Committee Subjective Knee Evaluation Form Research Articles

Reconstruction for chronic grade-II posterior cruciate ligament deficiency in Malaysian military personnel.

To evaluate the outcome of reconstruction for chronic grade-II posterior cruciate ligament (PCL) deficiency in Malaysian military personnel. Medical records of 16 male military personnel aged 25 to 41 years who underwent reconstruction for chronic grade-II PCL deficiency using the quadruple hamstrings tendon by a single surgeon were reviewed. The mean time from injury to surgery was 43.6 (range, 3-104) months. 10 patients had grade-I (n=4), grade-III (n=2), and grade-IV (n=4) lesions of the medial femoral condyles. Seven patients had medial (n=6) and lateral (n=1) meniscus tears. At the 2-year follow-up, patients were asked to complete a questionnaire consisting of the Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form. Posterior drawer test, KT-2000 arthrometer test for posterior translation of the tibia, and military health grade (MHG) were assessed by an independent assessor. At the 2-year follow-up, the mean Lysholm score was 83; the score was excellent in 2 patients, good in 9, fair in 4, and poor in one. The mean IKDC subjective score was 74. The median Tegner activity level increased from 5.5 to 6. The posterior drawer test of 11 patients improved to grade I and the remaining 5 remained at grade II. The mean posterior translation of the tibia was 2.4 mm postoperatively; the posterior translation was normal in 8 patients, nearly normal in 7, and abnormal (≥ 6 mm) in one. The MHG improved in 14 patients and remained unchanged in 2. The latter 2 patients had no chondral lesion or meniscus injury. The first one was 40 years old with a postoperative IKDC score of 55 and a Tegner activity level of 2. The second one was 34 years old with a postoperative IKDC score of 65 and posterior translation of the tibia of 6 mm. Surgical reconstruction for chronic grade-II PCL injury achieved satisfactory outcome and may be appropriate for military personnel.

Does Decreased Meniscal Thickness Affect Surgical Outcomes After Medial Meniscectomy?

Background: There have been no clinical studies regarding the effect of decreased meniscal thickness on outcomes after meniscectomy. Purpose: To examine the postoperative outcomes of partial meniscectomy with or without horizontal resection compared with the outcomes of subtotal meniscectomy and to evaluate the influence of decreased thickness of the medial meniscus on outcomes after partial meniscectomy. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 312 patients who underwent medial meniscectomy were retrospectively reviewed. Patients were divided into 3 groups: group A (n = 84) included patients with partial meniscectomy with vertical resection, group B (n = 140) consisted of those with partial meniscectomy with horizontal resection, and group C (n = 88) included those with subtotal meniscectomy. Clinical function was evaluated by use of the Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and Tapper and Hoover grading system. Radiologic evaluation was performed with the IKDC radiographic assessment scale as well as with measurements of the medial compartment height at the tibiofemoral joint. Preoperative values and postoperative values measured 5 years after operation were assessed. Results: Functional outcomes in group C were inferior to those in groups A and B according to the Lysholm knee score (mean ± SD for group A = 96.1 ± 4.7, group B = 94.9 ± 5.2, group C = 84.8 ± 11.4; P < .001), IKDC subjective score (group A = 92.1 ± 6.5, group B = 91.3 ± 8.8, group C = 81 ± 11.4; P < .001), and Tapper and Hoover grading system (P = .003). There was no significant difference in scores between groups A and B. With regard to radiologic evaluation, the IKDC radiographic grade for group C was worse than the grades for groups A and B (P < .001); there was no significant difference between groups A and B. However, the postoperative joint space on the affected side was higher for group A (4.7 ± 0.6 mm) than for groups B (4.3 ± 0.5 mm; P < .001) and C (3.7 ± 0.8 mm; P < .001). The joint space was higher in group B than in group C (P < .001). Conclusion: Despite joint space narrowing, decreases in meniscal thickness after partial meniscectomy for horizontal tear had no additional adverse effect on 5-year functional and radiographic outcomes compared with conventional partial meniscectomy preserving whole meniscal thickness. In treating horizontal tears of the meniscus, partial meniscectomy with complete resection of the unstable leaf was an effective method in a 5-year follow-up study.

The Efficacy of Platelet-Rich Plasma in the Treatment of Symptomatic Knee Osteoarthritis: A Systematic Review With Quantitative Synthesis

The purpose of this systematic review was to synthesize the available Level I and Level II literature on platelet-rich plasma (PRP) as a therapeutic intervention in the management of symptomatic knee osteoarthritis (OA). A systematic review of Medline, Embase, Cochrane Central Register of Controlled Trials, PubMed, and www.clinicaltrials.gov was performed to identify all randomized controlled trials and prospective cohort studies that evaluated the clinical efficacy of PRP versus a control injection for knee OA. A random-effects model was used to evaluate the therapeutic effect of PRP at 24 weeks by use of validated outcome measures (Western Ontario and McMaster Universities Arthritis Index, visual analog scale for pain, International Knee Documentation Committee Subjective Knee Evaluation Form, and overall patient satisfaction). Six Level I and II studies satisfied our inclusion criteria (4 randomized controlled trials and 2 prospective nonrandomized studies). A total of 577 patients were included, with 264 patients (45.8%) in the treatment group (PRP) and 313 patients (54.2%) in the control group (hyaluronic acid [HA] or normal saline solution [NS]). The mean age of patients receiving PRP was 56.1 years (51.5% male patients) compared with 57.1 years (49.5% male patients) for the group receiving HA or NS. Pooled results using the Western Ontario and McMaster Universities Arthritis Index scale (4 studies) showed that PRP was significantly better than HA or NS injections (mean difference, -18.0 [95% confidence interval, -28.8 to -8.3]; P < .001). Similarly, the International Knee Documentation Committee scores (3 studies) favored PRP as a treatment modality (mean difference, 7.9 [95% confidence interval, 3.7 to 12.1]; P < .001). There was no difference in the pooled results for visual analog scale score or overall patient satisfaction. Adverse events occurred more frequently in patients treated with PRP than in those treated with HA/placebo (8.4% v 3.8%, P = .002). As compared with HA or NS injection, multiple sequential intra-articular PRP injections may have beneficial effects in the treatment of adult patients with mild to moderate knee OA at approximately 6 months. There appears to be an increased incidence of nonspecific adverse events among patients treated with PRP. Level II, systematic review of Level I and II studies.

Long-term follow-up of ACL reconstruction with hamstring autograft

To investigate the differences in the incidence and severity of knee osteoarthritis (OA), joint space narrowing, knee laxity, and knee flexion and extension strength between an anterior cruciate ligament (ACL)-reconstructed knee and the contralateral non-reconstructed limb. Retrospective case series of patients from a single surgeon that had an ACL reconstruction with a semitendinosus/gracilis autograft more than 12 years ago. Outcome measures included radiographic analysis, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), KT-1000, Tegner Activity Level Scale, Lysholm Knee Score, ACL quality of life score (ACL-QOL) and knee flexor/extensor strength. Seventy-four patients consented and sixty-eight (43 male, 25 female) were included for analysis. Average age (SD) at the time of surgery was 31.2 (±9.1) years. At follow-up of 14.6 (1.9) years, 9% had re-ruptured their ACL, whereas 5% ruptured the contralateral ACL. Reconstructed knees had a greater incidence and severity of OA (P < 0.01). Medial meniscus surgery was a strong predictor of OA. Seventy-five per cent scored a normal or nearly normal knee on the IKDC. The mean Lysholm score was 75.8% and Tegner Activity Level Scale scores decreased (P < 0.001) from the time of surgery. Knee extension strength was greater in the contralateral knee at speeds of 60°/s (P = 0.014) and 150°/s (P = 0.012). Reconstructed knees have a greater incidence and severity of OA than non-reconstructed knees, which suggests degenerative changes are secondary to ACL rupture. Medial meniscus surgery is a strong predictor of OA. Despite this, 75% of patients reported good outcomes.

The Feasibility of a 3-Month Active Rehabilitation Program for Patients With Knee Full-Thickness Articular Cartilage Lesions: The Oslo Cartilage Active Rehabilitation and Education Study

Case series. To evaluate the feasibility of an active rehabilitation program for patients with knee full-thickness articular cartilage lesions. No studies have yet evaluated the effect of active rehabilitation in patients with knee full-thickness articular cartilage lesions or compared the effects of active rehabilitation to those of surgical interventions. As an initial step, the feasibility of such a program needs to be described. Forty-eight patients with a knee full-thickness articular cartilage lesion and a Lysholm score below 75 participated in a 3-month active rehabilitation program consisting of cardiovascular training, knee and hip progressive resistance training, and neuromuscular training. Feasibility was determined by monitoring adherence to the program, clinical changes in knee function, load progression, and adverse events. Patients were tested before and after completing the rehabilitation program by using patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation Form 2000) and isokinetic muscle strength and hop tests. To monitor adherence, load progression, and adverse events, patients responded to an online survey and kept training diaries. The average adherence rate to the rehabilitation program was 83%. Four patients (9%) showed adverse events, as they could not perform the exercises due to pain and effusion. Significant and clinically meaningful improvement was found, based on changes on the International Knee Documentation Committee Subjective Knee Evaluation Form 2000, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, isokinetic muscle strength, and hop performance (P<.05), with small to large effect sizes (standardized response mean, 0.3-1.22). The combination of a high adherence rate, clinically meaningful changes, and positive load progression and the occurrence of only a few adverse events support the potential usefulness of this program for patients with knee full-thickness cartilage lesions. This study was registered with the public trial registry ClinicalTrials.gov (NCT00885729). Therapy, level 4.

Correlation Between the Child Health Questionnaire and the International Knee Documentation Committee Score in Pediatric and Adolescent Patients With an Anterior Cruciate Ligament Tear

The modified International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form has recently been shown to be valid, reliable, and responsive in a pediatric and adolescent population. The correlations between the Pedi-IKDC and quality-of-life-related health measures have not been studied in depth to determine how a knee injury affects patients in this age group. The purpose of this study was to examine the association between the Pedi-IKDC score and the Child Health Questionnaire (CHQ) in a group of pediatric patients with an anterior cruciate ligament (ACL) injury. A prospectively collected registry of patients with ACL injuries was searched to indentify all patients who had completed both the Pedi-IKDC and CHQ (CHQ-CF87) questionnaires. These were analyzed to determine significant correlations between domains of the CHQ and the Pedi-IKDC. A total of 135 patients were included (80 male, 55 female) with a median age of 15.3 years (range, 13.1 to 17.2 y). The cohort included patients treated both operatively (120) and nonoperatively (15). The total Pedi-IKDC score was found to correlate with the majority of the CHQ including expected domains such as physical function (correlation coefficient = 0.64), bodily pain (0.7), and family activities (0.41), in addition to emotional role (0.45), mental health (0.46), self-esteem (0.45), and social limitations--physical (0.38) (P < 0.001 for all correlations). Seven of the 12 domains on the CHQ are significantly correlated with the IKDC in adolescent patients with an ACL tear. Self-esteem, mental health, emotional role, and social limitations categories are significantly correlated with knee function suggesting that quality-of-life in this population is affected in domains outside of physical function and pain. A greater understanding of the psychosocial impact of injury may be of utility in these patients. Level III cross-sectional study.

A Novel, Minimally-Invasive Technique of Cartilage Repair in the Human Knee Using Arthroscopic Microfracture and Injections of Mesenchymal Stem Cells and Hyaluronic Acid—A Prospective Comparative Study on Safety and Short-Term Efficacy

Most current cell-based cartilage repair techniques require some form of scaffolds and 2 separate surgical procedures. We propose a novel, scaffold-less technique of cartilage repair in the human knee that combines arthroscopic microfracture and outpatient intra-articular injections of autologous bone marrow-derived mesenchymal stem cells (MSCs) and hyaluronic acid (HA). Seventy matched (age, sex, lesion size) knees with symptomatic cartilage defects underwent cartilage repair with the proposed technique (n = 35) or an open technique (n = 35) in which the MSCs were implanted beneath a sutured periosteal patch over the defect. Prospective evaluation of both groups were performed using the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package, which included questions from the Short-Form (SF-36) Health Survey, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm knee scale, and Tegner activity level scale. Postoperative magnetic resonance imaging (MRI) evaluation was also performed at 1 year for most patients. There were no clinically significant adverse events reported through the course of our study. At the fi nal follow-up (mean = 24.5 months), there was significant improvement in mean IKDC, Lysholm, SF-36 physical component score and visual analogue pain scores in both treatment groups. In the short term, the results of this novel technique are comparable to the open procedure with the added advantages of being minimally invasive and requiring only a single operation under general anaesthesia. Its safety has been validated and its efficacy is currently being evaluated in an ongoing randomised controlled trial.

Translation and Cross-cultural Adaptation of the Lower Extremity Functional Scale Into a Brazilian Portuguese Version and Validation on Patients With Knee Injuries

Clinical measurement. To translate and culturally adapt the Lower Extremity Functional Scale (LEFS) into a Brazilian Portuguese version, and to test the construct and content validity and reliability of this version in patients with knee injuries. There is no Brazilian Portuguese version of an instrument to assess the function of the lower extremity after orthopaedic injury. The translation of the original English version of the LEFS into a Brazilian Portuguese version was accomplished using standard guidelines and tested in 31 patients with knee injuries. Subsequently, 87 patients with a variety of knee disorders completed the Brazilian Portuguese LEFS, the Medical Outcomes Study 36-Item Short-Form Health Survey, the Western Ontario and McMaster Universities Osteoarthritis Index, and the International Knee Documentation Committee Subjective Knee Evaluation Form and a visual analog scale for pain. All patients were retested within 2 days to determine reliability of these measures. Validation was assessed by determining the level of association between the Brazilian Portuguese LEFS and the other outcome measures. Reliability was documented by calculating internal consistency, test-retest reliability, and standard error of measurement. The Brazilian Portuguese LEFS had a high level of association with the physical component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.82), the Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.87), the International Knee Documentation Committee Subjective Knee Evaluation Form (r = 0.82), and the pain visual analog scale (r = -0.60) (all, P<.05). The Brazilian Portuguese LEFS had a low level of association with the mental component of the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.38, P<.05). The internal consistency (Cronbach α = .952) and test-retest reliability (intraclass correlation coefficient = 0.957) of the Brazilian Portuguese version of the LEFS were high. The standard error of measurement was low (3.6) and the agreement was considered high, demonstrated by the small differences between test and retest and the narrow limit of agreement, as observed in Bland-Altman and survival-agreement plots. The translation of the LEFS into a Brazilian Portuguese version was successful in preserving the semantic and measurement properties of the original version and was shown to be valid and reliable in a Brazilian population with knee injuries.

Return to Preinjury Sports Participation Following Anterior Cruciate Ligament Reconstruction: Contributions of Demographic, Knee Impairment, and Self-report Measures

Cross-sectional cohort. (1) To examine differences in clinical variables (demographics, knee impairments, and self-report measures) between those who return to preinjury level of sports participation and those who do not at 1 year following anterior cruciate ligament reconstruction, (2) to determine the factors most strongly associated with return-to-sport status in a multivariate model, and (3) to explore the discriminatory value of clinical variables associated with return to sport at 1 year postsurgery. Demographic, physical impairment, and psychosocial factors individually prohibit return to preinjury levels of sports participation. However, it is unknown which combination of factors contributes to sports participation status. Ninety-four patients (60 men; mean age, 22.4 years) 1 year post-anterior cruciate ligament reconstruction were included. Clinical variables were collected and included demographics, knee impairment measures, and self-report questionnaire responses. Patients were divided into "yes return to sports" or "no return to sports" groups based on their answer to the question, "Have you returned to the same level of sports as before your injury?" Group differences in demographics, knee impairments, and self-report questionnaire responses were analyzed. Discriminant function analysis determined the strongest predictors of group classification. Receiver-operating-characteristic curves determined the discriminatory accuracy of the identified clinical variables. Fifty-two of 94 patients (55%) reported yes return to sports. Patients reporting return to preinjury levels of sports participation were more likely to have had less knee joint effusion, fewer episodes of knee instability, lower knee pain intensity, higher quadriceps peak torque-body weight ratio, higher score on the International Knee Documentation Committee Subjective Knee Evaluation Form, and lower levels of kinesiophobia. Knee joint effusion, episodes of knee instability, and score on the International Knee Documentation Committee Subjective Knee Evaluation Form were identified as the factors most strongly associated with self-reported return-to-sport status. The highest positive likelihood ratio for the yes-return-to-sports group classification (14.54) was achieved when patients met all of the following criteria: no knee effusion, no episodes of instability, and International Knee Documentation Committee Subjective Knee Evaluation Form score greater than 93. In multivariate analysis, the factors most strongly associated with return-to-sport status included only self-reported knee function, episodes of knee instability, and knee joint effusion.

The Impact of Quadriceps Femoris Strength Asymmetry on Functional Performance at Return to Sport Following Anterior Cruciate Ligament Reconstruction

Cross-sectional study. To investigate the impact of quadriceps femoris (QF) muscle strength asymmetry at the time of return to sport on self-reported function and functional performance of individuals following anterior cruciate ligament reconstruction (ACLR). Evidence-based QF strength guidelines for return-to-sport decision making are lacking. Objective guidelines necessitate understanding the impact of QF strength deficits at the time of return to sport on function and performance. Fifty-five individuals (mean age, 17.3 years) who were cleared for return to sport following primary ACLR (ACLR group) and 35 uninjured individuals (mean age, 17.0 years) in a control group participated in the study. QF strength (maximum voluntary isometric contraction) was assessed, and the quadriceps index (QI) was calculated [(involved strength/uninvolved strength) × 100%]. The ACLR group was further subdivided into 2 groups, based on the QI: high quadriceps (QI of 90% or greater) and low quadriceps (QI of less than 85%). The International Knee Documentation Committee Subjective Knee Evaluation Form score was used to assess self-reported function, and hop tests were used to assess functional performance. Multivariate analysis of variance and hierarchical regression analyses were performed. The individuals in the ACLR group were weaker, reported worse function, and performed worse on hop tests compared to those in the control group (P<.05). The low-quadriceps group demonstrated worse performance on the hop tests compared to the high-quadriceps group and the control group (P ≤.016). Hop test performance did not differ between the high-quadriceps and control groups (P ≥.14). QF strength predicted performance on the hop tests beyond graft type, presence of meniscus injury, knee pain, and knee symptoms. At the time of return to sport, individuals post-ACLR who had weaker QF (QI of less than 85%) demonstrated decreased function, whereas those with minimal QF strength deficits (QI of 90% or greater) demonstrated functional performance similar to uninjured individuals. QF strength deficits predicted hop test performance beyond the influences of graft type, presence of meniscus injury, knee pain, and knee symptoms.

Rate of Force Development as an Adjunctive Outcome Measure for Return-to-Sport Decisions After Anterior Cruciate Ligament Reconstruction

Descriptive, prospective, longitudinal single-cohort study. To investigate the rate of force development to 30% (RFD(30)), 50% (RFD(50)), and 90% (RFD(90)) of maximal voluntary isometric contraction (MVIC) as an adjunct outcome measure for determining readiness for return to sport following an anterior cruciate ligament (ACL) reconstruction. One criterion of full recovery following an ACL reconstruction is the ability to achieve 85% or 90% of the maximal strength of the contralateral limb. However, the time required to develop muscular strength in many types of daily and sports activities is considerably shorter than that required to achieve maximal strength. Therefore, in addition to maximal strength, neuromuscular functions such as RFD should also be considered in the definition of recovery. Forty-five male professional soccer players who underwent an ACL reconstruction were recruited. Assessment with the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Tegner score, and KT1000 instrumented arthrometer was performed postinjury/prereconstruction and at 6 and 12 months after ACL reconstruction. MVIC, RFD(30), RFD(50), and RFD(90) testing was performed preinjury, as part of standard preseason assessment, and at 6 and 12 months post-ACL reconstruction. The average MVIC value 6 months postreconstruction was 97% of the preinjury average value. In contrast, at 6 months, the RFD(30), RFD(50), and RFD(90) values were 80% (P = .04), 77% (P = .03), and 63% (P = .007), respectively, of the preinjury values. The mean RFD values for the reconstructed knee attained or exceeded 90% of the preinjury mean values only at the 12-month post-ACL reconstruction assessment (RFD(30), P = .86; RFD(50), P = .51; RFD(90), P = .56). Despite the near recovery of MVIC strength to preinjury levels, there were still significant deficits in RFD at 6 months post-ACL reconstruction. An RFD similar to the preinjury RFD was achieved at 12 months post-ACL reconstruction, following a rehabilitation program focusing on muscle power. These results suggest that, following an ACL reconstruction, RFD criteria may be a useful adjunct outcome measure for the decision to return athletes to sports. J Orthop Sports Phys Ther 2012;42(9):772-780, Epub 19 July 2012. doi:10.2519/jospt.2012.3780.

Fibrocartilage Following Microfracture Is Not as Robust as Native Articular Cartilage

Commentary This study by Krych et al. compared the clinical outcomes of osteochondral autograft transfer (OAT) and microfracture (MFX). The patient-oriented outcomes of interest included the Short Form-36 (SF-36) Health Survey, the Activities of Daily Living Scale of the Knee Outcome Survey, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and the Marx Activity Rating Scale for Disorders of the Knee. The study design was a retrospective comparative study—a Level-III therapeutic study. For each patient in the OAT group, the authors matched a control MFX patient from an institutional cartilage registry, accounting for sex, chondral defect location, and chondral defect size. Patients were followed for a minimum of two years. In comparing the OAT and MFX groups, the authors found no significant differences at any of the time points (one, two, three, and five-year follow-up evaluations) for the SF-36, Knee Outcome Survey, or IKDC scores. However, the Marx Activity Rating Scale score for the MFX group declined from 7.3 at baseline to 4.1 at one year, 3.7 at two years, and 2.9 at three and five years. In contrast, the activity score for the OAT group responded more favorably, changing from 6.4 at baseline to 5.2 at one year, 7.3 at two years, 7.8 at three years, and 8.6 at five years. The authors of the current study proposed that the fibrocartilage that developed following MFX was less durable than the transferred hyaline cartilage. The authors further proposed that the lower activity scores in the MFX group were likely the result of patients modifying their activity level to one that provided satisfactory knee function and comfort. These theories are certainly plausible. These findings are consistent with the results of a randomized clinical trial by Gudas et al. comparing OAT and MFX in young athletes, in which it was reported that twenty-six (93%) of the OAT patients and fifteen (52%) of the MFX patients returned to sports activities at the preinjury level1. In addition, Gudas et al. reported that the MFX patients with a lesion larger than 2 cm2 had significantly worse clinical results compared with those who had smaller lesions1. They did not find such an association between defect size and the clinical outcome in the OAT group1. Similarly, in a randomized clinical trial by Knutsen et al. comparing autologous chondrocyte implantation (ACI) and MFX, the MFX patients with a lesion larger than 4 cm2 had significantly worse clinical results compared with patients with a smaller defect2. They did not find such an association between the size of the defect and the clinical outcome in the ACI group2. The impact of the paper by Krych et al. on clinical practice is primarily limited by the study design. Selection of the treatment choice was not randomized, which allowed for introduction of bias in the selection of the treatment for each patient. In fact, the MFX group included three patients with osteochondritis dissecans lesions (6%) compared with fifteen (31%) in the OAT group. Furthermore, no patients in the MFX group had undergone previous cartilage procedures, whereas sixteen patients (33%) in the OAT group had previously undergone an unsuccessful microfracture procedure. Randomization would have equally distributed known and unknown confounders among the study groups. The current study by Krych et al. supports the concept that the fibrocartilage that forms following MFX is not as robust as the hyaline cartilage that is transferred in OAT. I would be very interested to see these results stratified by lesion size. This paper has further educational value in highlighting how patients can remain satisfied with a procedure despite lowered activity levels.

Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS‐PS), Knee Outcome Survey Activities of Daily Living Scale (KOS‐ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS),

Patient-reported measures of knee function are important for the comprehensive assessment of rheumatology conditions in both clinical and research contexts. To merit inclusion in this review, measures of knee function were required to be patient reported and assess aspects considered important by adult patients with knee problems such as injury or osteoarthritis (OA). Therefore, measures used in rheumatology, orthopedics, and sports medicine were considered. Dimensions deemed to be important to patients included pain, function, quality of life, and activity level. To identify instruments fulfilling these criteria, we utilized published reviews of knee instruments (1), knee OA instruments (2), and measures for use in patellofemoral arthroplasty (3). Based on these reviews, as well as extensive searches of more recent literature, we included the following 9 patient-reported outcomes: Activity Rating Scale, International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form, Knee Outcome Survey Activities of Daily Living Scale, Lysholm Knee Scoring Scale, Tegner Activity Scale, Oxford Knee Score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Although the WOMAC can be applied to the hip and knee, this study contains data only applicable to the knee. Measures assessing activity level are listed separately. Psychometric data pertaining to the reliability and responsiveness of each patient-reported outcome are shown in Tables 1 and ​and2.2. The number of psychometric reports concerning each instrument ranges from 2–27. A higher number of reports indicates a higher degree of certainty in interpretation of the psychometric properties. Table 1 Summary of reliability data* Table 2 Summary of responsiveness data* Psychometric properties were based on data provided in Tables 1 and 2, and interpreted using standardized guidelines. Internal consistency was considered adequate if Cronbach’s alpha was at least 0.7 (4), and test–retest (intra-rater) reliability was adequate if the intraclass correlation coefficient was at least 0.8 for groups and 0.9 for individuals (5). Floor and ceiling effects were considered to be absent if no participants scored the bottom or top score, respectively, and acceptable if 0.8 were considered large (9). In this context, the minimum clinically important difference is the amount of change of a patient-reported outcome that represents a meaningful change to the patient, while the patient-acceptable symptom state is the least abnormal function score at which patients would consider themselves having acceptable function (10).

Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction

Background: It is unknown whether popliteal tendon reconstruction is necessary in anatomic posterolateral corner reconstruction, although the tendon has function in the varus and rotatory stability of the knee joint. Hypothesis: Anatomic reconstructions of the posterolateral corner with the popliteal tendon reconstructed will present better clinical and radiographic results than cases with the popliteal tendon not reconstructed. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed 32 cases of anatomic posterolateral corner reconstruction with a minimum 2-year follow-up. There were 17 cases of anatomic reconstruction with popliteal tendon reconstruction and 15 cases without popliteal tendon reconstruction. The authors compared preoperative and postoperative range of motion, varus instability by varus stress test, lateral joint opening on varus stress radiographs, posterolateral rotatory instability by dial test, Tegner activity score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee evaluation form and knee examination form between the 2 groups. They also compared posterior translation on posterior stress radiographs in cases with posterior cruciate ligament reconstruction. Results: There was no difference in range of motion, varus stress test, dial test, Tegner score, Lysholm score, or the score by IKDC subjective knee evaluation form. The side-to-side difference in lateral joint opening on the varus stress radiographs significantly improved after anatomic reconstruction in both groups (P < .001, P = .001), but there was no preoperative or postoperative differences between the groups. No difference was found in the grade distribution on the IKDC examination form. In the cases with posterior cruciate ligament reconstruction, there was also no difference in posterior translation between the groups on posterior stress radiographs at the last follow-up. Conclusion: No effect of popliteal tendon reconstruction was found in anatomic posterolateral corner reconstruction on the stability and clinical results.

A Prospective Randomized Study Comparing Arthroscopic Single-Bundle and Double-Bundle Posterior Cruciate Ligament Reconstructions Preserving Remnant Fibers

Background: Several controversies exist regarding the superiority of double-bundle (DB) posterior cruciate ligament (PCL) reconstruction versus single-bundle (SB) reconstruction, although DB reconstruction has been shown to restore the intact knee kinematics more closely than SB reconstruction. Hypothesis: Double-bundle PCL reconstruction will present better results than SB reconstruction in postoperative outcomes. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: The authors prospectively analyzed 25 cases of SB reconstruction and 28 cases of DB reconstruction using Achilles tendon allograft with a minimum 2-year follow-up. They compared preoperative and postoperative range of motion, posterior stability by posterior stress radiography, Tegner activity score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee evaluation form and knee examination form between the 2 groups. Results: There was no difference in range of motion, Tegner activity score, Lysholm score, and IKDC subjective knee evaluation form between the 2 groups at last follow-up. The side-to-side difference in posterior translation significantly improved in both groups. There was no preoperative difference in posterior instability between the groups but a significant difference at last follow-up. On the IKDC knee examination form, the DB reconstruction group presented better results in grade distribution. Conclusion: The DB reconstruction for PCL ruptures using the Achilles allograft showed better results in posterior stability and IKDC knee examination form than the SB reconstruction did. Although the difference of 1.4 mm in posterior stability was statistically significant, it is unclear that DB reconstruction is definitely superior to SB reconstruction clinically and functionally because there was no difference in the subjective scores.

Validity and Internal Consistency of the International Knee Documentation Committee Subjective Knee Evaluation Form in Children and Adolescents

Background The International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form (IKDC Knee Form) is a valid, reliable, and responsive measure of knee-related symptoms, function, and sports activities in adults. Despite the incidence of knee injuries in younger individuals, the measurement characteristics of the IKDC Knee Form have not been established. Hypothesis/Purpose The purpose of this study was to investigate the validity and internal consistency of the IKDC Knee Form in pediatric, adolescent, and young adult patients with a variety of knee conditions. The authors hypothesized that the IKDC Knee Form would be a valid and consistent measure of knee function in these age groups. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods The IKDC Knee Form and Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) physical functioning component were administered to 673 individuals between 6 and 18 years of age. The internal consistency and validity of the IKDC Knee Form were determined for the entire cohort and for age group cohorts (pediatric, 6-12 years; adolescent, 13-15 years; young adult, 16-18 years) using the PedsQL physical functioning component for comparison. Results The results were similar across all age groups. In the original format, internal consistency was high and factor analysis showed a single, dominant component underlying the item responses for each age group. Items 2, 3, and 6 may contribute to measurement error in young individuals. Correlation between the IKDC Knee Form and PedsQL physical functioning component score was moderately high for the entire cohort (r = .83) and for all age groups (pediatric, r = .84; adolescent, r = .84; young adult, r = .79). Conclusion In its current form, the IKDC Knee Form is a valid and consistent knee-specific measure of symptoms, function, and sports activity in individuals between the ages of 6 and 18 years with a variety of knee problems. Further work is needed to establish the reliability and responsiveness of the IKDC Knee Form for this age group.

Autologous Bone Marrow–Derived Mesenchymal Stem Cells Versus Autologous Chondrocyte Implantation

Background: First-generation autologous chondrocyte implantation has limitations, and introducing new effective cell sources can improve cartilage repair. Purpose: This study was conducted to compare the clinical outcomes of patients treated with first-generation autologous chondrocyte implantation to patients treated with autologous bone marrow–derived mesenchymal stem cells (BMSCs). Study Design: Cohort study; Level of evidence, 3. Methods: Seventy-two matched (lesion site and age) patients underwent cartilage repair using chondrocytes (n = 36) or BMSCs (n = 36). Clinical outcomes were measured before operation and 3, 6, 9, 12, 18, and 24 months after operation using the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package, which included questions from the Short-Form Health Survey, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm knee scale, and Tegner activity level scale. Results: There was significant improvement in the patients’ quality of life (physical and mental components of the Short Form-36 questionnaire included in the ICRS package) after cartilage repair in both groups (autologous chondrocyte implantation and BMSCs). However, there was no difference between the BMSC and the autologous chondrocyte implantation group in terms of clinical outcomes except for Physical Role Functioning, with a greater improvement over time in the BMSC group (P = .044 for interaction effect). The IKDC subjective knee evaluation (P = .861), Lysholm (P = .627), and Tegner (P = .200) scores did not show any significant difference between groups over time. However, in general, men showed significantly better improvements than women. Patients younger than 45 years of age scored significantly better than patients older than 45 years in the autologous chondrocyte implantation group, but age did not make a difference in outcomes in the BMSC group. Conclusion: Using BMSCs in cartilage repair is as effective as chondrocytes for articular cartilage repair. In addition, it required 1 less knee surgery, reduced costs, and minimized donor-site morbidity.

Validity and comprehensibility of the International Knee Documentation Committee Subjective Knee Evaluation form in Children

The International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form is a knee-specific measure developed for adults. Its usefulness in children is not established. This study describes how children interpret IKDC items, identifies sources of response errors, and provides suggestions for modification. Cognitive interviews were conducted in 30 children with a primary knee injury, purposefully sampled based on age and gender. Most children could not recall their injury date or symptoms 4 weeks after injury. All reported problems interpreting directions; half noted item timeframes were unclear and did not realize all questions pertained to their injured knee. Seventy percent read only the first half of a question, missing subtle differences between items. Children had difficulty comprehending the following concepts: strenuous/moderate activity, pivoting, locking, giving way, significant pain/swelling, and knee catching. Examples to describe activity levels either did not apply (e.g. housework) or were ranked differently by children. Younger children had difficulty using five-point responses. The two most difficult items were assessment of current and prior function. Children found the IKDC Subjective Knee Evaluation Form difficult to comprehend and to answer. Modifications to directions, item formatting, and definitions are needed to ensure comprehensibility and validity.

Force Production and Reactive Strength Capabilities After Anterior Cruciate Ligament Reconstruction

Ambiguity exists in the literature regarding whether individuals can restore function to 100% after anterior cruciate ligament (ACL) reconstruction. The response of force production and reactive strength in stretch-shortening cycle activities after surgery has not been established. To compare reactive strength and force production capabilities between the involved and uninvolved legs of participants who had undergone ACL reconstruction and rehabilitation with the reactive strength and force production capabilities of a control group. Repeated measures, cross-sectional. Research laboratory. Ten participants with ACL reconstructions who had returned to their chosen sports and 10 age-matched and activity-matched control subjects. We screened the ACL group with the International Knee Documentation Committee Subjective Knee Evaluation Form and functional performance tests to measure a basic level of function. We assessed force production capabilities and reactive strength using squat, countermovement, drop, and rebound jump protocols on a force sledge apparatus. The dependent variables were flight time, peak vertical ground reaction force, leg spring stiffness, and reactive strength index. No participant in the ACL group exhibited functional deficits in comparison with normative values or the control group. Using the force sledge apparatus, we found no notable differences in force production capabilities and reactive strength in the ACL group when comparing the involved with uninvolved legs or the degree of difference between legs with the control group. After ACL reconstruction, rehabilitated participants did not exhibit deficits in force production or reactive strength capabilities. Our results suggest that force production and reactive strength capabilities can be restored to levels comparable with the uninjured control limb and may not be limiting factors in ACL recovery.

The International Knee Documentation Committee Subjective Evaluation Form in a Preadolescent Population

Background The International Knee Documentation Committee Subjective Knee Evaluation Form is a knee-specific instrument composed of 18 questions. It is commonly used in adult and pediatric studies as a surgical outcome measure. Normative data exist for an adult population, but there have been no published normative results for younger subjects. Purpose To compile and report pilot normative International Knee Documentation Committee Subjective Knee Evaluation Form scores in a preadolescent population. Study Design Cross-sectional study; Level of evidence, 3. Methods The International Knee Documentation Committee Subjective Knee Evaluation Form was administered to 146 seventh-grade students (aged 12–14 years) at 2 local schools. The form was administered in its original format. Demographic and descriptive results were compiled. Results One hundred twenty-five completed responses were eligible for analysis. The mean age was 13.2 years (SD, 0.5; range, 12.2–14.2 years); 15% of participants had a history of knee injury or pain. The mean International Knee Documentation Committee score for all respondents was 89.4 (SD, 10.5; 95% confidence interval, 87.6–91.3; range, 52–100). Conclusion This study provides pilot normative data for mean International Knee Documentation Committee scores in a preadolescent population. The mean score in this younger cohort is consistent with normative data of adults age 35 years or younger. Although the International Knee Documentation Committee Subjective Knee Evaluation Form is often used in adolescent surgical studies, its validity in these populations remains to be established. Further work to establish the psychometric properties of the current form in younger age groups would be of significant benefit to clinicians.