Article Text

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
  1. Jackie L Whittaker1,2,
  2. Justin M Losciale1,2,
  3. Carsten B Juhl3,4,
  4. Jonas Bloch Thorlund3,5,
  5. Matilde Lundberg5,
  6. Linda K Truong1,2,
  7. Maxi Miciak6,
  8. Belle Lore van Meer7,
  9. Adam G Culvenor8,
  10. Kay M Crossley8,
  11. Ewa M Roos9,
  12. Stefan Lohmander10,
  13. Marienke van Middelkoop11
  1. 1 Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  2. 2 Arthritis Research Canada, Vancouver, British Columbia, Canada
  3. 3 Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark
  4. 4 Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Copenhagen, Denmark
  5. 5 Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
  6. 6 Rehabilitation Research Centre, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
  7. 7 Department of Orthopaedic Surgery, Erasmus MC Medical University, Rotterdam, The Netherlands
  8. 8 La Trobe Sport and Exercise Medicine Research Centre, La Trobe University School of Allied Health, Human Services and Sport, Melbourne, Victoria, Australia
  9. 9 Department of Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
  10. 10 Department of Clinical Sciences Lund, Orthopaedics, Lunds Universitet, Lund, Sweden
  11. 11 Department of General Practice, Erasmus MC Medical University, Rotterdam, The Netherlands
  1. Correspondence to Dr Jackie L Whittaker, Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, BC V6T 1Z4, Canada; jackie.whittaker{at}


Objective To identify and quantify potential risk factors for osteoarthritis (OA) following traumatic knee injury.

Design Systematic 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 sources MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to 2009–2021.

Eligibility Randomised 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.

Results Across 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.

Conclusion Moderate-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.

  • anterior cruciate ligament
  • meniscus
  • risk factor
  • osteoarthritis

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  • Twitter @jwhittak_physio, @JayLos18, @jbthorlund, @LKTphysio, @bellevanmeer, @agculvenor, @ewa_roos, @mvanmiddelkoop

  • Contributors AGC, JLW, ER and KMC were involved in priority theme setting. JLW coordinated the study. JLW, MvM, KMC, AGC, ER, JBT, CBJ, LKT, MM and BvM were involved in the design of the study. JLW, MvM, JML, JBT, LKT and BvM screened title and abstracts as well as full-text records. JLW, JML, JBT, LKT, MvM and ML performed data extraction and risk of bias assessment. MM contributed their lived experience to the design of (risk factors of interest), conduct (data extraction-author, year, country of publication, sample characteristics), and write-up (identification of key messages such as a focus on symptomatic versus structural OA). JLW and JML performed statistical analysis in conjunction with CBJ. JLW and JML wrote the first draft of the manuscript. All authors contributed to reviewing, editing and revising the manuscript and approved the final submitted version. JLW is the guarantor.

  • Funding Initial priority theme setting for the OPTIKNEE consensus ( was supported by a Canadian Institutes of Health Research Planning and Dissemination Grant (principal investigator JLW #161821) and a La Trobe University Research Focus Area Collaboration Grant (principal investigator AGC). The funders had no role in any part of the study or in any decision about publication.

  • Competing interests JLW and AGC are associate editors of the British Journal of Sports Medicine (BJSM). JLW is an editor with the Journal of Orthopaedic and Sports Physical Therapy. KMC is a senior advisor of BJSM, project leader of the Good Life with Osteoarthritis from Denmark (GLA:D) – Australia a not-for profit initiative to implement clinical guidelines in primary care, and holds a research grant from Levin Health outside the submitted work. CBJ an associate editor of Osteoarthritis and Cartilage. JBT holds a research grant from Pfizer outside the submitted work. ER is deputy editor of Osteoarthritis and Cartilage, developer of Knee injury and Osteoarthritis Outcome Score (KOOS) and several other freely available patient-reported outcome measures, and founder of the GLA:D). All other authors declare no competing interests.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.