Background:

Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist.

Purpose:

(1) To identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (<6 months after the 5-week program), 11% delayed ACLR (>6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation.

Results:

Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory.

Conclusion:

We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories’ validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

中文翻译：

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遵循特拉华-奥斯陆 ACL 队列治疗算法的患者出现四种不同的 5 年膝关节功能轨迹

背景：

前交叉韧带 (ACL) 损伤后的损伤和功能障碍差异很大，并且可能存在不同的亚组。

目的：

(1) 确定 ACL 损伤患者的亚组，这些患者从最初就诊到治疗算法后 5 年共享患者报告的膝关节功能的共同轨迹，他们选择 ACL 重建 (ACLR) 加康复或单独康复。(2) 评估与轨迹从属关系的关联。

学习规划：

队列研究；证据水平，3。

方法：

我们纳入了 276 名首次急性完全单侧 ACL 损伤的患者。在共同制定治疗决策过程之前，所有患者都接受了为期 5 周的神经肌肉和力量训练计划。在他们最近的随访中，62% 的患者接受了早期 ACLR（5 周项目后<6 个月），11% 的患者延迟了 ACLR（5 周项目后 >6 个月），27% 的患者仅进行了渐进性康复. 患者在入选时、5 周项目后以及 ACLR 或完成 5 周项目后 6 个月、1 年、2 年和 5 年完成了国际膝关节文献委员会主观膝关节表格 (IKDC-SKF)。仅接受康复治疗的患者）。

结果：

确定了四个不同的 IKDC-SKF 轨迹：低（n = 22；8.0% 的队列）、中等（n = 142；51.4%）、高（n = 105；38.0%）和下降前的高（n = 7；2.5%）。高轨迹在纳入时的得分高于中等轨迹，但两者都在 1 年内显着改善，此后保持稳定的高分。下降前的高位轨迹也开始相对较高，并在 1 年内显着改善，但在 2 至 5 年内经历了大幅恶化。低轨迹开始时很低，改善很小。新的膝关节损伤是高前下降轨迹的重要特征，伴随的半月板损伤与遵循低（相对于中）轨迹显着相关，

结论：

我们确定了患者报告的膝关节功能的 4 个不同的 5 年轨迹，表明 ACL 损伤患者的 4 个亚组。重要的是，88% 遵循我们的治疗算法的患者遵循以良好改善和高分为特征的中度和高度轨迹。由于我们队列中的资格标准和程序，我们只能将我们的模型推广到遵循类似治疗算法的没有重大伴随伤害的运动员。伴随的半月板损伤和新的膝关节损伤是不利的低和高前下降轨迹的重要因素。这些关联是探索性的，但支持轨迹的有效性。我们的研究结果有助于对患者进行预后教育，并支持持续预防继发性损伤的重要性。