Risk factor | Follow-up (years) and participants (n) | Phase of investigation (number of studies) | ROB | Inconsistency | Indirectness | Imprecision | Publication bias | Upgrading factors | Modified GRADE | Direction and magnitude* of relationship with symptomatic OA |
Sex66 74 89 95 96 | 12–37 (3400) | Phase I (3) Phase II (2) | X | X | ✓ | X | ✓ | X | + | Sex may not change OA odds |
Age at injury80 95 96 | 12–18 (3095) | Phase I (2) Phase II (1) | X | ✓ | ✓ | ✓ | ✓ | X | ++ | Older injury age may ↑ OA risk up to 1.1 times/year |
Age at surgery89 | 15 (210) | Phase II (1) | X | Unclear | X | ✓ | ✓ | X | + | Association of surgery age and OA odds is unclear |
Injury to surgery89 | 15 (210) | Phase II (1) | X | Unclear | X | ✓ | ✓ | X | + | Association of time from injury to surgery and OA odds is unclear |
Multistructure injury 97 | 19 (148 072) | Phase II (1) | ✓ | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | Multistructure injuries (vs isolated) may ↑ OA risk 3.2 times by 19 years |
Cruciate ligament tear 97 | 19 (148 072) | Phase III (1) | ✓ | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | Cruciate ligament tears may ↑ OA risk 6.8 times by 19 years |
ACL+concomitant injury 74 89 113 | 15–37 (68 974) |
Phase I (2) Phase II (2) Phase III (1) | X | ✓ | ✓ | ✓ | ✓ | ✓ | +++ | ACL+concomitant injury may ↑ OA odds up to 5.9 times |
ACL+chondral injury95 | 14 (1928) | Phase I (1) | XX | Unclear | ✓ | X | ✓ | X | + | Association of ACL+chondral injury and OA odds is unclear |
ACL+meniscal injury88 95 | 9–14 (66 542) | Phase I (1) Phase III (1) | X | Unclear | X | Unclear | ✓ | X | + | Association of ACL+meniscal injury and OA odds is unclear |
Collateral ligament injury 93 97 | 9–19 (151 677) |
Phase II (1) Phase III (1) | ✓ | Unclear | X | ✓ | ✓ | ✓ | +++ | Collateral ligament injuries may ↑ OA risk up to 2.1 times by 19 years |
Meniscal injury 93 97 | 9–19 (151,677) |
Phase II (1) Phase III (1) | ✓ | Unclear | X | ✓ | ✓ | ✓ | +++ | Meniscal injuries may ↑ OA risk up to 4.0 times at 19 years |
Chondral injury 97 | 19 (148,072) | Phase III (1) | ✓ | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | Chondral injuries may ↑ OA risk up to 2.4 times at 19 years |
Fracture 93 97 | 9–19 (151,677) |
Phase II (1) Phase III (1) | ✓ | Unclear | X | ✓ | ✓ | ✓ | +++ | Fracture may ↑ OA risk up to 7.0 times by 11 years |
TF dislocation 93 97 | 9–19 (151,677) |
Phase II (1) Phase III (1) | ✓ | Unclear | X | ✓ | ✓ | ✓ | +++ | TF dislocation may ↑ OA risk up to 3.0 times by 19 years |
PFJ dislocation 96 | 12 (971) | Phase II (1) | X | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | PFJ dislocation may ↑ OA risk up to 7.8 times |
PFJ dislocation+chondral defect 96 | 12 (971) | Phase II (1) | X | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | PFJ dislocation+chondral defect may ↑ OA risk up to 11.3 times |
Recurrent PFJ dislocation 96 | 12 (971) | Phase II (1) | X | Unclear | ✓ | ✓ | ✓ | ✓ | +++ | Recurrent PFJ dislocation may ↑ OA risk up to 4.5 vs one dislocation |
Soft tissue injury93 | 9 (3605) | Phase II (1) | X | Unclear | X | ✓ | ✓ | ✓ | +++ | Association of soft tissue injury† (vs mild‡ injury) and OA odds is unclear |
ACLnoSx80 85 88 95 | 9–18 (66 841) | Phase I (2) Phase II (1) Phase III (1) | X | X | ✓ | ✓ | ✓ | X | ++ | Association of ACLnoSx (vs ACLSx) with OA odds is unclear |
ACLnoSx+exercise therapy61 | 32–37 (153) | Phase I (1) | X | Unclear | ✓ | X | X | X | + | Association of ACLnoSx+exercise (vs ACLSx) with OA odds is unclear |
ACLRc85 88 95 | 9–14 (66 645) | Phase I (1) Phase II (1) Phase III (1) | X | ✓ | ✓ | ✓ | ✓ | X | ++ | ACLRc (vs ACLnoSx) may ↑ OA risk up to 6.0 times |
Early ACLRc61 80 88 95 | 9–37 (66 891) | Phase I (2) Phase III (1) | XX | ✓ | ✓ | ✓ | ✓ | X | + | Early ACLRc (vs ACLnoSx) may ↑ OA risk up to 1.2 times Association between early vs delayed ACLRC and OA odds is unclear |
Delayed ACLRc61 80 88 95 | 9–37 (66 891) | Phase I (3) Phase III (1) | XX | ✓ | ✓ | ✓ | ✓ | X | + | Association of delayed ACLRc and OA risk is unclear |
ACL or ACLRc+meniscal sx (anytime)74 85 88 | 2–37 (64 717) | Phase I (1) Phase II (1) Phase III (1) | X | ✓ | X | ✓ | ✓ | X | + | ACLRc+meniscal sx may ↑ OA risk up to 4.8 times |
ACLRc graft tension37 | 17 (72) | Phase II (1) | X | Unclear | ✓ | X | ✓ | X | + | Association between graft tension and OA odds is unclear |
ACLRc graft type95 | 14 (1928) | Phase I (1) | XX | Unclear | ✓ | X | ✓ | ✓ | + | Association of ACLRc allograft (vs autograft) and OA odds is unclear |
ACLRc graft donor site66 | 12 (164) | Phase I (1) | X | Unclear | ✓ | X | ✓ | X | + | Association of patellar (vs semitendinosus) graft and OA odds is unclear |
Meniscus repair90 | 10 (628 841) | Phase III (1) | ✓ | Unclear | ✓ | ✓ | ✓ | X | ++ | Association of meniscal repair and OA risk is unclear |
Patellar stabilisation sx96 | 12 (971) | Phase II (1) | X | Unclear | ✓ | Unclear | X | X | + | Association of patella stabilisation sx and OA odds is unclear |
Anterior tibial motion post ACL or ACLRc74 | 32–37 (127) | Phase I (1) | X | Unclear | ✓ | X | ✓ | X | + | Association of anterior tibial motion and OA odds is unclear |
AKP post-ACLRc77 | 20 (142) | Phase II (1) | ✓ | Unclear | X | X | ✓ | X | + | Association of AKP post-ACLRc and OA risk is unclear |
Return to pivoting sport89 | 15 (210) | Phase II (1) | X | Unclear | X | ✓ | ✓ | ✓ | ++ | Association of return to pivot sport and OA odds is unclear |
TF ROM post-ACL or ACLRc74 | 32–37 (127) | Phase I (1) | X | Unclear | X | X | ✓ | X | + | Association of knee ROM deficits at 4 years and OA odds is unclear |
Hop post-ACL or ACLRc74 | 32–37 (127) | Phase I (1) | X | Unclear | X | Unclear | ✓ | ✓ | + | Association of hop LSI post ACL or ACLRc and OA odds is unclear |
Strength post ACL or ACLRc66 74 | 12–37 (291) | Phase I (2) | X | ✓ | X | X | ✓ | X | + | Association of extension strength and OA odds is unclear |
SR function post-ACL or ACLRc66 74 89 | 12–37 (501) | Phase I (2) Phase II (1) | X | X | X | Unclear | ✓ | X | + | SR function§ may not change OA odds |
SR physical activity 4 years post-ACL74 | 32–37 (127) | Phase I (1) | X | Unclear | X | X | ✓ | X | + | Association of Tegner Activity Scale score and OA odds is unclear |
Patella alta96 | 12 (971) | PhaseII (1) | X | Unclear | X | ✓ | X | X | ++ | Association of patella alta and OA odds is unclear |
Trochlear dysplasia96 | 12 (971) | Phase II (1) | X | Unclear | X | ✓ | ✓ | ✓ | ++ | Trochlear dysplasia may ↑ OA odds up to 3.6 times |
Bold: Factor(s) with moderate to high quality evidence and OR or RR consistently (more than one analysis) positive, with the largest estimate ≥2.0.
Apparent redundancies in risk factors are based on differences in definitions use across included studies (eg, terminology used to describe injuries that involved more than one structure).
*Unclear (estimates significant in inconsistent directions), may (estimates mostly significant in the same direction or mostly not significant), increase or decrease (estimates consistently significant in the same direction).
†Soft tissue injury (diagnostic code).93
‡Mild knee injury (United States Military Injury Severity score of 0–3).93
§Cincinnati Knee Score ACL and Lysholm Knee Scoring Systems.
+++, moderate-certainty evidence; +, very low-certainty evidence; ++++, high-certainty evidence; ✓, no limitations; ++, low-certainty evidence; ACL, anterior cruciate ligament tear; ACLnoSx, ACL tear with no surgery; ACLRc, ACL reconstruction; AKP, anterior knee pain; GRADE, Grading of Recommendations Assessment, Development and Evaluation; LSI, limb symmetry index; n, number; OA, osteoarthritis; PFJ, patellofemoral joint; ROB, risk of bias; SR, self-reported; Sx, surgery; TF, tibiofemoral; X, serious limitations; XX, very serious limitations.