Limiting the Risk of Osteoarthritis after Anterior Cruciate Ligament Injury: Are We Missing the Opportunity to Intervene?

Purpose: Fifty percent of people with anterior cruciate (ACL) injury develop knee osteoarthritis (OA) within 6–10 years, even with ligament reconstruction. Despite evidence that targeted exercise, appropriate physical activity and weight management effectively limit symptomatic knee OA, only 27% (62/233) of Australians and Americans with ACL reconstruction 1-5 years previously, remembered discussing OA risk with any health care professional (HCP) and only 25 of these people were able to recall strategies for managing risk. In order to develop an intervention that limits development and progression of knee OA, the first step is to understand what HCPs (surgeons, primary care physicians (PCPs) and physiotherapists (PTs)) managing people with ACL injury do or do not tell their patients about their OA risk. The objective of this study was to determine: 1) if OA risk factor information is provided to non-elite athletes with ACL injury; 2) what factors influence discussion of OA risk; and, 3) when in the course of care OA risk is discussed. Methods: We surveyed practicing sports surgeons, PCPs and PTs who provide care to non-elite athletes with acute ACL injury. Retired HCPs or those no longer practicing in Canada were excluded. The electronic survey was distributed through an e-blast and newsletter link to the Canadian Academy of Sport and Exercise Medicine (CASEM) (largely PCPs) and the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association members. Orthopedic surgeons were contacted via phone and or email and completed the survey via fax, mail or online. The survey included four sections: practitioner demographics; frequency and specific factors discussed; when post-injury risk factors are discussed; and, recommendations for how and with whom risk factors and their management should be discussed. Descriptive statistics with 95% confidence intervals (CI) were calculated for all data. Results: There were 129 CASEM, 275 PTs and 72 orthopedic surgeon respondents. All Canadian provinces and 2 of 3 territories were represented. 53, 35 and 90 percent of CASEM, PT and surgeon respondents were male. 70% or more had greater than 5 years’ experience treating people with ACL injury. Table 1 shows that while more than 2/3s of CASEM and orthopedic surgeons always discuss OA risk, only 1/3 of PTs do. All groups reported that patient sex and type of acute management were least likely to influence the decision to discuss OA risk. A high proportion of providers discussed OA risk as part of initial management with many fewer respondents reporting such discussions 6 months after injury. Despite a lower proportion of PTs reporting always discussing OA risk, 80, 99 and 84% of CASEM, PT and surgeons indicated that PTs were best suited to provide OA risk information.Table 1HCP discussion of OA risk with ACL patientsCASEM (n = 129) % (95% CI)PT (n = 275) % (95% CI)Orthopedic Surgeon (n = 72) % (95% CI)Discuss OA risk factorsNever0.8 (0.1, 4.3)9.1 (6.2, 13.1)1.4 (0.2, 7.5)Sometimes29.5 (22.3, 37.8)56.6 (50.8, 62.4)19.4 (12.0, 30.0)Always69.8 (61.4, 77.4)34.3 (28.9, 40.2)79.2 (68.4, 86.9)Factors influencing OA risk discussion (yes)Age41.1 (32.8, 49.9)49.0 (42.9, 55.1)50.0 (38.7, 61.2)Sex6.5 (3.3, 12.8)7.6 (4.9, 11.6)17.1 (10.1, 27.6)Body weight45.6 (39.4, 56.3)53.0 (46.8, 59.256.3 (44.8, 67.3)Activity level52.0 (43.3, 60.7)64.4 (58.2, 70.2)54.3 (42.7, 65.4)Type of acute management36.7 (28.6, 45.8)35.5 (29.6, 41.8)50.0 (38.7, 61.2)Concurrent joint injury73.8 (65.3, 80.8)82.8 (75.5, 87.0)93.1 (84.8, 97.0)Revision ACL reconstruction62.9 (53.9, 71.2)69.7 (6.5, 75.3)82.6 (72.0, 90.0)Timing of OA risk discussion (yes)Initial ACL management80.6 (72.8, 86.6)59.9 (53.6, 65.9)91.3 (82.0, 95.9)3–6 months post-injury35.5 (27.6, 44.2)46.1 (40.2, 52.8)17.4 (10.2, 28.0)>6–12 months post-injury21.7 (15.4, 29.8)27.8 (22.5, 33.9)17.4 (10.2, 28.0)>12 months post-injury18.5 ( 12.7, 26.3)18.1 (13.7, 23.5)10.1 (0.5, 19.5) Open table in a new tab Conclusions: These results suggest that there is a communication gap as HCPs, particularly PTs, who routinely manage people with ACL injury do not consistently discuss OA risk post injury. Additionally, any discussions occur only early post injury when the focus is likely on ACL recovery such that there is a lack of emphasis on managing OA risk at final follow-up, when it's likely most important. Educational strategies are needed to develop care pathways inclusive of support for OA risk management post ACL injury.