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Knee osteoarthritis risk is increased 4-6 fold after knee injury – a systematic review and meta-analysis
  1. Erik Poulsen1,
  2. Glaucia H Goncalves2,
  3. Alessio Bricca3,
  4. Ewa M Roos1,
  5. Jonas B Thorlund1,
  6. Carsten B Juhl1,4
  1. 1 Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  2. 2 Department of Physical Therapy, Universidade Federal de Sao Carlos, Sao Carlos, Brazil
  3. 3 Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
  4. 4 Department of Occupational and Physical Therapy, Gentofte and Herlev Hospitals, Copenhagen University Hospital, Copenhagen, Denmark
  1. Correspondence to Dr Erik Poulsen, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense 5230, Denmark; epoulsen{at}


Objective To estimate knee osteoarthritis (OA) risk following anterior cruciate ligament (ACL), meniscus or combined ACL and meniscus injury.

Design Systematic review and meta-analysis.

Data sources MEDLINE, Embase, SPORTDiscus, CINAHL and Web of Science until November 2018.

Eligibility criteria for selecting studies Prospective or retrospective studies with at least 2-year follow-up including adults with ACL injury, meniscal injury or combined injuries. Knee OA was defined by radiographs or clinical diagnosis and compared with the contralateral knee or non-injured controls.

Study appraisal and synthesis Risk of bias was assessed using the SIGN50 checklist. ORs for developing knee OA were estimated using random effects meta-analysis.

Results 53 studies totalling ∼1 million participants were included: 185 219 participants with ACL injury, mean age 28 years, 35% females, 98% surgically reconstructed; 83 267 participants with meniscal injury, mean age 38 years, 36% females, 22% confirmed meniscectomy and 73% unknown; 725 362 participants with combined injury, mean age 31 years, 26% females, 80% treated surgically. The OR of developing knee OA were 4.2 (95% CI 2.2 to 8.0; I2=92%), 6.3 (95% CI 3.8 to 10.5; I2=95%) and 6.4 (95% CI 4.9 to 8.3; I2=62%) for patients with ACL injury, meniscal injury and combined injuries, respectively.

Conclusion The odds of developing knee OA following ACL injury are approximately four times higher compared with a non-injured knee. A meniscal injury and a combined injury affecting both the ACL and meniscus are associated with six times higher odds compared with a non-injured knee. Large inconsistency (eg, study design, follow-up period and comparator) and few high-quality studies suggest that future studies may change these estimates.

Clinical relevance Patients sustaining a major knee injury have a substantially increased risk of developing knee OA, highlighting the importance of knee injury prevention programmes and secondary prevention strategies to prevent or delay knee OA development.

PROSPERO registration number CRD42015016900

  • knee injuries
  • anterior cruciate ligament
  • meniscus
  • osteoarthritis
  • meta-analysis

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  • Contributors JBT, EMR and CBJ conceived and planned the study. GHG and CBJ performed the searches, and EP, GHG and AB performed the screening of papers. EP, GHG, AB and CBJ did the data extraction. CBJ independently performed the analyses, and EP, GHG, EMR, JBT and CBJ contributed to the draft of the manuscript. All authors participated in reviewing and editing the manuscript, and all authors have read and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.