James Lind Alliance First Time Soft Tissue Knee Injuries Priority Setting Partnership
In association with the British Association for Surgery of the Knee (BASK), British Orthopaedic Sports Trauma and Arthroscopy Association (BOSTAA) and British Orthopaedic Association, we are conducting a James Lind Alliance First Time Soft Tissue Knee Injuries Priority Setting Partnership.
Complete Survey here: https://cambridge.eu.qualtrics.com/jfe/form/SV_4NpiM7jJwM9RD4W
The knee is the most commonly injured joint in sporting accidents (1), but sports injuries account for only half of the knee injuries that are seen in practice (2). The largest population study, which comes from the Swedish registry, has demonstrated an annual incidence for soft tissue knee injuries to be 766 and 676 per 100,000 of the population for males and females, respectively. The peak rate of soft tissue knee injuries occurred in 15 to 19 year olds, with 1698/100,000 in males and 1464/100,000 in females (3).
Soft tissue injuries comprise a wide range of injuries, with meniscal (cartilage) tears accounting for about 11% of knee injuries, ligament injuries occurring in about 40% of all knee injuries (1) and ACL in approximately 50% of knee injuries (4). The annual incidence of ACL injuries has been shown to be 71/100,000 (3) while the incidence of meniscal injuries is estimated to be 60-70/100,00 per annum (5).
The burden of disease of ACL injuries continues to increase particularly in the paediatric population, with an estimated rise of 143% in ACL injuries in girls aged between 13 and 15, over an 18 year period (6). An estimated 15,000 ACL reconstructions take place in the UK per annum (7); the real figure is believed to be closer to 50,000 based on the incidence per 100,000 reported abroad (3). In the UK, there has been an estimated 12 fold rise in ACL reconstruction over a 20 year period (8).
Why are these injuries important?
Knee injuries frequently affect young people and can cause substantial disability, time off work, and may lead to long-term problems (9). Critically, injured knees have a 3 to 6 times increased risk of osteoarthritis , adding to the burden of osteoarthritis nationally (10,11). The risk of developing knee osteoarthritis by 65 years has been estimated to be about 14% in those who have had a knee injury in adolescence versus 6% in those who have not had a knee injury (12). With the cost of ACL surgery alone estimated (conservatively) at more than £60 million (13), the added cost of non-operative management and subsequent surgery related to sequelae from the initial soft tissue knee injury, is considerably higher.
Despite the significant burden of these injuries, their presentation and clinical treatment is very variable around the UK. Only around 20% of injuries present through A&E (14) and, often due to delays in diagnosis, it is not uncommon for treatment to occur following a period of delay, potentially affecting future outcomes (15). Even when treated, management is very variable around the country.
There remains a limited number of high-quality randomised controlled trials assessing soft tissue knee injuries, with no consensus found in a large scale Cochrane studies (16,17). With the clinical and financial burden rapidly increasing, key focus areas requiring answers include the prevention of injuries; provision of ‘acute knee’ care (ie early diagnosis/treatment pathways); patient support availability and the optimum management for acute and delayed soft tissue knee injuries. These remain key surgical priorities that need to be defined but also require the perspectives of patients in order to better understand deficits in care and improve planning of future management strategies.
Aims, objectives & scope
The aim of this Priority Setting Partnership is to identify the priorities for research in first time soft tissue knee injuries; to advance research and improve care for the large number of people who suffer from these injuries every year.
- Work with patients, carers and clinicians to identify uncertainties about the prevention, diagnosis, management and delivery of services relating to first time soft tissue knee injuries
- To agree by consensus a prioritised list of those uncertainties, for research
- To publicise the results of the PSP and process
- To take the results to research commissioning bodies to be considered for funding.
- The prevention, diagnosis, management and delivery of services relating to first time soft tissue knee injuries
- The first injury causing disability, which may lead to repeated injuries. These can be sports related or secondary to work and accidents e.g. twisting your knee whilst walking. They can cause swelling, pain, instability, difficulty walking and reduced movement of the affected knee.
- Include patella (knee cap) dislocations, ligament injuries, cartilage injuries (meniscus/joint surface)
- Include patients who are 12 years and older
- Chronic injuries (i.e. not the first injury)
- Patients younger than 12 years old
The Steering Group
The Steering Group is a key group of patients, carers and healthcare professionals who oversee the Priority Setting Partnership process and organise its activities.
We have a wide range of members in our Steering Group, providing their personal experience and expertise.
Jonathan is an NIHR James Lind Alliance (JLA) Adviser, having joined the JLA team in April 2019, and supports several JLA Priority Setting Partnerships. Jonathan has over 25 years of experience networking with charities, the public and private sectors. After spending many years as a biomedical researcher, Jonathan moved into research management and has worked in Research Council, University and NHS settings. He joined the NIHR Clinical Research Network in 2007, holding a number of different roles encompassing 26 different clinical specialties over a period of 12 years.
A/Professor Stephen McDonnell (Project Lead)
Consultant Orthopaedic Knee Surgeon (Addenbrooke’s Hospital, Cambridge) & Associate Professor at the University of Cambridge.
A/Professor Andy Metcalfe (BASK Research Lead & Representative)
Consultant Orthopaedic Knee Surgeon (Coventry) & Associate Professor at the Warwick Trials Unit. Research lead at the British Association for Surgery of the Knee.
Consultant Orthopaedic Knee Surgeon at Leeds Teaching Hospitals. He is passionate about providing early optimum treatment to the knee injuries, with an aim to preserve long term function. He has led on national guidance on ACL injuries besides contributing to other national guidance on meniscus and patella injuries.
Mr Nicolas Nicolaou (BOSTAA Academic Secretary & Representative)
Consultant Paediatric Orthopaedic Surgeon at Sheffield Children’s Hospital where he specialises in the treatment of child and adolescent knee pathology. He is also the academic secretary of the British Orthopaedic Sports Trauma and Arthroscopy Association (BOSTAA)
Trauma & Orthopaedic Registrar in the East of England Deanery. He studied at Guy’s, King’s and St.Thomas’ Medical School and Imperial College London (intercalated BSc). He is currently an MPhil candidate at the University of Cambridge. The Priority Setting Partnership forms his main research project.
General Practitioner working in both in-hours and Out of Hours services in the Windsor and surrounding East Berkshire localities. I am very interested in how we can improve care and access to specialists for patients who have had a new knee injury, and am very happy to be joining the team to provide a viewpoint from a GP’s perspective.
Research Physiotherapist at the Nuffield Orthopeadic Centre in Oxford. He is also a Senior Lecturer at Oxford Brookes University. Jon is the Chair of the Association of Trauma and Orthopaedic Chartered Physiotherapists (ATOCP).
Clinical Specialist Physiotherapist at the University Hospitals of Derby and Burton NHS Foundation Trust. She is a member of the ATOCP committee and her research interests are in the management of knee injuries (particularly anterior cruciate ligament injuries) and patient engagement in physical activity. She has recently been awarded an NIHR Clinical Doctoral Research Fellowship to continue her research in the preoperative management of ACL injuries.
Lead Extended Nurse Practitioner at Addenbrooke’s Hospital, Cambridge.
I am a specialist musculoskeletal physiotherapist working in the acute setting of accident and emergency minor injuries unit at Addenbrookes hospital. I have a particular interest in acute soft tissue injuries.
Dr Deepak Krishnaa
Dr. Deepak Krishnaa is an Emergency medicine trainee with special interest in musculoskeletal ultrasound. He also has taught on various Level 1 ultrasound courses.
Consultant Musculoskeletal Radiologist at Luton & Dunstable Hospital.
Patients, Carers & Charities
Secondary school student at Sheffield. She fractured her patella a couple of years ago and required two surgical operation. This has equipped her with the first-hand experience of how these injuries can affect young people and the excellent services provided by NHS. She has also been actively involved in research and conducted a study exploring the effects of Covid-19 and lockdown on children and students.
Educated in science and engineering disciplines, received her PhD in the field of food process engineering. Applying her research skills she crossed into the business management environment, specialising in strategy development, business planning and business change. Currently she works as an Independent Business Management Consultant and one of her more interesting engagements has been as Associate Tutor for the MSc stream at Warwick Manufacturing Group, University of Warwick. Here she has occasionally given lectures and regularly supervises students undertaking their research projects. Sushilla has suffered repeated subluxations and dislocations of the patellae of both her knees since childhood. Decades later, she has finally received successful reconstructive surgery.
Chloe is works within the social care sector and takes part in a variety of physical activities in her free time. Chloe suffered a soft tissue knee injury whilst bouldering. She has recently had reconstruction surgery and repair. Chloe hopes to get back to physical activity as soon as she is able to.
Final year Medical student at the University of Warwick. Previous 1st class honors degree in biochemistry from University of Nottingham. Published research regarding the efficacy of platelet-rich plasma in ACL reconstruction. Have an interest in orthopedics as a career. Have suffered multiple ACL injuries and required ACL reconstruction and revision.
Liz is a teacher from Cambridge. She required surgery to repair a tear in the meniscus, although is unsure exactly how she did it . Liz was surprised at how an initial small seeming injury can be very disruptive and to all aspects of every day life for a surprising length of time.
Chris joined Day One in July 2021 as Director of Service Delivery and Development after almost 20 years working across the charity sector. Having led some of the UK’s biggest fundraising programmes Chris switched focus in 2014, taking on the role of CEO at a regional cancer charity.
How will it be conducted?
The process will involve identifying evidence uncertainties, which will then be checked against available research. Patients, carers and healthcare professionals will then work together to create a top 10 list of questions, which identifies the main priorities for research going forward.
What are evidence uncertainties?
Evidence uncertainties are the basis of the PSP process. As per the JLA, they reflect questions about healthcare (treatment, testing, prevention, delivery of services etc), that lack current evidence to provide an answer. The lack of answers can either be due to no systematic reviews being present, or the evidence showing that there is an uncertainty. Thus, these uncertainties can come from more than one source, with the usual 4 being, patients, carers, clinicians and existing guidelines/systematic reviews. Uncertainties will be identified using a survey.
The survey will be launched on the 14th of March 2022. Paper and online versions will be available. It will be disseminated via partner organisations and in clinics to gain as many responses as possible from patients, carers and healthcare professionals.
We would like to thank the BOA, BASK, BOSTAA and Day One Trauma Charity for their support of this Priority Setting Partnership.
The project started in January 2022. Our Final Workshop will take place on January 14th 2023 at the Institute of Sport, Exercise & Health in London.
For further information about the James Lind Alliance and Priority Setting Partnerships , please visit: https://www.jla.nihr.ac.uk
For any further queries, please email firstname.lastname@example.org
Please follow us on Twitter @KneeInjuriesPSP
- Nicholl JP, Coleman P, Williams BT. Pilot study of the epidemiology of sports injuries and exercise related morbidity. Br J Sports Med 1991 Mar;25(1):61-6.
- Yawn BP, Amadio P, Harmsen WS, Hill J, Ilstrup D, Gabriel S: Isolated acute knee injuries in the general population. J Trauma. 2000, 48: 716-723.
- Peat, G., et al., Population-wide incidence estimates for soft tissue knee injuries presenting to healthcare in southern Sweden: data from the Skane Healthcare Register. Arthritis Res Ther, 2014. 16(4): p. R162
- Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Phys Ther Sport. 2004;5(3):125–145
- Maffulli N, Longo UG, Campi S, et al; Meniscal tears. Open Access J Sports Med. 2010 Apr 261:45-54. eCollection 2010.
- Weitz FK, Sillanpää PJ, Mattila VM. The incidence of paediatric ACL injury is increasing in Finland. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):363-368. doi:10.1007/s00167-019-05553-9
- Jameson, S.S., et al., Complications following anterior cruciate ligament reconstruction in the English NHS. Knee, 2012. 19(1): p. 14-9.
- AbramSGF, Price AJ, Judge A, et al Anterior cruciate ligament (ACL) reconstruction and meniscal repair rates have both increased in the past 20 years in England: hospital statistics from 1997 to 2017British Journal of Sports Medicine 2020;54:286-291
- Thorstensson, C.A., et al., Choosing surgery: patients’ preferences within a trial of treatments for anterior cruciate ligament injury. A qualitative study. BMC Musculoskelet Disord, 2009. 10: p. 100.
- Oiestad, B.E., et al., Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med, 2009. 37(7): p. 1434-43
- Muthuri SG, McWilliams DF, Doherty M, Zhang W: History of knee injuries and knee osteoarthritis: a meta-analysis of observational studies. Osteoarthritis Cartilage 2011, 19:1286–1293
- Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med 2000 Sep 5;133(5):321-8.
- Davies, L., Cook, J., Leal, J. et al. Comparison of the clinical and cost effectiveness of two management strategies (rehabilitation versus surgical reconstruction) for non-acute anterior cruciate ligament (ACL) injury: study protocol for the ACL SNNAP randomised controlled trial. Trials 21, 405 (2020). https://doi.org/10.1186/s13063-020-04298-y
- Schappert SM, Burt CW: Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 2001–02. ital Health Stat 13. 2006, 159: 1-66.
- Bollen SR, Scott BW. Rupture of the anterior cruciate ligament–a quiet epidemic? Injury. 1996;27(6):407–9.
- Linko, E., et al., Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev, 2005(2): p. Cd001356
- Smith TO, DonellS, Song F, Hing Surgical versus non‐surgical interventions for treating patellar dislocation. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD008106. DOI: 10.1002/14651858.CD008106.pub3