Lu Yining, Jurgensmeier Kevin, Lamba Abhinav, Yang Linjun, Hevesi Mario, Camp Christopher L, Krych Aaron J, Stuart Michael J
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
Am J Sports Med. 2025 Apr;53(5):1050-1060. doi: 10.1177/03635465251322803. Epub 2025 Mar 13.
Nonoperative and operative management techniques after anterior cruciate ligament (ACL) injury are both appropriate treatment options for selected patients. However, the subsequent development of posttraumatic knee osteoarthritis (PTOA) remains an area of active study.
To compare the risk of PTOA between patients treated without surgery and with ACL reconstruction (ACLR) after primary ACL disruption using a machine learning causal inference model.
Cohort study; Level of evidence, 3.
A geographic database identified patients undergoing ACLR between 1990 and 2016 with minimum 7.5-year follow-up. Variables collected include age, sex, body mass index, activity level, occupation, relevant comorbid diagnoses, radiographic findings, injury characteristics, and clinical course. Treatment effects of ACLR on the development of PTOA and progression to total knee arthroplasty (TKA) were analyzed with machine learning models (MLMs) in a causal inference estimator (targeted maximum likelihood estimation, TMLE), while controlling for confounders.
The study included 1194 patients with a minimum follow-up of 7.5 years, among whom 974 underwent primary reconstruction and 220 underwent nonoperative treatment. A total of 215 (22%) patients developed symptomatic PTOA in the ACLR group compared with 140 (64%) in the nonoperative treatment group ( < .001), whereas 25 (3%) patients underwent TKA in the ACLR group compared with 50 (23%) in the nonoperative treatment group ( < .001). Patients in the ACLR group had delayed TKA compared with patients in the nonoperative treatment group (193.4 vs 166.0 months, respectively; = .02). TMLE evaluation revealed that reconstruction decreased the risk of PTOA by 11% (95% CI, 8%-13%; < .001) compared with nonoperative treatment but did not demonstrate a significant effect on the rate of progression to TKA. Survival analysis with random forest algorithm demonstrated significant delay to the onset of PTOA as well as time to progression of TKA in patients undergoing ACLR. Additional risk factors for the development of PTOA, irrespective of treatment, included older age at injury, greater body mass index, total number of arthroscopic knee surgeries, and residual laxity at follow-up.
MLMs in a causal inference estimator found ACLR to exert a significant treatment effect in reducing the rate of development of PTOA by 11% compared with nonoperative treatment. ACLR also delayed the onset of PTOA and progression to TKA.
前交叉韧带（ACL）损伤后的非手术和手术管理技术对特定患者而言都是合适的治疗选择。然而，创伤后膝关节骨关节炎（PTOA）的后续发展仍是一个活跃的研究领域。
使用机器学习因果推断模型比较初次ACL断裂后未接受手术治疗的患者与接受ACL重建（ACLR）的患者发生PTOA的风险。
队列研究；证据等级，3级。
一个地理数据库识别出1990年至2016年间接受ACLR且随访至少7.5年的患者。收集的变量包括年龄、性别、体重指数、活动水平、职业、相关合并症诊断、影像学检查结果、损伤特征和临床病程。在控制混杂因素的同时，使用机器学习模型（MLMs）在因果推断估计器（靶向最大似然估计，TMLE）中分析ACLR对PTOA发生和进展为全膝关节置换术（TKA）的治疗效果。
该研究纳入了1194例患者，最短随访时间为7.5年，其中974例接受了初次重建，220例接受了非手术治疗。ACLR组共有215例（22%）患者出现有症状的PTOA，而非手术治疗组为140例（64%）（P <.001）；ACLR组有25例（3%）患者接受了TKA，而非手术治疗组为50例（23%）（P <.001）。与非手术治疗组患者相比，ACLR组患者的TKA时间延迟（分别为193.4个月和166.0个月；P =.02）。TMLE评估显示，与非手术治疗相比，重建使PTOA的风险降低了11%（95%CI，8%-13%；P <.001），但对进展为TKA的发生率没有显著影响。随机森林算法的生存分析表明，接受ACLR的患者发生PTOA的时间以及进展为TKA的时间均显著延迟。无论治疗方式如何，PTOA发生的其他风险因素包括受伤时年龄较大、体重指数较高、膝关节镜手术总数以及随访时的残余松弛。
因果推断估计器中的MLMs发现，与非手术治疗相比，ACLR在降低PTOA发生率方面具有显著的治疗效果，降低了11%。ACLR还延迟了PTOA的发生以及进展为TKA的时间。
