Knee Documentation Committee Subjective Evaluation Research Articles

Paper 14: Leukocyte-Poor Platelet Rich Plasma versus Leukocyte-Poor Platelet Rich Plasma Plus Hyaluronic Acid for the Treatment of Symptomatic Knee Osteoarthritis: A Prospective, Randomized Control Trial with 2 Year Follow Up

Objectives:The main objective of this study was to determine if hyaluronic acid (HA) injected at the same time as leukocyte-poor platelet rich plasma LP-PRP would improve the performance compared to LP-PRP alone in the treatment of symptomatic knee osteoarthritis. We hypothesized that the addition of hyaluronic acid would improve the efficacy of LP-PRP.Methods:Patients between the ages of 30 and 80 who had symptomatic Kellgren-Lawrence grades 1-4 were eligible for the study. Patients were offered enrollment and screened with inclusion and exclusion criteria. The participants were randomized into two study groups and scheduled to receive a three-injection series. Group 1 [LP-PRP] received 3 intra-articularinjections of LP-PRP dosed at one week intervals. Group 2 [LP-PRP/HA] received 3 intra-articular injections of LP-PRP dosed at one week intervals, with hyaluronic acid (Hymovis) injected concomitantly for the first two injections. The Arthrex Autologous Conditioned Plasma system was used to prepare all LP-PRP injections. Participants were blinded to injection randomization and wore a blind fold for the first two injections. Participants completed patient reported outcome questionnaires prior to their injections and at 1, 3, 6, 12, 18, and 24 months after the final injection. The questionnaires included the Western Ontario and McMaster Universitys Osteoarthritis Index (WOMAC), International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS).Results:The study population included 63 total subjects, 32 subjects were randomized to Group 1 (ACP) with average age 55.8 +/- 11.4, 31 subjects were randomized to group 2 (ACP+HA) with average age 60.4 +/- 9.0. Both groups demonstrated improvement over baseline at 1 and 3 months, with improvement plateauing at 3 months. Both groups demonstrated improvement over baseline out to 24 months. The LP-PRP/HA group demonstrated increased improvement compared to group 1 at 1 and 3 months but consistently trended down in both the WOMAC, IKDC, and KOOS scores however statistical significance was not reached. The LP-PRP groups improvement was consistent until the 18 month time point. Complete patient reported outcome data is included in Table 1. Change in WOMAC, IKDC and KOOS scores over time are represented in Figures 1, 2, and 3 respectively.Conclusions:Both groups demonstrated improvement over baseline at 1 and 3 months, with improvement plateauing at 3months. Both groups demonstrated improvement over baseline out to 24 months. The LP-PRP/HA group demonstrated increased improvement compared to the LP-PRP group at 1 and 3 months, however statistical significance was not reached and the improvement diminished after the 12 month time point. The LP-PRP group did not see a diminishing improvement until the 18 month time point.Figure 1.IKDCScore.Figure 2.WOMAC Score.Figure 3.KOOS Scores.

Effects of Aquatic Training and Bicycling Training on Leg Function and Range of Motion in Amateur Athletes with Meniscal Allograft Transplantation during Intermediate-Stage Rehabilitation.

Meniscal allograft transplantation (MAT) is a treatment modality for restoring knee function in patients with irreversible meniscal injury. Strengthening programs to promote functional recovery are treated with caution during the intermediate rehabilitation phase following MAT. This study analyzed the effects of aquatic training (AQT) and bicycling training (BCT) during the intermediate stage of rehabilitation in amateur athletes that underwent MAT. Participants (n = 60) were divided into AQT (n = 30) and BCT (n = 30) groups. Both groups performed training three times per week from 6 to 24 weeks following surgery. International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) score, knee joint range of motion (ROM), isokinetic knee strength, and Y-balance test (YBT) performance were evaluated. All measured variables for the AQT and BCT groups improved significantly after training compared with pre-training values. The IKDC score and YBT were significantly higher for AQT than for BCT. The knee flexion ROM and isokinetic muscle strength were significantly improved in the BCT group compared to those in the AQT group. The AQT group exhibited greater improvement in dynamic balance, whereas BCT provided greater improvement in isokinetic muscle strength. AQT and BCT were effective in reducing discomfort and improving knee symptoms and functions during intermediate-stage rehabilitation following MAT in amateur athletes.

Determining the Substantial Clinical Benefit Values for Patient-Reported Outcome Scores After Primary ACL Reconstruction.

Background:Little is known about the threshold of patient-reported outcomes (PROs) at which patients perceive to have attained a substantial clinical benefit (SCB) after anterior cruciate ligament reconstruction (ACLR).Purpose:To determine the SCB value of PROs 1 year after ACLR in the general population and to determine factors that predict SCB attainment.Study Design:Case series; Level of evidence, 4.Methods:The Lysholm, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), Tegner, and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scores were examined postoperatively in 88 patients who underwent ACLR. At the 12-month follow-up visit, the patients answered 2 independent anchor questions about daily discomfort and functional recovery. Receiver operating characteristic (ROC) curve analysis was used to differentiate PRO scores between patients who responded as having no difficulty versus some difficulty with daily knee discomfort (anchor question 1) and between patients with substantial recovery versus nonsubstantial recovery of knee function (anchor question 2). The area under the ROC curve (AUC) was calculated to assess reliability, and the differences between the AUC values were compared. Multivariate logistic regression analyses were performed to determine predictors affecting SCB attainment.Results:There were 76 patients enrolled in this study. The 12-month Lysholm, IKDC-SKF, Tegner, and ACL-RSI scores that corresponded to the SCB were 88.0, 85.1, 6.5, and 64.2 for anchor question 1 and 84.5, 77.7, 5.5, and 57.1 for anchor question 2, respectively. The AUC values obtained from the ROC curve analyses showed acceptable to excellent reliability (anchor question 1: Lysholm, 0.90; IKDC-SKF, 0.86; Tegner, 0.71; ACL-RSI, 0.92; anchor question 2: Lysholm, 0.80; IKDC-SKF, 0.90; Tegner, 0.82; ACL-RSI, 0.82) and were all statistically significant (P < .001 to P = .028). For all PROs, younger age (Odds Ratio (OR), 0.88-0.94; P < .001 to P = .027) and greater muscle strength (OR, 1.03-1.07; P < .001 to P = .023) were predictive factors of SCB attainment.Conclusion:The postoperative Lysholm, IKDC-SKF, Tegner, and ACL-RSI scores showed acceptable to excellent reliability in predicting the SCB after ACLR in the general population. Age at surgery and thigh muscle strength influenced SCB attainment for all PROs.

The Arabic Version of the Tegner Activity Scale in Patients with Anterior Cruciate Ligament Reconstruction: Translation, Validation, and Cross-Cultural Adaptation.

Background: The Tegner activity scale is a patient-reported questionnaire that is frequently used to measure activity levels in patients with anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to translate, cross-culturally adapt, and validate the Tegner activity scale into Arabic. Methods: The Tegner activity scale–Arabic version (TAS-Ar) was forward and backward translated, cross-culturally adapted, and validated according to established guidelines. Seventy-five patients who underwent ACLR were instructed to complete the TAS-Ar, the International Knee Documentation Committee (IKDC) subjective knee evaluation form, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) scale. The test-retest reliability of the TAS-Ar was assessed in 39 patients. Statistical tests were conducted to test the reliability and construct validity of the TAS-Ar. Results: The TAS-Ar showed excellent test-retest reliability, with intraclass correlation coefficients of 0.836 (p < 0.001). The TAS-Ar was significantly correlated with the IKDC (Spearman’s rho = 0.476, p < 0.001), all KOOS subscales (Spearman’s rho = 0.195–0.497, p < 0.05), and the KOOS total score (Spearman’s rho = 0.469, p < 0.001). Conclusions: The Arabic version of the Tegner activity scale is a reliable and valid measure that can be used to evaluate the activity level of Arabic-speaking patients following ACLR.

Maquet osteotomy for isolated patellofemoral arthritis, a forgotten surgical technique.

Abstract: Maquet osteotomy for isolated patellofemoral arthritis, a forgotten surgical technique. Objective. The aim of our study is in the physiologically younger patinets who had anterior knee pain does not resolve with conservative treatment, report the results of Maquet osteotomy. Materials and Methods. We performed a retrospective review of 11 consecutive patients (5 [45.5%] males, 6 [54.5%] females; mean age, 51.8 years) who underwent Maquet osteotomy for isolated patellofemoral osteoarthritis between May 2017 and August 2018. Thirteen osteotomies were performed in 11 patients; 2 patients underwent bilateral procedures. All patients were clinically rated before surgery and at the final follow-up using International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC 2000) and the Kujala Anterior Knee Pain Scale. Also complications were reported. Results. The median follow-up duration was 25 (range=19-33) months. The median preoperative IKDC score was 50 (range = 42-54) points, which had increased to 67 (range=61-72) points at the final follow-up visit (p&lt;.001). The median preoperative Kujala score was 59 (range=48-65) points, which had increased to 77 (range = 67-86) points at the final follow-up (p&lt;.001). We observed 1 major and 1 minor complication in 13 procedures. Conclusion. Although it looks like an extensile surgery, Maquet osteotomy is applicable, safe, easy and a strong alternative for arthroplasty in patellofemoral arthritis.

Arabic Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation.

Background:The short version of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) scale is a self-reported questionnaire developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR).Purpose:To translate, cross-culturally adapt, and validate the short version of the ACL-RSI scale into the Arabic language (ACL-RSI-Ar).Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:The original short version of the ACL-RSI scale was forward and backward translated, cross-culturally adapted, and validated following international standardized guidelines. Sixty patients who participated in sports activities and underwent ACLR completed the ACL-RSI-Ar, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and Knee injury and Osteoarthritis Outcome Score (KOOS) scales. To assess test-retest reliability, 34 participants completed the ACL-RSI-Ar scale twice. Statistical tests were conducted to test the internal consistency, reliability, and construct and discriminant validity of the ACL-RSI-Ar scale.Results:The ACL-RSI-Ar showed adequate internal consistency (Cronbach alpha = 0.734) and excellent test-retest reliability (intraclass correlation coefficient, 0.871). The ACL-RSI-Ar was strongly correlated with the IKDC (Spearman ρ = 0.515, P < .001) and weakly to strongly correlated with all KOOS subscales (Spearman ρ = 0.247-0.590, P < .05). Patients who returned to sports had significantly higher scores on the ACL-RSI-Ar scale when compared with those who did not return to sports (P = .001).Conclusion:The short ACL-RSI-Ar scale, as translated, was internally consistent, reliable, and valid for evaluating psychological readiness to return to sports after ACLR in Arabic-speaking patients.

Design Features and Rationale of the BEAR-MOON (Bridge-Enhanced ACL Restoration Multicenter Orthopaedic Outcomes Network) Randomized Clinical Trial.

Background:BEAR (bridge-enhanced anterior cruciate ligament [ACL] restoration), a paradigm-shifting technology to heal midsubstance ACL tears, has been demonstrated to be effective in a single-center 2:1 randomized controlled trial (RCT) versus hamstring ACL reconstruction. Widespread dissemination of BEAR into clinical practice should also be informed by a multicenter RCT to demonstrate exportability and compare efficacy with bone--patellar tendon–bone (BPTB) ACL reconstruction, another clinically standard treatment.Purpose:To present the design and initial preparation of a multicenter RCT of BEAR versus BPTB ACL reconstruction (the BEAR: Multicenter Orthopaedic Outcomes Network [BEAR-MOON] trial). Design and analytic issues in planning the complex BEAR-MOON trial, involving the US National Institute of Arthritis and Musculoskeletal and Skin Diseases, the US Food and Drug Administration, the BEAR implant manufacturer, a data and safety monitoring board, and institutional review boards, can usefully inform both clinicians on the trial’s strengths and limitations and future investigators on planning of complex orthopaedic studies.Study Design:Clinical trial.Methods:We describe the distinctive clinical, methodological, and operational challenges of comparing the innovative BEAR procedure with the well-established BPTB operation, and we outline the clinical motivation, experimental setting, study design, surgical challenges, rehabilitation, outcome measures, and planned analysis of the BEAR-MOON trial.Results:BEAR-MOON is a 6-center, 12-surgeon, 200-patient randomized, partially blinded, noninferiority RCT comparing BEAR with BPTB ACL reconstruction for treating first-time midsubstance ACL tears. Noninferiority of BEAR relative to BPTB will be claimed if the total score on the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the knee arthrometer 30-lb (13.61-kg) side-to-side laxity difference are both within respective margins of 16 points for the IKDC and 2.5 mm for knee laxity.Conclusion:Major issues include patient selection, need for intraoperative randomization and treatment-specific postoperative physical therapy regimens (because of fundamental differences in surgical technique, initial stability construct, and healing), and choice of noninferiority margins for short-term efficacy outcomes of a novel intervention with evident short-term advantages and theoretical, but unverified, long-term benefits on other dimensions.

Revision Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft Combined With Modified Lemaire Technique Versus Hamstring Graft Combined With Anterolateral Ligament Reconstruction: A Clinical Comparative Matched Study With a Mean Follow-up of 5 Years From The SANTI Study Group

Background: Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved clinical outcomes and reduced failure rates in revision anterior cruciate ligament (ACL) reconstruction (ACLR). However, no data are available on clinical outcomes and reoperation after revision ACLR using different LET procedures. Purpose: To compare the clinical outcomes of ACL + anterolateral ligament (ALL) reconstruction using hamstring tendon graft (HT-ALL) and a bone–patellar tendon–bone (BPTB) graft + modified Lemaire tenodesis procedure (BPTB-Lemaire) in the setting of revision ACLR and to determine whether ALL reconstruction is associated with an increased rate of adverse outcomes when compared with a modified Lemaire tenodesis procedure. Study Design: Cohort study; Level of evidence, 3. Methods: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with LET between 2009 and 2018 with a minimum follow-up of 2 years. Patients with an HT autograft combined with ALL reconstruction (HT-ALL group) were matched in a 1:1 propensity ratio to patients with a BPTB autograft combined with a modified Lemaire LET procedure (BPTB-Lemaire group). The evaluated parameters included complications and reoperations; knee laxity tests; return to sports; and various scores, including the Lysholm knee score, Tegner activity scale, Anterior Cruciate Ligament Return to Sport After Injury scale, Marx activity rating scale, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Results: In total, 36 matched pairs were included in the analysis. The mean follow-up durations for the BPTB-Lemaire and HT-ALL groups were 56 ± 35 and 57 ± 23 months, respectively (P = .91). No significant differences were found in graft rupture rate (HT-ALL, 0%; BPTB-Lemaire, 11.1%; P = .13) or reoperations (HT-ALL, 8.3%; BPTB-Lemaire, 22.2%; P = .23). No specific complications with regard to LET were noted in either group. Additionally, there were no significant differences in knee laxity parameters, return to sports, or clinical scores between the groups at the final follow-up, except for the Tegner activity scale score (HT-ALL, 6.4; BPTB-Lemaire, 7.3; P = .03). HT-ALL was associated with a shorter surgical time (41.4 vs 59.8 minutes; P < .0001). Conclusion: HT-ALL was at least equivalent, in terms of clinical outcomes, to the more commonly performed procedure, BPTB-Lemaire. Performing ALL reconstruction in the setting of revision ACLR is therefore safe and effective.

Four of five frequently used orthopedic PROMs possess inadequate content validity: a COSMIN evaluation of the mHHS, HAGOS, IKDC-SKF, KOOS and KNEES-ACL.

Content validity is the most important property of PROMs. The COSMIN initiative has published guidelines for evaluating the content validity of PROMs, but they have only sparsely been applied to relevant PROMs for musculoskeletal conditions. The aim of this study was to use the COSMIN Risk of Bias checklist to evaluate the content validity of five PROMs, that are highly relevant in musculoskeletal research and used by the arthroscopic surgery community: the modified Harris' Hip Score (mHHS), the Copenhagen Hip and Groin Outcome Score (HAGOS), the International Knee Documentation Committee Subjective Knee evaluation Form (IKDC-SKF), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Knee Numeric-Entity Evaluation Score ACL (KNEES-ACL). The development articles for the five PROMs were identified through searches in PubMed and SCOPUS. A literature search was performed to identify additional studies assessing content validity of the PROMs. Additional information, necessary for the assessments, was obtained from the PROM developers after direct request. To evaluate the quality of the development studies and rate the content validity, the COSMIN Risk of Bias checklist was applied to all studies. All five development studies were identified. Three subsequent content validity studies were identified, all evaluating KOOS and one also IKDC. One content validity study was of inadequate quality and excluded from further analysis. The development of mHHS, IKDC-SKF, and KOOS was rated inadequate and possess insufficient content validity for their target populations. Due to the irrelevance of multiple items, KOOS was in particular inappropriate to evaluate patients with an ACL injury. The development of HAGOS was also rated inadequate, although the insufficiency aspects can be regarded as minor. KNEES-ACL possessed sufficient content validity. Out of five PROMs, only KNEES-ACL possessed sufficient content validity. Particularly, KOOS should not be used as an outcome for patients with an ACL injury. There is an urgent need for condition-specific PROMs for musculoskeletal conditions, developed with adequate methods. III.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Versus Hamstrings Alone: A Comparative Cohort Study.

Background:Few studies have reported the return-to-sports (RTS) rate in patients after augmentation of autologous anterior cruciate ligament reconstruction (ACLR) with the Ligament Augmentation and Reconstruction System (LARS).Purpose/Hypothesis:The purpose of this study was to compare postoperative outcomes in patients who underwent ACLR with single-bundle 4-strand hamstring autograft either without augmentation (HA-ACLR group) or with LARS augmentation (AUG-ACLR group). It was hypothesized that clinical outcomes and RTS rates would be better in the AUG-ACLR group at the 1-year follow-up, with similar outcomes in both cohorts by 2 years.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent ACLR between April 2014 and December 2017 were included in the current comparative study if they were skeletally mature and had 1- and 2-year follow-up outcomes; patients with concomitant meniscal surgery were also included. Included were 66 patients with AUG-ACLR (mean age, 26.8 years; 67% male) and 130 patients with HA-ACLR (mean age, 27.5 years; 61% male). Subjective outcome measures included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score, Lysholm scale, Tegner activity scale, and the Noyes sports activity rating scale. Objective measures included knee laxity, maximal isokinetic knee flexion and extension strength, and the results of 4 functional hop tests.Results:There were no significant differences between the study groups in age, sex distribution, body mass index, time to surgery, or number of concurrent meniscal surgeries. At the 1-year follow-up, the AUG-ACLR group had a significantly higher Tegner score (P = .001) and rates of RTS (P = .029) and return to preinjury level of sport (P = .003) compared with the HA-ACLR group. At the 2-year follow-up, there were no differences in these measures between groups. There were no between-group differences in other subjective outcomes, knee laxity, or strength and hop test results at either postoperative time point. There were also no differences in rerupture rates or other complications between the groups.Conclusion:Patients with AUG-ACLR had higher 1-year postoperative Tegner scores and rates of RTS and preoperative sport level compared with the HA-ACLR group. The 2-year rerupture rate for the AUG-ACLR group was low, and no intra-articular inflammatory complications were noted.

Long-term Minimum 15-Year Follow-up After Lateral Discoid Meniscus Rim Preservation Surgery in Children and Adolescents.

Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. The purpose of our study was to examine long-term patient-reported outcomes of lateral discoid meniscus (LDM) treated with meniscal-preserving techniques. Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and Western Ontario and McMaster University Osteoarthritis Index Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and SD, median and interquartile range (interquartile range), or frequency and percent, as appropriate. Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (±SD) age at initial surgery was 10.8 (±3.4) and 30.3 (±3.7) years at final follow-up. The mean (±SD) follow-up time from initial surgery was 19.5 (±2.8) years (range, 16 to 27). Patient-reported outcomes included: International Knee Documentation Committee 77.4±17.2, Lysholm 78.6±21, Western Ontario and McMaster University Osteoarthritis Index 7.6±11.3, Tegner Activity 7 (of 10), and Marx Activity Rating Scale 8 (of 10). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement. Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of LDM. While two thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with objective outcome measures are important to further elucidate the natural history of LDM and understand how rim-preserving procedures may prevent the development of degenerative processes. Level IV-case series, prognostic study.

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman’s, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman’s test. Though not significant, IKDC scores and Lysholm’s scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.

Outcomes of single bundle arthroscopic anterior cruciate ligament reconstruction in a limited resource setting

ObjectivesDespite various challenges, orthopaedic sports surgeons are still providing the arthroscopic service in low-income and middle-income countries like Nepal; however, it is hardly being reported. The main purpose of this study was to compare the clinical outcomes and complications of patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) in the urban group and that of the rural group.MethodsWe evaluated a total of 194 patients, including 98 patients in the urban group and 96 patients in the rural group, undergoing arthroscopic ACLR between August 2015 and February 2018, and had completed a minimum of 2-year follow-up. Subjective evaluations were performed using the Tegner-Lysolm score and International Knee Documentation Committee (IKDC) subjective knee evaluation form. Laxity assessments were performed using the Lachman test and the Pivot-shift test. Functional evaluation included the range of motion, single-leg hop test and overall IKDC score. Radiological assessment was performed according to the IKDC guidelines. SPSS was used for data analysis.ResultsThere was statistically significant differences in the subjective assessments between 2 groups. No statistically significant differences existed between 2 groups in terms of laxity and functional assessments. However, the proportion of laxity, in terms of Lachman test and Pivot-shift test, was higher in the young and active individuals and the proportion of abnormal and severely abnormal in all parameters of functional outcomes was higher in the older female in the rural group. Graft failure occurred in 19 (17.6%) knees in the urban group and 17 (16.8%) knees in the rural group. Graft failure in the urban group was higher in young and active male patients, whereas failure in the rural group was more in female patients. Similarly, overall infection occurred in 13 (6.2%) knees, including 5 (2.3%) deep infections and 8 (3.8%) superficial infections.ConclusionWe advised similar rehabilitation protocol for all the patients; however, the outcomes were significantly lower in patients living in rural areas as they are found to have poor compliance with the rehabilitation protocol. The overall graft failure rate was 17.2%; however, the reoperation rate was higher in the urban group than the rural group. The rate of deep infection was higher in the rural group as compared with the urban group.Level of evidenceLevel III, retrospective comparative study.

EARLY OUTCOMES AFTER SUTURE TAPE REINFORCEMENT OF QUADRICEPS TENDON AUTOGRAFT ACL RECONSTRUCTION IN ADOLESCENT ATHLETES

Background:Recently, anterior cruciate ligament reconstruction (ACLR) with suture-tape reinforcement has been popularized for protection of the graft during the revascularization and remodeling phase of incorporation. To date, there are limited short-term data regarding the outcomes of suture tape reinforcement to ACLR. Furthermore, its use with quadriceps tendon autograft (QT) ACLR is limited.Purpose:The purpose of this study was to review the early, preliminary results of ACLR in adolescent patients using QT autograft with suture tape reinforcement (QT-SR).Methods:A retrospective review was performed of skeletally mature adolescent patients who underwent primary ACLR with all-soft tissue QT-SR since 2018. Surgeries were performed by a single surgeon using an all-inside technique. All patients followed the same standardized rehabilitation protocol. Twelve-month patient-reported outcome measures (PROMs) and complications were analyzed. PROMs included the Pediatric International knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, and the Tegner activity level scale. Psychological readiness was assessed with the ACL-Return to Sport after Injury (ACL-RSI) scale.Results:39 patients (24 girls, 15 boys) were identified. The mean age at the time of surgery was 15.7 ± 1.3 years (range, 13-18 years). 82% of patients were high school athletes. Soccer was the primary sport for 48.7% of patients. The mean graft diameter was 9.5 ± 0.4 mm. 51.3% of patients had concomitant meniscus repairs. The mean time to return-to-sport clearance was 10.1 ± 1.4 months. At 12 months, the mean postoperative Pedi-IKDC was 95.6 ± 4.0, the mean Lysholm score was 97.6 ± 3.9, and the mean Tegner score was 8.8 ± 0.9. All PROMs improved significantly compared to the preoperative scores (Pedi-IKDC: p = 0.003, Lysholm: p = 0.006, Tegner: p = 0.003). The mean ACL-RSI was 93.4 ± 4.7. Complications included return to surgery due to postoperative stiffness in two patients. There were no cases of postoperative instability, graft rupture, or contralateral ACL injury.Conclusion:QT-SR ACLR results in excellent clinical and patient-reported outcomes in adolescent athletes at 12 months follow-up. The long-term effect of QT-SR remains to be investigated.

The Application of Computerized Adaptive Testing to the International Knee Documentation Committee Subjective Knee Evaluation Form

Background: Patient-reported outcome measures (PROMs) are commonly used to monitor functional outcomes for clinical and research purposes; unfortunately, many PROMs include redundant, burdensome questions for patients. The use of predictive models to implement computerized adaptive testing (CAT) offer a potential solution to reduce question burden in outcomes research. Purpose: To validate the usage of an appropriate CAT system to improve the efficiency of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Validation was based on electronically collected patient responses from 2 separate orthopaedic sports medicine clinics. Diagnoses included, but were not limited to, meniscal lesions, ligamentous injuries, and chondral defects. The CAT system was previously developed through analysis of an electronic knee PROM database that did not contain any of these cases. Results: A total of 2173 patient responses (1229 patients) were collected. The CAT model was able to reduce the question burden by a mean of 9.33 questions (45.1%). Higher CAT-predicted scores correlated strongly with higher actual scores (r = 0.99; intraclass correlation coefficient = 0.99). The mean difference between the CAT-predicted score and the actual PROM score was 0.48 of a point on a scale of 0 to 100. Conclusion: The use of CAT systems, in conjunction with electronic PROMs, can accurately predict outcome scores for IKDC PROMs, while dramatically decreasing the number of questionnaire items needed for any given patient. By decreasing questionnaire burden, clinicians and researchers can potentially increase patient participation and follow-up in both clinical assessments and research trials.

Effect of Leg Dominance on Medium- to Long-Term Functional Outcomes, Quality of Life, and Revision Rates After Isolated ACL Reconstruction.

Background:The effect of leg dominance on short-term functional outcomes and return to sports after arthroscopic anterior cruciate ligament reconstruction (ACLR) has been evaluated. However, postoperative medium- to long-term recovery and revision rates are not well known.Purpose:To investigate whether leg dominance affects medium- to long-term clinical and functional scores and revision rates after ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:Included in this study were 235 patients (205 male and 30 female) who underwent isolated arthroscopic ACLR. Patients were divided according to the leg dominance status of their injured limb into 2 groups: dominant leg injured (120 patients) and nondominant leg injured (115 patients). Preoperative and postoperative functional outcomes and health-related quality of life (HRQoL) were evaluated using the visual analog scale for pain, Tegner activity scale, Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, 36-Item Short Form Health Survey (SF-36), and overall patient satisfaction. Moreover, the revision rates of the 2 groups were compared according to leg dominance, patient characteristics, and operative features.Results:The mean follow-up period was 8.0 ± 2.3 years (range, 5-13 years). A significant preoperative to postoperative improvement in range of motion and functional scores was noticed in both groups (P < .001 for all). However, the improvement was significantly higher in the dominant leg group for the Tegner (P = .001), Lysholm (P = .006), and IKDC (P < .001) scores as well as for the SF-36 domain scores for general health (P = .009), social role (P = .048), and emotional role (P = .032). Also, patient satisfaction was significantly higher in the dominant leg group (P = .007). The dominant leg group was associated with a lower revision rate compared with the nondominant leg group (5.8% vs 15.7%, respectively; P = .015).Conclusion:High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. However, leg dominance had a significant effect on postoperative medium- to long-term functional outcomes, HRQoL, and revision rates.

Changes in Infrapatellar Fat Pad Volume 6 to 12 Months After Anterior Cruciate Ligament Reconstruction and Associations With Patient-Reported Knee Function.

Hypertrophy of the infrapatellar fat pad (IFP) in idiopathic knee osteoarthritis has been linked to deleterious synovial changes and joint pain related to mechanical tissue impingement. Yet little is known regarding the IFP's volumetric changes after anterior cruciate ligament reconstruction (ACLR). To examine changes in IFP volume between 6 and 12 months after ACLR and determine associations between patient-reported outcomes and IFP volume at each time point as well as the volume change over time. In a subset of individuals, we examined interlimb IFP volume differences 12 months post-ACLR. Prospective cohort study. Laboratory. We studied 26 participants (13 women, 13 men, age = 21.88 ± 3.58 years, body mass index = 23.82 ± 2.21 kg/m2) for our primary aims and 13 of those participants (8 women, 5 men, age = 21.15 ± 3.85 years, body mass index = 23.01 ± 2.01 kg/m2) for our exploratory aim. Using magnetic resonance imaging, we evaluated the IFP volume change between 6 and 12 months post-ACLR in the ACLR limb and between-limbs differences at 12 months in a subset of participants. International Knee Documentation Committee subjective knee evaluation (IKDC) scores were collected at 6-month and 12-month follow-ups, and associations between IFP volume and patient-reported outcomes were determined. The IFP volume in the ACLR limb increased from 6 months (19.67 ± 6.30 cm3) to 12 months (21.26 ± 6.91 cm3) post-ACLR. Greater increases of IFP volume between 6 and 12 months were significantly associated with better 6-month IKDC scores (r = .44, P = .03). The IFP volume was greater in the uninjured limb (22.71 ± 7.87 cm3) than in the ACLR limb (20.75 ± 9.03 cm3) 12 months post-ACLR. The IFP volume increased between 6 and 12 months post-ACLR; however, the IFP volume of the ACLR limb remained smaller than that of the uninjured limb at 12 months. In addition, those with better knee function 6 months post-ACLR demonstrated greater increases in IFP volume between 6 and 12 months post-ACLR. This suggests that greater IFP volumes may play a role in long-term joint health after ACLR.

Outcomes from Osteochondral Autograft Transplant or Mosaicplasty in 26 Patients with Type V Osteochondral Lesions of the Talus.

BackgroundMosaicplasty osteochondral transplantation (MOT) has been proved a feasible choice for the treatment of talus osteochondral injury. It can reduce ankle pain and allow performance of daily living activities and elementary sports. However, there are very little data on the restoration of normal life with large lesions. Our investigation focused on assessing outcomes in patients with large lesions.Material/MethodsThe MOT operation was used, and the donor site was located at the lateral condyle of the femur. Clinical evaluation included the Berndt and Harty outcome question, Visual Analog Scale (VAS) pain score (during rest, walking and running), American Orthopedic Foot and ankle Association (AOFAS) score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and the Short Form 36 (SF-36). Twenty-four months after surgery, the graft binding was assessed by MRI using the magnetic resonance observation of cartilage repair tissue (MOCART) score.ResultsWe assessed 26 patients, including 14 males and 12 females. The average follow-up time was 33.9±5.2 months. The average lesion size was 173.1±23.5 mm2. The average VAS score during rest improved from 4.62±0.85 preoperatively to 1.08±0.27 postoperatively (P<0.05), the score during walking improved from 5.19±0.63 preoperatively to 1.15±0.37 postoperatively (P<0.05), and the score during running improved from 6.08±0.74 preoperatively to 1.39±0.57 postoperatively (P<0.05). The average postoperative AOFAS ankle score improved to 91.5±2.6 (range, 88 to 96), compared with preoperative 75.0±2.8 (range, 70 to 79) (P<0.05). Two patients developed pain in the donor site of the knee joint, and both of them had 2 or more osteochondral plugs harvested. The postoperative SF-36 score increased to 92.2±2.4 (P<0.05). In the last follow-up, 18 patients answered the Berndt and Harty outcome question, all with “good” as the result.ConclusionsMOT is a feasible choice for patients with larger lesions. It can improve the VAS/AOFAS/IKDC/SF-36 scores, and has high patient satisfaction. Graft incorporation helps improve patient quality of life. Our results indicate that a larger osteochondral plug area increases the risk of developing knee donor site pain.

Magnetic Resonance Imaging 1 Year After Hamstring Autograft Anterior Cruciate Ligament Reconstruction Can Identify Those at Higher Risk of Graft Failure: An Analysis of 250 Cases

Background: There is currently no analysis of 1-year postoperative magnetic resonance imaging (MRI) that reproducibly evaluates the graft of a hamstring autograft anterior cruciate ligament reconstruction (ACLR) and helps to identify who is at a higher risk of graft rupture upon return to pivoting sports. Purpose: To ascertain whether a novel MRI analysis of ACLR at 1 year postoperatively can be used to predict graft rupture, sporting level, and clinical outcome at a 1-year and minimum 2-year follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: Graft healing and integration after hamstring autograft ACLR were evaluated using the MRI signal intensity ratio at multiple areas using oblique reconstructions both parallel and perpendicular to the graft and tunnel apertures. Clinical outcomes were assessment of side-to-side laxity and International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm, and Tegner activity level scores at 1 year. Repeat outcome measures and detection of graft rupture were evaluated at a minimum of 2 years. Results: A total of 250 patients (42.4% female) underwent MRI analysis at 1 year, and assessment of 211 patients between 1 year and the final follow-up (range, 24-36 months) detected 9 graft ruptures (4.3%; 5 in female patients). A significant predictor for graft rupture was a high signal parallel to the proximal intra-articular graft and perpendicular to the femoral tunnel aperture (P = .032 and P = .049, respectively), with each proximal graft signal intensity ratio (SIR) increase by 1 corresponding to a 40% increased risk of graft rupture. A cutoff SIR of 4 had a sensitivity and specificity of 66% and 77%, respectively, in the proximal graft and 88% and 60% in the femoral aperture. In all patients, graft signal adjacent to and within the tibial tunnel aperture, and in the mid intra-articular portion, was significantly lower than that for the femoral aperture (P < .001). A significant correlation was seen between the appearance of higher graft signal on MRI and those patients achieving top sporting levels by 1 year. Conclusion: ACLR graft rupture after 1 year is associated with MRI appearances of high graft signal adjacent to and within the femoral tunnel aperture. Patients with aspirations of quickly returning to a high sporting level may benefit from MRI analysis of graft signal. Graft signal was highest at the femoral tunnel aperture, adding further radiographic evidence that the rate-limiting step to graft healing occurs proximally.

Rationale for a Parsimonious Measure of Subjective Knee Function Among Individuals With Anterior Cruciate Ligament Reconstruction: A Rasch Analysis.

The International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) is the most frequently used patient-reported measure of subjective knee function among individuals with anterior cruciate ligament reconstruction (ACLR). Yet, due to the limitations of traditional validation approaches, whether the IKDC measures knee function as intended is unclear. Rasch analysis offers a robust validation approach, which may enhance the clinical interpretation of the IKDC. To assess the psychometric properties, ability to classify health status, and relationships between the IKDC and objective measures of strength and functional performance relative to a newly proposed reduced-item instrument. Cross-sectional study. Laboratory. A total of 77 individuals with primary unilateral ACLR (age = 21.9 ± 7.8 years, time postsurgery = 6.2 ± 1.0 months) and 76 age-matched control individuals (age = 22.0 ± 4.2 years). Rasch analysis was used to assess the psychometric properties of the IKDC. Receiver operator characteristic curves and logistic regression were calculated to assess the accuracy of classifying participants with ACLR versus control participants. Pearson product moment and Spearman rank order correlation analyses were conducted to evaluate relationships among subjective knee function, quadriceps torque, and single-limb hop performance. Rasch analysis aided the development of a reduced 8-item instrument (IKDC-8), which yielded improved psychometric properties in the rating scale performance (IKDC-8 = 0, IKDC = 3 nonmonotonic "misbehaving" items), percentage of variance accounted for by 1 dimension (IKDC-8 = 71.5%, IKDC = 56.7%), and precision in item separation (IKDC-8 = 9.79, IKDC = 5.02). The IKDC was an outstanding diagnostic tool, and the IKDC-8 was excellent, correctly classifying 87.2% and 82.7% of cases, respectively. Using the Hanley-McNeil formula, we found no difference in the areas under the respective receiver operator characteristic curves. Equivalent associations between subjective and objective knee function were observed regardless of the instrument used. We demonstrated evidence of enhanced reliability and validity for a parsimonious measure of subjective knee function. The proposed instrument reduces the number of items, increases the score interpretability as measuring a single construct, and improves the rating scale functioning while not diminishing its ability to classify participants with ACLR versus control participants or changing existing relationships with objective measures of recovery. We suggest the IKDC-8 may enhance clinical use by reducing administration time, improving the interpretation of the subjective knee function score, and clarifying functional ability.