Committee Subjective Knee Evaluation Form Research Articles

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes

BackgroundSurgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts. HypothesisMLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes. MethodsBetween November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters. ResultsThree of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, −2.1–2.2mm), mean varus SSD was 1.4mm±2.5mm (range, −1.7–6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2–16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, −4.8–16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport—6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis. ConclusionsUsing non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level. Level of evidenceLevel IV, case series.

Increased Chondrocytic Gene Expression Is Associated With Improved Repair Tissue Quality and Graft Survival in Patients After Autologous Chondrocyte Implantation

Background: Assays to quantitate the quality of autologous chondrocyte implants have recently become available. However, the correlation of the assay score with radiological and clinical outcomes has not been established. Purpose/Hypothesis: The purpose was to assess the influence of cell identity (chondrocyte/synoviocyte gene expression ratio) and viability on patient-reported outcome measures, graft survival, and repair tissue quality. It was hypothesized that greater cell product quality as assessed through an identity assay and cell viability is associated with superior outcomes after autologous chondrocyte implantation (ACI) for symptomatic cartilage defects. Study Design: Cohort study; Level of evidence, 3. Methods: Seventy-nine patients with a minimum follow-up of 2 years were included in this study. Of these, 67 patients were available for imaging assessment utilizing the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Patients were assigned to groups either below or above the cohort’s mean based on their individual cell identity score and viability percentage. Results: Patients were predominantly female (57.7%) with a mean age of 30.0 ± 9.3 years. No differences were seen between Knee injury and Osteoarthritis Outcome Score, Lysholm, Tegner, or International Knee Documentation Committee Subjective Knee Evaluation Form within the viability and cell identity groups at a final follow-up of 3.8 ± 1.4 years after ACI (P > .05). In a subset of patients, the mean MOCART score was 68.3 ± 15.6 at an average magnetic resonance imaging follow-up of 17.7 ± 9.56 months. Low cell identity was significantly associated with the degree of defect filling (P = .025), integration of border zone (P = .01), effusion (P = .024), and ACI graft failure (P = .002). Patients with above-average cell identity scores had a significantly higher survival rate at 5-year follow-up compared with patients with below-average scores (95.8% vs 64.7%; P = .013). Cell viability did not influence MOCART subscales or graft failure (all P > .05). Cell viability and identity showed no significant correlation with each other (r = −0.045; P = .694). Conclusion: Cell identity was significantly correlated with structural repair quality and graft survival after second-generation ACI for symptomatic chondral lesions in the knee. While improved imaging outcome and higher graft survivorship were associated with a higher individual cell identity score indicating a higher chondrocyte/synoviocyte gene expression ratio in the final cell product, clinical outcome did not correlate with the identity score.

Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in Just 10 Post-Operative Return-to-Sport Training Sessions

Objectives: Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly acceptable and are worse among young female athletes. Developing better rehabilitation and return-to-sport (RTS) training programs and evaluating their outcomes are essential. The purposes of this study were to: 1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP+PERT) on strength, hops, functional outcomes, activity levels, and RTS rates in young female athletes 1 and 2 years after ACLR; and 2) Compare 2-year functional outcomes and activity levels among young female athletes in the ACL-SPORTS trial to homogeneous cohorts who completed criterion-based post-operative rehabilitation alone (MOON) and in combination with extended pre-operative rehabilitation (DE-Oslo). We hypothesized that SAPP+PERT would result in superior outcomes compared to SAPP alone; and female athletes who structured completed post-operative RTS training, compared to those who did not, would have higher functional outcomes. Methods: Aim 1 is a randomized control trial (NCT01773317) while aim 2 is a cohort study. For aim 1, we enrolled 39 female athletes, based on power calculations described previously. Athletes were enrolled 3-9 months after primary ACLR when they achieved impairment resolution. Participants were randomized to 10 SAPP or SAPP+PERT sessions (˜2x/week) and tested 1 and 2 years after ACLR on quadriceps strength, 4 hop tests, functional outcome measures, and RTS rates. We used 2x2 mixed-model ANOVA to test aim 1 (α = 0.05). Secondary to no group differences, we collapsed across SAPP and SAPP+PERT for aim 2. We applied inclusion/exclusion criteria and constrained sex (female) and age (13 to < 25 years) to compare these athletes who received post-operative RTS training (ACL-SPORTS) to homogeneous subsets who completed criterion-based post-operative rehabilitation alone (MOON) and combined with extended pre-operative rehabilitation (DE-Oslo) on 2-yr outcomes: the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Marx Activity Rating Scale. We tested aim 2 using 3-way ANOVA and Chi-Square test of proportions to compare the proportion of individuals in each group who met the Patient Acceptable Symptom State (PASS) thresholds. Results: There were no significant or clinically meaningful differences between SAPP and SAPP+PERT; groups were collapsed for comparison to the other cohorts. ACL-SPORTS had the highest scores on every outcome (Table 1). A higher proportion of ACL-SPORTS achieved the PASS thresholds for the IKDC, KOOS Activities of Daily Living, and KOOS Sport and Recreation (Fig 1, p ≤ .01). Conclusion: Our 1st hypothesis, that the addition of perturbation training would result in superior clinical and functional outcomes, was not supported. Our 2nd hypothesis, that a structured RTS training program would improve outcomes over existing cohorts, was supported. Post-operative RTS training incorporating strengthening, agilities, and plyometrics but not necessarily perturbation training, may improve functional outcomes and activity levels among young female athletes after ACLR. We provide a prototype for RTS training that would be feasible to implement into group or non-clinical environments. Future RCTs should assess the comparative effectiveness of RTS training in various settings. [Table: see text][Figure: see text][Figure: see text][Figure: see text]

Sex differences in knee extension rate of torque development and patient-reported function among individuals with anterior cruciate ligament reconstruction

Purpose: Men and women with anterior cruciate ligament reconstruction (ACLR) continue to receive similar rehabilitative care despite evidence that women are more likely to experience poor clinical outcomes, a more than 4 times greater risk for second ACL injury, and a 45% greater risk of developing post-traumatic osteoarthritis (PTOA) when compared to men of similar age and activity level. While the mechanism of PTOA development following ACLR remains unclear, altered knee joint loading characteristics during activities of daily living have been hypothesized as potential contributors to the early stages of this process. Recently, knee extension strength, knee extension rate of torque development (RTD), and patient-reported psychological readiness have been shown to influence lower extremity loading characteristics, but it remains unclear if sex differences are present in these outcome measures. If present, this would help to explain the disparate outcomes experienced by men and women with ACLR. Identification of modifiable outcomes such as knee extension strength characteristics and psychological readiness early after ACLR may provide clinicians with feasible targets for patient-centered intervention within this population. Therefore, the primary purpose of this study was to determine the effect of participant sex on measures of knee extension strength characteristics and psychological readiness among men and women within the first year after ACLR. Methods: Thirty-three women (age= 19.0±4.3 years, time since surgery= 6.8±1.6 months) and 29 men (age= 21.4±6.8 years, time since surgery= 7.4±2.3 months) with a history of ACLR were enrolled in an on-going cohort study from which these data were obtained. Participants were included if they were between the ages of 13 and 40, had a history of ACLR, were within 2 weeks of their final clinical visit to their orthopaedic surgeon, and had not yet returned to sport participation. Participants completed a detailed health history, the ACL Return to Sport After Injury (ACL-RSI) scale, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form after which they performed a bilateral assessment of knee extension maximal voluntary isometric contraction (MVIC) strength using a multimodal dynamometer. After a standardized familiarization protocol, participants completed 3 knee extension MVIC trials during which they were instructed to “kick out as hard and fast as possible” while being provided visual feedback on a nearby monitor. Peak knee extension MVIC torque (Nm) was documented from each trial and normalized to body mass (Nm/kg). Additionally, RTD100 was calculated as the slope of the torque x time curve from contraction initiation to 100ms following contraction initiation (Nm*kg-1*s-1) and RTD200 was calculated as the slope from of the torque x time curve from 100ms to 200ms after contraction initiation (Nm*kg-1*s-1). Participant demographics were compared between the sexes using independent samples t-tests while patient-reported outcome measures and knee extension strength characteristics were compared using ANCOVA with months since surgery as a covariate. Results: There were no significant sex differences in age (p= 0.10), time since surgery (p=0.65), patient-reported knee function (Female= 80.9±11.2, Male= 85.1±9.2; p= 0.11), or psychological readiness for sport (Female= 69.3±23.8, Male= 62.8±24.5; p= 0.25) among participants with ACLR. Female participants displayed lesser involved limb (Female= 1.99±0.53 Nm/kg, Male= 2.71±0.71 Nm/kg; p < 0.001) and contralateral limb (Female= 2.62±0.59 Nm/kg, 3.17±0.52 Nm/kg; p < 0.001) knee extension MVIC torque as well as lesser involved limb knee extension RTD100 (Female= 6.41±2.39 Nm*kg-1*s-1, Male= 8.24±3.17 Nm*kg-1*s-1; p= 0.01) and involved limb RTD200 (Female= 6.62±2.21 Nm*kg-1*s-1, Male= 9.43±3.40 Nm*kg-1*s-1; p < 0.001; Figure 1) when compared to male participants. Conclusions: Our findings indicate that women experience larger magnitude deficits in involved limb knee extension strength and RTD when compared to men during the terminal phase of clinical care following ACLR. This is despite no significant differences in patient-reported knee function or psychological readiness between the sexes. While not perceived as a functional limitation among women with ACLR, persistent quadriceps dysfunction and the associated alterations in lower extremity loading characteristics may set the stage for early degenerative changes in knee joint articular cartilage structure. Early identification of sex-based disparities in modifiable functional outcomes (knee extension strength and RTD) following ACLR may provide clinicians with goals for patient-centered impairment-based rehabilitation strategies to improve lower extremity loading characteristics which are implicated in the early progression of PTOA.

DELIVERY OF COMMON KNEE PATIENT-REPORTED OUTCOME INSTRUMENTS BY AUTOMATED MOBILE PHONE TEXT MESSAGING IN PEDIATRIC SPORTS MEDICINE

Background: Patient-reported outcome (PRO) instruments measure a patient’s health status in a variety of domains, including physical, mental and social well-being. The delivery of such instruments has become an integral part of healthcare, commonly employed to assess treatment efficacy and outcomes in sports medicine. With the proliferation of mobile phones, administration of PROs across patient-friendly platforms (e.g. apps, text messaging) may increase completion rates, particularly among younger patients. The purpose of this study was to validate the collection of common knee PROs with text messaging in sports medicine, by correlating text messaging responses with traditional paper delivery in adolescents and young adults. Methods: Patients presenting to a hospital-based pediatric orthopaedic sports medicine clinic with a knee injury were enrolled in this prospective investigation. Patients were excluded if they were undergoing a same-day office procedure, underwent surgery within the previous 90 days, and/or had no access to a mobile phone. Paper versions of the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and the Pediatric Functional Activity Brief Scale (Pedi-Fab Scale) questionnaires were completed during the patients’ initial clinic visit. Over the next 72 hours, the patients subsequently completed the mobile phone portion of the study outside of the clinic (Figure 1), which included text message delivery of the Pedi-IKDC and Pedi-Fab Scale, assigned in a random order. Correlations between paper and text message delivery of the two PROs were assessed. Secondary analyses were conducted to examine overall completion time and associations between patient demographics and text compliance. Results: Of the 91 patients (Age M=16.0 ±2.0 years; 48% female) initially enrolled in the study, 55 (60.4%) completed the text Pedi-Fab Scale, 48 (52.7%) completed the text Pedi-IKDC, and 39 (42.9%) completed both PROs. Among the evaluable sample, the intraclass correlation coefficient (ICC) between the paper and mobile phone delivery of the Pedi-Fabs was 0.95 (95% CI, 0.91-0.97). The ICC between the paper and mobile phone delivery of the Pedi-IKDC was 0.96 (95% CI, 0.93-0.98). Average Pedi-Fab scores on paper (M=12.7) and mobile phone (M=12.3) were not significantly different (p=0.52). Similarly, average Pedi-IKDC scores on paper (M=68.8) and mobile phone (M=67.7) were not significantly different (p=0.41). A Bland-Altman plot and linear regression revealed there was no proportional bias between the mean and difference for the Pedi-Fab scores (p=0.55) and Pedi-IKDC scores (p=0.56). The average completion time for the text delivered Pedi-Fab and Pedi-IKDC were 102±224 minutes and 159±155 minutes, respectively. For Pedi-Fab, there were no patient demographics that were significantly associated with text completion. However, high school students (p=0.025), female sex (p=0.036), and race (p=0.002), were significantly associated with the text completion of Pedi-IKDC. In addition, order of the delivery of the questionnaires and paper scores were not associated with text completion for either survey. Conclusion: Text message delivery using mobile phones permits valid assessment of Pedi-IKDC and Pedi-Fabs scores in this prospective observational study. Questionnaire delivery by automated text messaging allows asynchronous response and may increase compliance among high school students while also reducing the labor cost of collecting PROs.

Korean Version of the Anterior Cruciate Ligament-Return to Sport after Injury Scale: Translation and Cross-cultural Adaptation.

BackgroundTo translate into Korean and culturally adapt the anterior cruciate ligament-return to sports after injury (ACL-RSI) scale assessing psychological readiness to return to sports after ACL reconstruction and to validate its psychometric properties.MethodsThe ACL-RSI scale was forward translated into Korean and back-translated into English for cultural adaptation according to the standardized guideline. For validation, the Korean version of the ACL-RSI (ACL-RSI Kr) was administered to patients who underwent ACL reconstruction. The following subjective questionnaires were also administered: International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), Lysholm scale, Knee injury and Osteoarthritis Outcome Score (KOOS), and a Return to Sports Questionnaire. Test-retest reliability, internal consistency, content validity, construct validity, and discriminant validity of the ACL-RSI Kr were assessed.ResultsA total of 129 patients (102 men and 27 women) were included in the study. Their mean age was 28.3 years. The average follow-up duration was 13.2 months. Test-retest reliability was remarkable (intraclass correlation coefficient, 0.949), internal consistency was high (Cronbach's alpha, 0.932), and floor and ceiling effects were confirmed to be less than 10%. Construct validity assessed by correlation analysis with KOOS, IKDC-SKF, and Lysholm scale showed the correlation coefficients ranging from 0.169 to 0.679 (all p < 0.01). Compared with the Return to Sports Questionnaire, statistically significant difference was found in the ACL-RSI Kr between patients who received more than 7 points and less than 7 points (72.2 vs. 60.3, p = 0.025) for performance level scored using a 10-point Likert scale, proving its discriminative value.ConclusionsThe ACL-RSI Kr demonstrated good psychometric properties. This scale can be an excellent instrument for evaluating patient's psychological readiness to return to sports after ACL injury.

The Minimal Clinically Important Difference and Substantial Clinical Benefit in the Patient-Reported Outcome Measures of Patients Undergoing Osteochondral Allograft Transplantation in the Knee.

Little is known regarding the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) with regard to the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm score, and Short Form 12 (SF-12) score of patients who undergo osteochondral allograft transplantation (OCA). We aimed to determine the MCID and SCB associated with those patient-reported outcome measures (PROMs) after OCA. We analyzed the data of 86 consecutive patients who underwent OCA and who completed satisfaction surveys at a minimum of 1 year postoperatively and had at least one repeated PROM. MCID was determined using an anchor-based method: the optimal cutoff point for receiver operative characteristic (ROC) curves. If an anchor-based method was inapplicable, distribution-based methods were employed. SCB was determined using ROC curve analysis. Based on the ROC curve analysis, MCID was 16.7 for KOOS pain, 25 for KOOS sports/recreation, and 9.8 for IKDC. SCB was 27.7 for KOOS pain, 10.7 for KOOS symptom, 30 for KOOS sports/recreation, 31.3 for KOOS quality of life, 26.9 for IKDC, 25 for Lysholm, and 12.1 for SF-12 physical component summary. No significant association was noted between SCB achievement and the baseline patient factors and baseline PROMs. We demonstrated the MCIDs and SCBs of several PROMs in patients undergoing OCA. These results will aid the interpretation of the effect of treatment and clinical trial settings. Moreover, the SCBs will help surgeons in the counseling of patients, where patients expect optimal results rather than minimal improvement.

Worsen depression after viscosupplementation treatment for geriatric people with knee osteoarthritis?

Background/objective: Knee osteoarthritis (OA) in older people may result in psychological impairment, including anxiety and depression. This study investigates the effect of intraarticular hyaluronic acid injection (IAHA) on geriatric patients with OA. Method: A total of 102 geriatric patients with knee OA undergoing IAHA were prospectively enrolled in this study. Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and Visual Analogue Scale (VAS) for pain were recorded. All outcomes were measured at baseline before injection and during two, four, and six month follow-ups. Results: IAHA had a significant short-term effect, relieving pain at the two month follow-up, but the effect was weaker at the four month follow-up. Both IKDC and WOMAC scores were significantly improved at the two month follow-up. Viscosupplementation did not improve STAI. GDS exhibited significant deterioration at the four month follow-up. Conclusions: Although IAHA for the treatment of OA provided short-term efficiency, it had no effects on anxiety and increased depression of geriatric people. Health education should be provided with caution before viscosupplementation treatment to manage expectations of the efficacy of treatment for geriatric OA patients.

Landing biomechanics in anterior cruciate ligament reconstructed females who pass or fail a functional test battery

BackgroundA functional test battery (FTB) has been proposed to determine return to full activity following anterior cruciate ligament reconstruction (ACLR). However, there is little biomechanical evidence of FTB usefulness. The purpose of this study was to compare knee joint landing and cutting biomechanics between ACLR patients who passed (ACLR-Pass), failed (ACLR-Fail), and healthy females (Healthy) before and after exercise. MethodsThirty females were included: 10 ACLR-Pass, eight ACLR-Fail and 12 Healthy. Participants performed a FTB consisting of The 2000 International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee Outcome Survey Activities of Daily Living Scale, and quadricep strength and single-leg hop tests. Double-leg jump landing (DLJL) and single-leg jump cutting (SLJC) biomechanics were assessed before and after exercise. ResultsSignificant main effects of exercise were found during DLJL: lesser knee flexion angle at initial contact after exercise (before exercise: 15.8 ± 5.0, after exercise: 14.2 ± 5.4, P = 0.01, ηp 2 = 0.25); and during SLJC: smaller peak knee extension moment (before exercise: −0.33 ± 0.1, after exercise: −0.31 ± 0.1, P = 0.02, ηp 2 = 0.18). While there was a significant group by time interaction effect with lesser peak knee flexion angle after exercise, this interaction effect was likely driven by a reduction in peak knee flexion in only the Healthy group. ConclusionsHealthy females exhibited a reduction in peak knee flexion during SLJC after exercise. However, there were no differences in ACLR knee biomechanics during DLJL and SLJC performed before and after exercise.

Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series

ABSTRACTObjectives: There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.Methods: A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.Results: A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17–43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4–15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.Conclusions: Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.

Younger age and greater preoperative function predict compliance with 2-year follow-up visits after ACL reconstruction: an analysis of the PIVOT multicentre trial

ObjectivesThe purpose of this investigation was to identify clinical and demographic variables that may predict compliance, defined as patient follow-up at 1-year and 2-year postoperative appointments, after anterior cruciate ligament reconstruction (ACLR).MethodsA total of 107 patients undergoing primary ACLR across four centres were prospectively followed for 2 years. Demographic and clinical data were recorded preoperatively and postoperatively, including patient-reported outcomes such as the Marx Activity Rating Scale, Cincinnati Occupational Rating Scale (CORS), International Knee Documentation Committee Subjective Knee Evaluation Form and Activities of Daily Living Scale (ADLS). Compliance was retrospectively defined using the presence or lack of outcome measures at 1-year and 2-year postoperative visits. Univariate analysis was done to compare demographic and clinical variables between compliant and non-compliant patients at 1-year and 2-year follow-up. Significant variables were entered into a logistic regression model. Significance was set at p<0.05.ResultsThe overall rate of compliance at 1-year and 2-year postoperative appointments was 83.2% (89/107) and 57.0% (61/107), respectively. Regression analysis showed that residence in Kobe, Japan compared with Pittsburgh, USA (OR 10.28; 95% CI 1.0003 to 105.28), and ‘very strenuous’ (OR 16.74; 95% CI 3.21 to 87.43) and ‘strenuous’ (OR 18.78; 95% CI 2.01 to 175.78) preinjury activity level were independent factors associated with compliance at 1-year follow-up. At 2 years follow-up, younger age (OR 0.95; 95% CI 0.91 to 0.997), and greater preoperative score on CORS (OR 1.03; 95% CI 1.01 to 1.06) and on ADLS (OR 1.04; 95% CI 1.01 to 1.07) were independently associated with compliance.ConclusionWhile patients with greater level of strenuous activity were more likely to follow-up after ACL surgery at 1 year, patients who were younger and had higher preoperative function measured by CORS and ADLS were more likely to follow-up at 2 years. Differences in follow-up rates among the USA, Italy, Sweden and Japan may highlight important cultural, socioeconomic and infrastructural differences across international healthcare systems. Orthopaedic surgeons may consider the results of this study during preoperative discussion with their patients and design of future ACL clinical research trials.Level of evidenceLevel III, prospective cohort.

Temporary postoperative treatment with compartment-unloading knee braces or wedge insoles does not improve clinical outcome after partial meniscectomy

PurposeTo investigate whether temporary postoperative compartment-unloading therapy after arthroscopic partial meniscectomy (APM)—with either knee braces or wedge insoles—leads to superior clinical outcome as compared to controls. This difference in clinical outcome was tested in the form of two knee scores, physical activity and general health outcome over the first postoperative year.MethodsSixty-three patients who underwent arthroscopic partial meniscectomy (APM) were randomized to one of the following three groups: 12 weeks postoperative knee compartment-unloading therapy with either a knee brace (brace group) or wedge insoles (insole group) or no specific postoperative therapy (control group). Patient-reported outcome was assessed with the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC Score), the Knee Injury and Osteoarthritis Outcome Score (KOOS), the MARX score (physical activity) and the SF-12 (general health).ResultsSixty-three patients were available for analysis. Except for the SF-12 mental score, all other scores showed significant improvement over time. With regard to the hypotheses proposed, no significant group * time interactions were observed for any of the outcome parameters. This means that the group (i.e. the type of postoperative treatment) was not related to the degree of improvement of any of the scores.ConclusionsIt was concluded that 12 weeks of compartment-unloading therapy—with either a knee brace or wedge insoles—is ineffective with regard to clinical outcome after APM. This applies to the knee score outcome, physical activity and general health outcome over the first year following APM.Level of evidenceRandomized controlled trial, Level I.

The clinical relevance of PCL index on the reconstruction of anterior cruciate ligament with hamstring tendon autograft.

The posterior cruciate ligament index (PCL index) has been reported as a diagnostic and prognostic marker for anterior cruciate ligament (ACL) reconstruction. The clinical relevance of PCL index on the reconstruction of ACL with hamstring tendon autograft has not been described in the literature. The objective of this study is to evaluate the importance of the PCL index as a marker of anatomic reconstruction and of functional improvement of patients undergoing ACL reconstruction with HT autograft. Twenty-four patients were submitted to ACL reconstruction with HT autograft. The PCL index was assessed by magnetic resonance imaging before and after surgery. The functional evaluation was performed through the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form© and Knee Society Knee Scoring System© (IKS). Patients presented a significant positive variation of the PCL index, IKDC and IKS scores. There is no significant correlation between PCL index variation and IKDC and IKS scores (p > 0.05). Unlike other studies reporting a relationship between the PCL index, control of rotational kinematics, and functional improvement in patients undergoing ACL reconstruction with bone-patellar tendon-bone autograft, this study does not demonstrate this association. There is evidence in this study to show that the PCL index may be used as an anatomic reconstructive marker of ACL but not to predict the clinical outcome in this type of reconstruction.

A combined procedure with Bereiter-type trochleoplasty leads to a stable patellofemoral joint at 5-year follow-up.

Trochlear dysplasia is a major risk factor predisposing to patellar instability and has been reported to occur in up to 85% of patients with recurrent patellar dislocation. Different operative techniques have been described to correct trochlear dysplasia, including the Bereiter technique, in which subchondral bone is removed and the cartilage can be compressed into a U-shaped groove. The hypothesis was that after a Bereiter-type trochleoplasty combined with medialisation of the tibial tubercle and MPFL reconstruction, patellar pain and instability decreased and anatomic reconstruction can be seen radiographically after 5-year follow-up. Between 2004 and 2011, a combined procedure including Bereiter-type trochleoplasty was performed on 21 consecutively included patients (22 knees) with objective patellar instability and severe trochlear dysplasia. Instability and pain were assessed preoperatively and 3, 6, 12, 24 and 60months postoperatively with the visual analogue scale (VAS) for pain and instability, Kujala, International Knee Documentation Committee Subjective Knee Evaluation (IKDC SKE) and Short Form Health Survey (SF-36). Pre- and postoperatively, a true lateral radiograph was made to investigate the presence of the crossing sign and to measure the trochlear bump and trochlear depth, as well as a sunrise patella view to measure the sulcus angle. VAS pain and instability, Kujala and IKDC SKE improved significantly 5 years after trochleoplasty (p < 0.05). SF-36 showed no significant improvement. None of the patients reported patellar dislocations postoperatively. Sport activities remained limited. Postoperative radiographs showed no crossing sign. There was a significant increase in trochlear depth (p < 0.0001) and also a significant decrease in trochlear bump and sulcus angle (both p < 0.0001). A combined procedure consisting of Bereiter-type trochleoplasty, medialisation of the tibial tubercle and MPFL reconstruction in patients with objective patellar instability and severe trochlear dysplasia resulted in a clear decrease of pain and instability. Radiological assessment showed anatomical reconstruction. Nevertheless, residual symptoms remain and the possibility of future cartilage damage is uncertain. IV.

Continued Improvements in Quadriceps Strength and Biomechanical Symmetry of the Knee After Postoperative Anterior Cruciate Ligament Reconstruction Rehabilitation: Is It Time to Reconsider the 6-Month Return-to-Activity Criteria?

Patients who undergo anterior cruciate ligament reconstruction (ACLR) present with strength and biomechanical deficits at return to activity (RTA). Deficits in strength and biomechanical symmetry impair function during activity and may predispose patients to subsequent injury. To compare strength and biomechanical function in patients with ACLR at RTA and more than 12 months post-ACLR. Descriptive laboratory study. Research laboratory. A total of 20 participants (12 females, 8 males; age = 21.40 ± 5.60 years, height = 171.3 ± 10.2 cm, mass = 73.21 ± 19.41 kg) who had undergone ACLR and were cleared to RTA were recruited. Strength was measured during knee extension and evaluated by the isometric and isokinetic quadriceps index. Biomechanical function was evaluated using symmetry values for sagittal-plane knee-joint rotations, changes in sagittal-plane knee-joint rotation, knee-extension moments, and changes in knee-extension moment that were recorded during a single-legged forward hop. Self-reported function was measured using the International Knee Documentation Committee Subjective Knee Evaluation Form. Participants were assessed at RTA (212.25 ± 28.11 days) and more than 12 months post-ACLR (556.25 ± 230.89 days). At RTA, strength and biomechanical values were less than 80% symmetric. We observed improvements from RTA to more than 12 months post-ACLR for the isometric quadriceps index ( F1,18 = 29.22, P < .001), isokinetic quadriceps index ( F1,18 = 10.88, P = .004), sagittal-plane knee-joint rotations ( F1,19 = 9.58, P = .006), change in sagittal-plane knee-joint rotations ( F1,19 = 7.83, P = .01), knee-extension moments ( F1,19 = 5.73, P = .03), change in knee-extension moments ( F1,19 = 21.10, P < .001), and self-perceived function ( F1,19 = 11.50, P = .003). Of the 7 variables that showed improvement at more than 12 months post-ACLR, only 3 met the recommended criteria (≥90%). Patients with ACLR showed asymmetry in strength and biomechanics at RTA. These asymmetries, along with self-perceived function, improved over time. However, despite improvements in strength and biomechanics at RTA, asymmetries of more than 10% were still present more than 12 months post-ACLR.

Decision to Return to Sport Participation After Anterior Cruciate Ligament Reconstruction, Part II: Self-Reported and Functional Performance Outcomes.

Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments. To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR. Case-control study. University research laboratory. Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years). The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged-hop tests, isokinetic quadriceps and hamstrings strength at 60°/s and 180°/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session. The Limb Symmetry Index was calculated for all functional performance measures. Mann-Whitney U tests were used to compare measures between groups ( P < .10). Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67-97.70; NRTS median = 82.76, range = 63.22-96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54-100; NRTS median = 71, range = 54-100; P = .08). No differences were observed for any functional performance measures. The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices.

Outcomes and Return to Sport After Revision Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

Background:The number of adolescent anterior cruciate ligament (ACL) injuries is rising with increased participation in higher level athletics at earlier ages. With an increasing number of primary ACL reconstructions (ACLRs) comes a rise in the incidence of revision ACLRs.Purpose:To evaluate the clinical results of revision ACLR across a group of high-level adolescent athletes with at least 2-year follow-up.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review of 21 adolescent athletes (age range, 10-19 years) who underwent revision ACLR with at least 2-year follow-up was conducted. Patient-reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, Tegner activity level scale, and modified Cincinnati Knee Rating System. Return to sport (RTS) and overall patient satisfaction were also assessed.Results:The mean age at the time of surgery was 16.5 years (range, 14-19 years), and the mean follow-up was 46.4 months (range, 24-97 months); 42.9% of patients were female, and 52.4% of patients participated in collision sports. The mean time to failure after primary ACLR was 13.1 ± 8.0 months, and the most common mechanism of failure was noncontact in at least 66.7% of cases. The revision graft type included bone–patellar tendon–bone (BPTB) in 71.4% of cases; 26.7% of BPTB grafts were from the contralateral extremity. Concomitant procedures were performed for intra-articular lesions in 71.4% of patients. The mean patient satisfaction rate was 95.3%. There were 3 cases of a graft reinjury at a mean of 25 months postoperatively. The mean PROM scores were as follows: IKDC, 87.5 ± 12.7; Tegner, 7.2 ± 2.0; Lysholm, 93.7 ± 9.8; and Cincinnati, 93.4 ± 10.0. Of those attempting to RTS, 68.4% of patients successfully returned at the same level of competition. Patients with a lateral compartment chondral injury were less likely to RTS (P < .05). Independent variables shown to have no significant relationship to PROMs or RTS included age, follow-up, sport classification, associated meniscal tears, revision graft size/type, and concomitant procedures.Conclusion:Revision ACLR can be an effective surgical option in adolescents participating in collision and contact sports, with good to excellent subjective outcome scores. At a minimum 2-year follow-up, a graft rupture after revision ACLR occurred in 14% of cases. Of the athletes attempting to RTS, 68.4% returned to their preinjury level of competition.

Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs?

Study Design Prospective cohort study. Background While meeting objective criterion cutoffs is recommended prior to return to sports following anterior cruciate ligament (ACL) reconstruction, the number of young athletes who meet recommended cutoffs and the impact of cutoffs on longitudinal sports participation are unknown. Objectives To test the hypothesis that a higher proportion of young athletes who meet recommended cutoffs will maintain the same level of sports participation over the year following return-to-sport clearance compared to those who do not meet recommended cutoffs. Methods At the time of return-to-sport clearance, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), quadriceps and hamstring strength limb symmetry index (LSI), and single-leg hop test LSI were assessed. Proportions of participants who met individual (IKDC score of 90 or greater; strength and hop test LSIs of 90% or greater) and combined cutoffs were calculated. Proportions of participants who continued at the same level of sports participation over the year following return-to-sport clearance (assessed using the Tegner activity scale) were compared between those who met and did not meet cutoffs. Results Participants included 115 young athletes (88 female). The proportions meeting individual cutoffs ranged from 43.5% to 78.3%. The proportions meeting cutoffs for all hop tests, all strength tests, and all combined measures were 53.0%, 27.8%, and 13.9%, respectively. A higher proportion of participants who met cutoffs for both strength tests maintained the same level of sports participation over the year following return-to-sport clearance than those who did not (81.3% versus 60.2%, P = .02). Conclusion The proportions of young athletes after ACL reconstruction recently cleared for return to sports who met the combined criterion cutoffs were low. Those who met the criterion cutoffs for both strength tests maintained the same level of sports participation at higher proportions than those who did not. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther 2017;47(11):825-833. Epub 7 Oct 2017. doi:10.2519/jospt.2017.7227.

Translation, cross-adaptation and measurement properties of the Brazilian version of the ACL-RSI Scale and ACL-QoL Questionnaire in patients with anterior cruciate ligament reconstruction

BackgroundScales to assess the quality of life and return-to-sport after reconstruction of the anterior cruciate ligament (ACL) may help the clinical decision-making process. ObjectiveTo cross-culturally adapt and determine the validity of the Brazilian versions of the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) and the Quality of Life Questionnaire (ACL-QoL). MethodsThe process of translation and cross-cultural adaptation followed the recommendations of international guidelines. One hundred participants filled out the Brazilian versions of these instruments, the Tampa Scale for Kinesiophobia (TSK), the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and the 36-Item Short Form Health Survey (SF-36). The measurement properties of reliability, internal consistency and construct validity were measured. ResultsThe ACL-RSI and the ACL-QoL were successfully translated and cross-culturally adapted. Both questionnaires showed good test–retest reliability (ICC2,1=0.78, 95% CI=0.67–0.85 for the ACL-RSI; and ICC2,1=0.84, 95% CI=0.76–0.90 for the ACL-QoL) and good internal consistency (Cronbach's alpha=0.87 for the ACL-RSI; and Cronbach's alpha=0.96 for the ACL-QoL). A reasonable correlation was found between both questionnaires and the TSK, and a low to reasonable correlation was found between the questionnaires and the SF-36 in terms of validity. Compared to the IKDC Subjective Knee Evaluation Form, the ACL-RSI had a reasonable correlation and the ACL-QoL had a good correlation. ConclusionThe Brazilian versions of the ACL-RSI and the ACL-QoL have adequate measurement properties and may be used in assessing Brazilians after ACL reconstruction.

Preoperative Short Form Health Survey Score Is Predictive of Return to Play and Minimal Clinically Important Difference at a Minimum 2-Year Follow-up After Anterior Cruciate Ligament Reconstruction

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR). Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP. Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m2, respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID (P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID. Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.