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Meta-analysis
ACE Report #3033

Reduced risk of ACL injury in athletes undergoing ACL injury prevention programs


Study Type:Meta analysis
OE Level Evidence:1
Journal Level of Evidence:N/A

Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs

J Bone Joint Surg Am. 2012 May 2;94(9):769-76

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OE EXCLUSIVE

Dr. Sadoghi speaks on ACL injury prevention training programs

Synopsis

This meta-analysis identified 8 controlled studies that examined anterior cruciate ligament (ACL) injury prevention programs. The purpose of this meta-analysis is to examine the effectiveness of ACL prevention programs and to determine if there is evidence for the "best" program, while assessing the quality of the current literature on ACL injury prevention. The pooled results showed that individuals who underwent ACL injury prevention programs had a 62% decrease in the risk of ACL rupture compared to the control group.

Publication Funding Details +
Funding:
Non-funded
Conflicts:
None disclosed

Risk of Bias

10/10

Reporting Criteria

18/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

4/4

Analysing Data

3/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

ACL tears are serious injuries that occur frequently in the United States and can incur millions of dollars annually. Having this injury may also predispose patients to osteoarthritis, leading to more pain and a reduced quality of life. Approximately 80% of ACL tears occur in non-contact situations, which suggests that preventative efforts may reduce ACL injuries. This meta-analysis identified 8 prospective, controlled studies on prevention programs for ACL injuries and examined whether ACL prevention programs actually reduce the risk of injury, and if there is a "best" program, and the validity of the findings.

What was the principal research question?

Does the use of ACL injury prevention programs reduce the risk of ACL injuries and is there a optimal prevention program?

Study Characteristics -
Data Source:
A search was conducted using the internet databases PubMed, MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health), and Cochrane Central Register of Controlled Trials databases.
Index Terms:
"(anterior cruciate ligament OR knee) AND (control OR prevention) AND injury"
Study Selection:
Studies included were 8 prospective, controlled trials that directly examined the use of ACL injury prevention programs compared to non prevention programs. Eligibility of the studies were in triplicate and cross-checked to prevent errors.
Data Extraction:
Outcome data from the identified studies were extracted in triplicate and crosschecked to avoid errors. Bibliographies of chosen studies were also reviewed to find additional relevant studies. Disagreements were resolved either by discussion or by the decision of the senior author.
Data Synthesis:
Data from the 8 identified studies were pooled and outcomes were expressed as risk ratios and risk differences using the DerSimonian-Laird random-effect models. Calculations were performed using the Intercooled State program and P=0.05 was considered significant for the pooled estimates. Heterogeneity was calculated using I-squared method. There was significant heterogeneity between the results (p=0.001) with an I-squared index of 64.0%.

What were the important findings?

  • The pooled risk ratio was 0.38 (95%CI, 0.20 to 0.72) which represented a 62% decrease in the risk of ACL rupture for the prevention group (P=0.003)
  • The pooled risk ratio, when stratified by sex, was 0.48 for female athletes (95%CI, 0.26-0.89) and 0.15 for male athletes (95%CI, 0.08 to 0.28)
  • In evaluating study quality, the mean Jadad score for the studies included was 1 point (95%CI, 0.43 to 1.57 points)
  • Heterogeneity was significant between the studies used (p=0.011) with an I-squared index of 64.0%
  • A "best" training program was unable to be determined due to the heterogeneity of the included studies

What should I remember most?

The results from this meta-analysis supports the use of ACL injury prevention programs, as it suggests a risk reduction of 52% in female athlete population and a risk reduction of 85% in the male athlete population. Quality of the studies involved were evaluated by the Jadad scoring system and was given a mean score of one point. An optimal prevention program was not determined due to the heterogeneity of the studies included.

How will this affect the care of my patients?

The results from this meta-analysis indicate that male and female athletes may find risk reduction in ACL injuries by participating in ACL injury prevention programs. Further studies are required to determine a specific type of prevention program that provides the most effective results.

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