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In this randomized, controlled trial of young, active adults with an acute anterior cruciate ligament (ACL) injury, rehabilitation plus early ACL reconstruction was not superior to rehabilitation plus optional delayed ACL reconstruction with respect to pain, symptoms, knee function, and knee-related quality of life, and it resulted in significantly more knee reconstructions. Rupture of the anterior cruciate ligament (ACL) is a serious knee injury that affects mainly physically active young people. The injury is characterized by joint instability that leads to decreased activity, unsatisfactory knee function, and poor knee-related quality of life in the short term, 1 , 2 and it is associated with an increased risk of osteoarthritis of the knee. 3 Surgical reconstruction of the torn ligament has been regarded as critical for a good outcome and is commonly performed, particularly in those wishing to resume sports activities. 2 , 4 , 5 Despite a lack of evidence from high-quality randomized, controlled trials comparing ACL reconstruction . . .

ObjectivesWe aimed to determine the lifetime genetic risk for anterior cruciate ligament (ACL) rupture.MethodsWe used a twin study approach, linking the Swedish Twin Register with national healthcare data to form a 30 year, population wide, longitudinal twin cohort. We studied ACL rupture in this cohort of 88 414 identical and fraternal twins, aged ≥17 years, to determine the familial risk and heritability of ACL rupture.ResultsThe incidence rate of ACL rupture was 70 (95% CI 66 to 74) per 100 000 person years. The familial risk, which is the excess risk ratio (RR) of the second twin having ACL rupture given that the first twin has had such a rupture, was higher in identical twin pairs (RR=8.6, 95% CI 6.2 to 11.0) than in fraternal twin pairs (RR=1.9, 95% CI 0.9 to 3.0). The overall heritability of ACL rupture was high, 69% (95% CI 47 to 91), increasing from 60% at age 17 years to 80% at age 60 years. Women and men had similar familial risk and heritability of ACL rupture.ConclusionThe genetic contribution to ACL rupture of ~69% is high and suggests strong familial clustering. If clinicians recognise the high genetic risk of such injury, they may be better able to counsel athletes whose near relatives have had ACL rupture.

Purpose To present age- and sex-specific cumulative annual incidences of primary traumatic lateral patellar dislocation (LPD) and to detail patient characteristics and concomitant chondral injuries including osteochondral fractures, as visualized on magnetic resonance imaging (MRI), in a large consecutive cohort of knee-injured individuals. Methods Data on primary traumatic lateral patellar dislocations were collected from a large consecutive cohort of knee injuries examined with sub-acute MRI in a single centre with a well-defined catchment area. Annual incidences for different age-groups in relation to gender were calculated together with the risk of concomitant chondral and osteochondral injury, during sports and in general. Results A total of 184 primary patellar dislocations were identified in the cohort of 1145 acute knee injuries ( n =175) and surgical records ( n =9). Knee MRI was performed within a median of six days of injury. Median age of patients with primary LPD was 16 years (interquartile range, 14–21; range, 9–47) and 41% were females. Males were significantly older than females at the time of injury (median age 17 vs. 15, P = 0.021) and sustained their primary LPD during sports more often than females (65 vs. 40%, P < 0.001). Primary LPD occurred most frequently at the age of 13 to 15 years where the annual incidence was 125 (95% CI, 96–160) per 100,000 persons. The overall annual incidence of primary LPD was 14 (95% CI, 12–16) per 100,000 persons, with a predominance of males versus females (17 vs. 11, P = 0.01). Concomitant lesions to joint surfaces were displayed on MRI or during surgery in 75 (43%) knees. Osteochondral fractures were seen in 32 knees (18%). We found no statistically significant difference in the risk of osteochondral fracture between those injured during sports or during leisure activity (14 vs. 24%, P = 0.08). Conclusions The annual incidence of first-time patellar dislocation was found to be 14 per 100,000 individuals with the highest incidence found among those aged 13–15 years. Primary LPD was more common among males and was sustained during sports activity in 55% of the cases. Associated injuries to the chondral surfaces should be expected in 43% of knees with primary LPD where 18% represent osteochondral fractures.

IntroductionIn sports physiotherapy, medicine and orthopaedic randomised controlled trials (RCT), the investigators (and readers) focus on the difference between groups in change scores from baseline to follow-up. Mean score changes are difficult to interpret (‘is an improvement of 20 units good?’), and follow-up scores may be more meaningful. We investigated how applying three different responder criteria to change and follow-up scores would affect the ‘outcome’ of RCTs. Responder criteria refers to participants’ perceptions of how the intervention affected them.MethodsWe applied three different criteria—minimal important change (MIC), patient acceptable symptom state (PASS) and treatment failure (TF)—to the aggregate Knee injury and Osteoarthritis Outcome Score (KOOS4) and the five KOOS subscales, the primary and secondary outcomes of the KANON trial (ISRCTN84752559). This trial included young active adults with an acute ACL injury and compared two treatment strategies: exercise therapy plus early reconstructive surgery, and exercise therapy plus delayed reconstructive surgery, if needed.ResultsMIC: At 2 years, more than 90% in the two treatment arms reported themselves to be minimally but importantly improved for the primary outcome KOOS4. PASS: About 50% of participants in both treatment arms reported their KOOS4 follow-up scores to be satisfactory. TF: Almost 10% of participants in both treatment arms found their outcomes so unsatisfactory that they thought their treatment had failed. There were no statistically significant or meaningful differences between treatment arms using these criteria.ConclusionWe applied change criteria as well as cross-sectional follow-up criteria to interpret trial outcomes with more clinical focus. We suggest researchers apply MIC, PASS and TF thresholds to enhance interpretation of KOOS and other patient-reported scores. The findings from this study can improve shared decision-making processes for people with an acute ACL injury.

AimIdentify injury-related, patient-reported and treatment-related prognostic factors for 5-year outcomes in acutely ACL-ruptured individuals managed with early reconstruction plus exercise therapy, exercise therapy plus delayed reconstruction or exercise therapy alone.MethodsExploratory analysis of the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559). Relationships between prognostic factors (baseline cartilage, meniscus and osteochondral damage, baseline extension deficit, baseline patient-reported outcomes, number of rehabilitation visits, graft/contralateral ACL rupture, non-ACL surgery and ACL treatment strategy) and 5-year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, sport/recreation and quality of life (QOL) scores were explored using multivariable linear regression. Estimates were adjusted for sex, age, body mass index, preinjury activity level, education and smoking.ResultsFor all participants (n=118), graft/contralateral ACL rupture, non-ACL surgery and worse baseline 36-item Short-Form Mental Component Scores were associated with worse outcomes. Treatment with exercise therapy alone was a prognostic factor for less knee symptoms compared with early reconstruction plus exercise therapy (regression coefficient 10.1, 95% CI 2.3 to 17.9). Baseline meniscus lesion was associated with worse sport/recreation function (−14.4, 95% CI −27.6 to –1.3) and osteochondral lesions were associated with worse QOL (−12.3, 95% CI −24.3 to –0.4) following early reconstruction plus exercise therapy. In the same group, undergoing additional non-ACL surgery and worse baseline KOOS scores were prognostic for worse outcome on all KOOS subscales. Following delayed reconstruction, baseline meniscus damage was a prognostic factor for less pain (14.3, 95% CI 0.7 to 27.9). Following exercise therapy alone, undergoing non-ACL surgery was prognostic for worse pain.ConclusionsTreatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals.Trial registration numberCurrent Controlled Trials ISRCTN84752559.

ObjectivesTo determine development of new and worsening meniscal damage over 5 years after acute anterior cruciate ligament (ACL) injury comparing rehabilitation plus early ACL reconstruction (‘early-ACLR’) versus rehabilitation with optional delayed ACL reconstruction (‘optional-delayed-ACLR’).MethodsWe used knee MRIs from the only randomised controlled trial in the field including 121 young adults. One musculoskeletal radiologist read baseline and 5-year follow-up images using the Anterior Cruciate Ligament Osteoarthritis Score (ACLOAS). We defined development (ie, new and worsening) of meniscal damage both dichotomously and as a sum score representing severity (based on the reclassified ACLOAS meniscus grades). In the full analysis set, we analysed development of meniscal damage (yes/no) with logistic regression and severity with zero-inflated Poisson regression and adjusted for age, sex and baseline meniscal damage.ResultsOver 5 years, new or worsening meniscal damage developed in 45% of subjects with early-ACLR and in 53% of subjects with optional-delayed-ACLR. The relative risk for development of meniscal damage on knee level was 1.3 (95% CI 0.9 to 1.9) in optional-delayed-ACLR versus early-ACLR. For medial and lateral meniscal damage, respectively, the relative risks were 2.1 (95% CI 1.1 to 3.9) and 1.0 (95% CI 0.6 to 1.5). The mean severity score was 1.5 higher (more severe damage) on knee level in optional-delayed-ACLR versus early-ACLR (95% CI 1.1 to 1.9) among those with meniscal damage at 5 years. For medial and lateral meniscal damage, respectively, the corresponding scores were 1.7 (95% CI 1.2 to 2.5) and 1.1 (95% CI 0.8 to 1.4).ConclusionA strategy of early-ACLR may reduce development of medial meniscal damage following acute ACL injury. For the lateral meniscus, ACLR seems neither to be protective nor to increase the risk of damage.Trial registration numberISRCTN 84752559.

Background The additional effect of anterior cruciate ligament (ACL) reconstruction on muscle strength and physical performance after a structured exercise programme is not well understood. Objectives To investigate and compare muscle strength and physical performance test results after a structured exercise programme, in young active adults with acute ACL injury, between those treated with and without ACL reconstruction (ACLR) and to evaluate these test results as predictors of clinical outcomes 2 and 5 years after injury. Study design Prospective cohort study. Methods In a treatment randomised controlled trial of acute ACL injury (the KANON-study), 87/121 young active adults underwent two muscle strength tests and five physical performance tests after a structured exercise programme (median 37 (IQR 24) weeks after injury). Results were presented and compared as limb symmetry indices (LSI); endpoints in predictive analyses were having a delayed ACLR over the first 5 years and self-reported knee function (Knee injury and Osteoarthritis Outcome Score; KOOS4) at 2 and 5 years. Results Overall, 74–95% of patients had LSI≥90% in the individual tests, with no difference between treatment groups (p=0.08–0.92). Results of the one-leg rise tests predicted KOOS4 at 2 and 5 years (R2=0.25 and 0.24, p=0.001 and 0.002) and vertical hop results predicted having a delayed ACLR over a 5-year course after injury (p=0.048) in those starting with exercise alone (n=21). Conclusions After an acute ACL tear, the majority of young active adults regain physical performance and muscle strength after a structured exercise programme, with or without surgical reconstruction. Poor physical performance at the end of rehabilitation predicted worse patient-reported outcomes at 2 and 5 years regardless of treatment. Registration number: ISRCTN84752559.

STUDY QUESTION In young active adults with an acute anterior cruciate ligament (ACL) rupture, do patient reported or radiographic outcomes after five years differ between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction? SUMMARY ANSWER At five years, patients assigned to rehabilitation plus early ACL reconstruction did not differ significantly in patient reported or radiographic outcomes from those assigned to initial rehabilitation with the option of having a later reconstruction if needed. WHAT IS KNOWN AND WHAT THIS PAPER ADDS The relative efficacy of surgical reconstruction and rehabilitation for short and long term outcomes of ACL rupture is debated. Clinicians and young active adult patients should consider rehabilitation as a primary treatment option following an acute ACL tear.

Objective To compare, in young active adults with an acute anterior cruciate ligament (ACL) tear, the mid-term (five year) patient reported and radiographic outcomes between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction.Design Extended follow-up of prospective randomised controlled trial.Setting Orthopaedic departments at two hospitals in Sweden.Participants 121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. One patient was lost to five year follow-up.Intervention All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed.Main outcome measure The main outcome was the change from baseline to five years in the mean value of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS4). Other outcomes included the absolute KOOS4 score, all five KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at five years.Results Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (seven between two and five years). The mean change in KOOS4 score from baseline to five years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points, 95% confidence interval −8.5 to 4.5; P=0.54 after adjustment for baseline score). At five years, no significant between group differences were seen in KOOS4 (P=0.45), any of the KOOS subscales (P≥0.12), SF-36 (P≥0.34), Tegner activity scale (P=0.74), or incident radiographic osteoarthritis of the index knee (P=0.17). No between group differences were seen in the number of knees having meniscus surgery (P=0.48) or in a time to event analysis of the proportion of meniscuses operated on (P=0.77). The results were similar when analysed by treatment actually received.Conclusion In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.Trial registration Current Controlled Trials ISRCTN84752559.

BackgroundTo analyse 5-year cost-effectiveness of early versus optional delayed acute anterior cruciate ligament (ACL) reconstruction.Methods121 young, active adults with acute ACL injury to a previously uninjured knee were randomised to early ACL reconstruction (n=62, within 10 weeks of injury) or optional delayed ACL reconstruction (n=59; 30 with ACL reconstruction within 6–55 months); all patients received similar structured rehabilitation. Real life data on health care utilisation and sick leave were obtained from regional and national registers. Costs and quality-adjusted life years (QALYs) were discounted at 3%. Full-analysis set (based on study randomisation) and as-treated analysis (according to actual treatment over 5 years) principles were applied.ResultsMean cost of early ACL reconstruction was €4695 higher than optional delayed ACL reconstruction (p=0.19) and provided an additional 0.13 QALYs (p=0.11). Full-analysis set showed incremental net benefit of early versus optional delayed ACL reconstruction was not statistically significantly different from zero at any level. As-treated analysis showed that costs for rehabilitation alone were €13 650 less than early ACL reconstruction (p<0.001). Results were robust to sensitivity analyses.ConclusionsIn young active adults with acute ACL injury, a strategy of early ACL reconstruction did not provide extra economic value over a strategy of optional delayed ACL reconstruction over a 5-year period. Results from this and previous reports of the KANON-trial imply that early identification of individuals who would benefit from either early ACL reconstruction or rehabilitation alone might reduce resource consumption and decrease risk of unnecessary overtreatment.Trial registrationISRCTN84752559.