcross 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.ConclusionModerate-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.

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

“…The seven systematic reviews we conducted to synthesise the evidence (table 1), incorporated the findings of approximately 230 studies containing data from >133 000 persons with traumatic knee injuries 17 29 30 35–38. Of the seven systematic reviews, four performed quantitative syntheses, and all seven performed semi-quantitative or narrative syntheses.…”

“…What is often missing is the information to translate evidence into the clinical setting or to act beyond knee injury to mitigate PTOA risk. For example, we have identified unmodifiable risk factors for knee PTOA, but not modifiable risk factors (ie, treatment targets)29 35 for poor prognosis or PTOA. While we have a sense of what evidence-based care is for ACL tears, we are unclear if these approaches are appropriate for other injury types (eg, meniscal tears) or if they mitigate PTOA risk 30 35.…”

“…One individual with lived experience of ACL tear (and ACL reconstruction (ACLR)) and four clinicians (ie, physiotherapists and orthopaedic surgeons) contributed to the priority theme setting for the OPTIKNEE consensus. One patient partner and one clinician (sports and exercise medicine physician) were authors on the risk factor review, 29 and one additional patient and clinician partner provided feedback on one of the intervention reviews. 30 A patient partner and a clinician (physiotherapist) provided feedback on this manuscript.…”

“…RoB: NIHQAT 34 Certainty: GRADE 50 Risk factors for knee OA after traumatic knee injury 29 Primary: identify and quantify the magnitude of potential modifiable and non-modifiable risk factors for symptomatic and structural knee OA following a traumatic knee injury Meta-analyses and semi-quantitative RoB: QUIPS 51 Certainty: GRADE approach for prognostic factor reviews 52 Rehabilitation after traumatic ACL and meniscal tear: clinical outcomes 30 Primary: critically appraise and synthesise systematic review evidence of RCTs assessing rehabilitation interventions following ACL and/or meniscal tear to improve symptomatic, functional, clinical, psychosocial or quality of life outcomes and prevent re-injury Narrative RoB: ROBIS tool 53 Certainty: GRADE 54 Rehabilitation after traumatic ACL and meniscal tear: structural and molecular biomarkers 35 Primary: synthesise existing RCT evidence of different management strategies and rehabilitation approaches to ACL and/or meniscal tear on structural and molecular biomarkers of knee joint health Narrative RoB: Cochrane ROB 2.0 tool 1 Certainty: GRADE 43 Meaningful thresholds for patient reported outcomes for traumatic ACL or meniscal tear 36 Primary: identify, critically appraise and synthesise estimates for thresholds defining meaningful PROs scores for use with individuals treated for a traumatic ACL tear and/or meniscal injury…”

Knee

“…A group from Vancouver (Canada) tried to establish what the risks factors were for traumatic arthritis following injury to the knee and informed their consensus statement with a systematic review and meta-analysis. 9 The systematic review was well done, and the Grading of Recommendations, Assessment, Development and Evaluations approach was used to undertake the review. The estimation of odds of osteoarthritis (OA) was undertaken using evidence synthesis and random effects models for establishing risk of OA, and prognostic factors were also explored.…”