International Knee Documentation Committee Scale Research Articles

Bifocal Patellar Tendon Avulsion Fractures in Children and Adolescents: Diagnosis and Treatment Considerations for a Unique Injury Pattern

PurposeTo highlight important diagnostic and treatment considerations in patients who present with bifocal patellar tendon avulsion fractures from the tibial tubercle and inferior patellar pole.MethodsRadiographic presentation, surgical technique, and complications of 5 children who sustained bifocal patellar tendon avulsion fractures with ≥6 months postoperative follow-up were retrospectively reviewed. Hospital for Special Surgery (HSS) Brief Functional Activity Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, PROMIS mobility, and Pediatric International Knee Documentation Committee Scale (Pedi-IKDC) were assessed at most recent follow-up.ResultsFive children (4 boys, 1 girl) presented with bifocal patellar tendon avulsion fractures with a median follow-up of 12.8 months (range 7.7 to 26.4). In 1 case, advanced imaging was not pursued, and the bifocal nature of injury was subsequently discovered intraoperatively. In all other cases, magnetic resonance imaging (MRI) correctly characterized the bifocal injuries and revealed the full extent of fractures and soft tissue injury. Surgical management involved suture anchor repair with heavy nonabsorbable sutures. Postoperative functional and patient-reported outcomes were within the range of population healthy/normative values (for those that were available for comparison, e.g., Pedi-IKDC), and clinically relevant improvement was noted when comparing preoperative and postoperative patient-reported outcome measures of both pain and mobility.ConclusionsAdvanced imaging (e.g., MRI) is required to understand the full extent of injury and should be obtained in the setting of traumatic patella alta to evaluate for the presence of a bifocal lesion and plan surgical intervention accordingly. These patients demonstrate satisfactory functional and patient-reported outcomes after operative repair.Level of EvidenceIV, therapeutic case series.

Development of a Core Set for Knee Dysfunction Based on the International Classification of Functioning, Disability and Health: A Cross-sectional Study

ObjectiveTo develop an International Classification of Functioning, Disability and Health core set for patients with knee dysfunction. DesignCross-sectional study. SettingThe study was conducted at all levels of care (general community, primary care units, rehabilitation clinics/centers, hospital). ParticipantsParticipants (N=388) with knee dysfunction with or without clinical diagnosis of knee pathology, with or without complaint of pain, with or without instability, and/or with or without knee movement restriction of any type. InterventionsNot applicable. Main Outcome MeasuresParticipants were assessed using the core sets for acute and postacute musculoskeletal conditions, the subjective form from the International Knee Documentation Committee scale, the self-report of general health and functionality, and the general health and functionality classified by the researcher. To identify the categories that best explain knee dysfunction, linear regression analyses were performed. ResultsTwenty-four categories were identified from the 75 core set categories for acute and postacute musculoskeletal conditions. Eleven categories belong to the component body functions, 3 represent body structures, 7 represent activities and participation, and 3 represent environmental factors. ConclusionsA core set for knee dysfunction that can be used at all levels of health care was proposed, which offers a system for disability assessment related to knee dysfunction, including environmental and social factors. These factors are important for a broad assessment because they include the multiple aspects of functionality, usually not considered in other knee dysfunction assessment instruments. Further analysis of the content and construct validity of the core set is required.

Who Passes Return-to-Sport Tests, and Which Tests Are Most Strongly Associated With Return to Play After Anterior Cruciate Ligament Reconstruction?

Background:Return-to-sport (RTS) testing after anterior cruciate ligament (ACL) reconstruction (ACLR) surgery has become popular. It has been recommended that such testing should incorporate several domains, or set of tests, but it is unclear which are most associated with a successful RTS.Purpose:To determine (1) the proportion of patients who can pass a set of self-report and functional tests at 6 months after ACLR; (2) age, sex, and activity level differences between patients who pass and those who do not; and (3) whether specific types of tests are associated with a return to competitive sport at 12 months.Study Design:Cohort study; Level of evidence, 2.Methods:This was a prospective longitudinal study of 450 patients who had primary ACLR. At 6 months postoperatively, patients completed 2 self-report measures, the International Knee Documentation Committee (IKDC) subjective knee form and ACL–Return to Sport after Injury (ACL-RSI) scale, and 3 functional measures: single hop and triple crossover hop for distance and isokinetic quadriceps strength. Limb symmetry index scores of ≥90 for functional tests, IKDC scores ≥85, and ACL-RSI scores ≥65 were considered indicators of satisfactory recovery. Proportional statistics and contingency analysis were used to determine associations between age, sex, preinjury sports level, and (1) meeting test thresholds and (2) RTS at 12 months.Results:Only 17 (3.8%) patients met all 5 test criteria at 6 months, and 95 (21%) patients did not pass any test. More of the younger patients (<21 years) passed all of the functional tests (P < .01), and more male patients met the IKDC threshold (P = .03). Patients who played level I sports before injury had the same pass rates as those who played level II/III sports. Patients who passed the thresholds for the ACL-RSI and IKDC scales had 4 and 3 times the odds, respectively, of RTS at 12 months (both P < .0001). Meeting the threshold for quadriceps strength or either of the hop tests at 6 months was not associated with RTS.Conclusion:At 6 months after ACLR, few patients met all of the thresholds of the common tests used to assess RTS ability, although younger patients had higher rates of passing the functional tests. Self-perceived symptoms/function and psychological readiness were associated with a return at 12 months.

Quadriceps Strength and Kinesiophobia Predict Long-Term Function After ACL Reconstruction: A Cross-Sectional Pilot Study.

Many patients live with long-term deficits in knee function after an anterior cruciate ligament reconstruction (ACLR). However, research is inconclusive as to which physical performance measure is most strongly related to long-term patient-reported outcomes after ACLR. Quadriceps strength would be most strongly associated with patient-reported long-term outcomes after ACLR. Cross-sectional study. Level 3. A total of 40 patients (29 female) consented and participated an average of 10.9 years post-ACLR (range, 5-20 years). Patients completed the Lower Extremity Functional Scale (LEFS), the International Knee Documentation Committee (IKDC) Scale, Knee injury and Osteoarthritis Outcome Score Quality of Life (KOOS QoL) and Sport (KOOS Sport) subscales, and the Tampa Scale of Kinesiophobia (TSK-17). Each patient subsequently performed maximal isometric quadriceps contraction, a 60-second single-leg step-down test, and the single-leg single hop and triple hop for distance tests. Multivariate linear and logistic regression models determined how performance testing was associated with each patient-reported outcome when controlling for time since surgery, age, and TSK-17. When controlling for time since surgery, age at the time of consent, and TSK-17 score, maximal isometric quadriceps strength normalized to body weight was the sole physical performance measure associated with IKDC (P < 0.001), KOOS Sport (P = 0.006), KOOS QoL (P = 0.001), and LEFS scores (P < 0.001). Single-leg step-down, single hop, and triple hop did not enter any of the linear regression models (P > 0.20). Additionally, TSK-17 was associated with all patient-reported outcomes (P ≤ 0.01) while time since surgery was not associated with any outcomes (P > 0.05). Isometric quadriceps strength and kinesiophobia are significantly associated with long-term patient-reported outcomes after ACLR. These results suggest that training to improve quadriceps strength and addressing kinesiophobia in the late stages of recovery from ACLR may improve long-term self-reported function.

Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes.

To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study wasto improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A (n = 54) underwent ACLR, while those in group B (n = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18-40) and 24 (18-33) years in groups A and B, respectively, and the median follow-up was 60 (55-65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively (p < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2-6.1) mm in patients in group A and 1.2 ± 0.7 (1.2-3.2) mm in patients in group B (p < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores (p < 0.001). Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. 1.

Analysis of modified double-bundle anterior cruciate ligament reconstruction with implantless fixation on tibial side

PurposeTo avoid potential problems of double-bundle anterior cruciate ligament reconstruction (ACLR), various modifications have been reported. This study analyzed a novel technique of modified double-bundle (MDB) ACLR without implant on tibial side in comparison to single-bundle (SB) ACLR. MethodsEighty cases of isolated anterior cruciate ligament tear (40 each in SB group or MDB group) were included. SB ACLR was performed by outside in technique with quadrupled hamstring graft fixed with interference screws. In MDB group, ACLR harvested tendons were looped over each other at the center and free ends whipstitched. Femoral tunnel was created by outside in technique. Anteromedial tibial tunnel was created with tibial guide at 55°. The anatomic posterolateral aiming guide (Smith-Nephew) was used to create posterolateral tunnel. With the help of shuttle sutures, the free end of gracillis was passed through posterolateral tunnel to femoral tunnel followed by semitendinosus graft through anteromedial tunnel to femoral tunnel. On tibial side the graft was looped over bone-bridge between external apertures of anteromedial and posterolateral tunnel. Graft was fixed with interference screw on femoral side in 10° knee flexion. International Knee Documentation Committee (IKDC), Tegner score, Pivot shift and knee laxity test (KLT, Karl-Storz) were recorded pre- and post-surgery. At one year magnetic resonance imaging (MRI) was done. Statistical analysis was done by SPSS software. ResultsMean preoperative KLT reading of (10.00 ± 1.17) mm in MDB group improved to (4.10 ± 0.56) mm and in SB group it improved from (10.00 ± 0.91) mm to (4.80 ± 0.46) mm. The mean preoperative IKDC score in MDB group improved from (49.49 ± 8.00) to (92.5 ± 1.5) at one year and that in SB group improved from (52.5 ± 6.9) to (88.4 ± 2.6). At one-year 92.5% cases in MDB group achieved their preinjury Tegner activity level as compared to 60% in SB group. The improvement in IKDC, KLT and Tegner scale of MDB group was superior to SB group. MRI confirmed graft integrity at one year and clinically at 2 years. ConclusionMDB ACLR has shown better outcome than SB ACLR. It is a simple technique that does not require fixation on tibial side and resultant graft is close to native ACL.

Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention. Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA. Study Design: Meta-analysis of level 1 studies. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was platelet-rich plasma hyaluronic acid knee osteoarthritis randomized. Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP. Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores (P < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients (P < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients (P < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP (P < .05). Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.

Preservation of the Tibial Remnant in Anterior Cruciate Ligament Reconstruction May Improve Postoperative Proprioceptive Function.

The purpose of this study was to retrospectively compare clinical results, including proprioceptive function, after anterior cruciate ligament (ACL) reconstruction between 2 groups using techniques that preserve and eliminate the tibial remnant. Forty-eight patients who were followed for at least 24 months after ACL reconstruction with 4-strand hamstring tendon autografts were enrolled in this study. They were then divided into 2 groups: the remnant-preserving group (group A, 26 patients), in whom more than 7 mm of the remnant tibial stump (approximately 20% of the mean length of the ACL) was preserved; and the remnant-eliminating group (group B, 22 patients), in whom the tibial remnant was eliminated during ACL reconstruction. The average duration of follow-up was 25.5 months. At last follow-up, patients were evaluated using the International Knee Documentation Committee scale, Hospital for Special Surgery score, Lachman test, arthrometer, reproduction of passive positioning (RPP) test, threshold to detection of passive motion (TTDPM) test, one-leg hop test, and single-limb standing test. The clinical results between the 2 groups were statistically compared. Group A showed significantly better results on the RPP test at 15° (P=.040) and 30° (P=.010), one-leg hop test (P=.017), and single-limb standing test (P=.007) compared with group B. The other results showed no significant differences. The remnant-preserving technique in ACL reconstruction yields better proprioceptive and functional outcomes and may help achieve postoperative patient satisfaction. [Orthopedics. 2020;43(4):e231-e236.].

Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS–Sports and Recreation (P = .04), and KOOS–Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Triaxial accelerometer evaluation is correlated with IKDC grade of pivot shift.

The purpose of this study was to evaluate the correlation between tibial acceleration parameters measured by the KiRA device and the clinical grade of pivot shift. The secondary objective was to report the risk factors for pre-operative high-grade pivot shift. Two-hundred and ninety-five ACL deficient patients were examined under anesthesia. The pivot shift tests were performed twice by an expert surgeon. Clinical grading was performed using the International Knee Documentation Committee (IKDC) scale and tibial acceleration data was recorded using a triaxial accelerometer system (KiRA). The difference in the tibial acceleration range between injured and contralateral limbs was used in the analysis. Correlation coefficients were calculated using linear regression. Multivariate logistic regression was used to identify risk factors for high grade pivot shift. The clinical grade of pivot shift and the side-to-side difference in delta tibial acceleration determined by KiRA were significantly correlated (r = 0.57; 95% CI 0.513-0.658, p < 0.0001). The only risk factor identified to have a significant association with high grade pivot shift was an antero-posterior side to side laxity difference > 6mm (OR = 2.070; 95% CI (1.259-3.405), p = 0.0042). Side-to-side difference in tibial acceleration range, as measured by KiRA, is correlated with the IKDC pivot shift grade in anaesthetized patients. Side-to-side A-P laxity difference greater than 6mm is reported as a newly defined risk factor for high grade pivot shift in the ACL injured knee. Level II.

Medial Patellofemoral Ligament Reconstruction in Traumatic Patellar Dislocation without Patellar Fixation.

Acute traumatic patellar dislocation is a common injury, and spontaneous reduction may occur at the time of injury or may be reduced at the field of the accident by someone. It may be associated with osteochondral fractures and rupture of medial patellar stabilizers leading to recurrent patellar instability. The aim of this prospective study was to evaluate the outcomes of medial patellofemoral (PF) ligament (MPFL) reconstruction in recurrent traumatic patellar dislocation. Forty-five patients presented with PF instability as a result of traumatic rupture MPFL with normal patellar tracking underwent MPFL reconstruction without patellar fixation hardware through two parallel transpatellar tunnels and one screw in femoral tunnel. All patients were evaluated clinically preoperatively and at a minimum follow-up of 24 months, and International Knee Documentation Committee (IKDC) and Kujala scores were used to assess the clinical results. All patients were available for evaluation at a minimum of 24 months (up to 36 months). The mean age of these patients at the time of surgery was 22.82 years (range: 18-34 years). All patients gave history of trauma of their knees. Mean IKDC scale showed significant improvement as it rose from 47.17 preoperatively to 77.94 postoperatively, and mean Kujala score rose from 53.88 preoperatively to 86.24 postoperatively (p < 0.001). No recurrence of dislocation was recorded. Only three patients had mild atrophy of thigh and one patient had some difficulty in jumping. Reconstruction of MPFL by this method provides good clinical result in the treatment of PF instability by using autologous graft (semitendinosus and gracilis). Less hardware were used with less complications.

Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy?

Background: The Patient Reported Outcomes Information System (PROMIS) is an efficient metric able to detect changes in global health. Purpose: To assess the responsiveness, convergent validity, and clinically important difference (CID) of PROMIS compared with disease-specific scales after knee arthroscopy. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: A prospective institutional review board–approved study collected PROMIS Physical Function (PF), PROMIS Pain Interference (PI), International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) results in patients undergoing knee arthroscopy. The change from preoperative to longest follow-up was used in analyses performed to determine responsiveness, convergent validity, and minimal and moderate CID using the IKDC scale as the anchor. Results: Of the 100 patients enrolled, 76 were included. Values of the effect size index (ESI) ranged from near 0 to 1.69 across time points and were comparable across scales. Correlations of the change in KOOS and PROMIS with IKDC ranged from r values of 0.61 to 0.79. The minimal CID for KOOS varied from 12.5 to 17.5. PROMIS PF and PI minimal CID were 3.3 and −3.2. KOOS moderate CID varied from 14.3 to 18.8. PROMIS PF and PI moderate CID were 5.0 and −5.8. Conclusion: The PROMIS PF and PI showed similar responsiveness and CID compared with disease-specific scales in patients after knee arthroscopy. PROMIS PI, PROMIS PF, and KOOS correlations with IKDC demonstrate that these scales are measuring a similar construct. The ESIs of PROMIS PF and PI were similar to those of KOOS and IKDC, suggesting similar responsiveness at 6 months or longer (ESI >1.0). Minimum and moderate CID values calculated for PROMIS PF and PI using IKDC as an anchor were sufficiently low to suggest clinical usefulness. Clinical Relevance: PROMIS PF and PI can be accurately used to determine improvement or lack thereof with clinically important changes after knee arthroscopy.

Reconstrucción primaria del ligamento cruzado anterior utilizando porción central de tendón Cuadricipital. Cohorte longitudinal

BackgroundThe use of a free quadriceps tendon graft without the use of a bone plug is not the first choice for primary anterior cruciate ligament reconstruction. A series of patients, with a minimum follow-up of two years, is presented in which the choice of free quadricipital tendon graft without a bone plug will be evaluated as a reliable and safe alternative for primary reconstruction of the anterior cruciate ligament. MethodsPatients undergoing surgery for a period of 24 months (2013-2015) were included in this study. A follow-up was carried out for a minimum of 2 years. Controls were carried out at 8 and 15 days, when the sutures were removed. The first 2 months were then evaluated every 3 weeks and every 6 weeks for 6 months, and then at 1 year, 18 months, and two years. A record was made of the values obtained by each patient on the Lysholm, Tegner, and IKDC (International Knee Documentation Committee) scales. ResultsThe study included 92 patients that met the inclusion criteria. The mean subjective IKDC score at one-year follow-up was 80.44 points, and the mean Tegner activity index reduction was 0.82 index points. The mean Lysholm and Gillquist score was 89 points per year, with good results being obtained in 89.1%. DiscussionThe central quadriceps tendon graft without a bone plug is a technically reproducible procedure with no greater morbidity in the donor site. This has been reflected in the excellent scores on functional scales and in the satisfaction expressed by the patients during two years of follow-up.Evidence Level: III.

Evaluate the Effect of Duration for Injury on International Knee Documentation Committee (IKDC) Score With an Anterior Cruciate Ligament Injury Patients

The anterior cruciate ligament (ACL) tear is one of the most common knee injuries. Aim; to evaluate the effect of duration for injury on IKDC score with an anterior cruciate ligament injury patients. Patients and methods; Non-equivalent control group design was utilized to conduct this study. The study sample,60 adult patients with an ACL injury, patients were divided into two equal groups, group one their injury less than 3 months and group two their duration of injury more than 3 months. Tools; the International Knee Documentation Committee (IKDC) scale and exercise program. Results, the mean age were (24.7), and the majority of them were students, regarding the IKDC scale there was a highly statistically significant difference between both groups during pre-operative and all of the follow up periods. Conclusion; An improvement was observed at 3&6 months follow up of patients with an ACL injury of less than 3 months than those patients whose injury more than 3 months. Recommendation; providing patients with instructions for seeking medical advice for their sports injuries of great importance for early diagnosis and management of their injuries.

Comparative Matched-Pair Analysis of Open-Wedge High Tibial Osteotomy With Versus Without an Injection of Adipose-Derived Mesenchymal Stem Cells for Varus Knee Osteoarthritis: Clinical and Second-Look Arthroscopic Results

Background: High tibial osteotomy (HTO) is reported to be an effective treatment for varus knee osteoarthritis (OA) by redistributing the load line within the knee joint. The cell-based tissue engineering approach using mesenchymal stem cells (MSCs) has addressed the issue of articular cartilage repair in knee OA. Purpose: This study aimed to compare the clinical, radiological, and second-look arthroscopic outcomes of open-wedge HTO with versus without an MSC injection and to identify the association between cartilage regeneration and HTO outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Among 271 patients treated with HTO for varus knee OA from September 2009 to April 2014, patients treated with HTO alone (conventional group; n = 50) were pair-matched with those who underwent HTO with an MSC injection (injection group; n = 50) based on sex, age, and lesion size. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) score and Lysholm score. Radiological outcomes evaluated were the femorotibial angle and posterior tibial slope. At second-look arthroscopic surgery, cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) grade. Results: At the time of second-look arthroscopic surgery (mean, 12.4 months [conventional group] and 12.7 months [injection group]), the mean IKDC and Lysholm scores in each group significantly improved: conventional group, from 38.4 ± 9.2 to 55.2 ± 15.0 and from 56.7 ± 12.2 to 79.6 ± 13.5, respectively; and injection group, from 36.5 ± 4.7 to 62.7 ± 14.1 and from 55.7 ± 11.9 to 80.6 ± 15.6, respectively (P < .001 for all). Clinical outcomes at final follow-up (mean, 38.8 months [conventional group] and 37.2 months [injection group]) further improved from 62.7 ± 14.1 to 64.8 ± 13.4 (IKDC) and from 80.6 ± 15.6 to 84.7 ± 16.1 (Lysholm) (P < .001 and P = .034, respectively) only in the injection group when compared with the values at second-look arthroscopic surgery. At final follow-up, there was a significant difference in the mean IKDC and Lysholm scores between groups (P = .049 and P = .041, respectively). Overall ICRS grades, which significantly correlated with clinical outcomes, were better in the injection group than in the conventional group. Radiological outcomes at final follow-up showed improved knee joint alignment relative to patients’ preoperative conditions but showed no significant correlation with clinical outcomes or ICRS grade in either group (P > .05 for all). Conclusion: The group that received an MSC injection scored better on the IKDC and Lysholm scales at final follow-up than the group that did not, although these differences were relatively small. When performing HTO for patients with varus knee OA, an MSC injection should be considered as an additional procedure for improved cartilage regeneration with better clinical outcomes.

Tension Band Wire Fixation Technique for Anterior Cruciate Ligament Tibial Avulsion Fracture: A New Fixation Technique.

This study evaluated clinical results of tension band wire fixation technique in the arthroscopic treatment of anterior cruciate ligament (ACL) tibial avulsion fracture. This study included 148 cases of ACL tibial avulsion fracture treated using arthroscopic tension band wire fixation technique. Patients were followed up for 25 to 36 months with an average of 27 months and evaluated in accordance with the International Knee Documentation Committee (IKDC) and Lysholm knee scoring scale. Fractures were united within 3 months after surgery in all cases. During the last follow-up, the anterior drawer, Lachman, and pivot shift tests showed negative, except for eight patients who had a 1-degree positive anterior drawer test. KT-1000 knee stability test showed no anterior instability exceeding 2 mm in 132 patients and 4 mm in 8 patients. In accordance with the IKDC scale, the knees of 132 patients were graded normal, whereas 8 other patients were nearly normal. Lysholm scores before surgery and during the last follow-up were 72.4 ± 3.2 and 97.5 ± 2.2, respectively. Statistically significant differences were observed among the Lysholm scores (p < 0.05). The Tegner scores were 6.5 ± 0.9 before injury and 6.4 ± 0.7 at the last follow-up (p > 0.05). No statistically significant differences between the preinjury and postoperative activity level were observed. All patients were satisfied with the outcomes of operation. Arthroscopic treatment of ACL tibial avulsion fracture by using tension band wire fixation technique ensures fracture healing and restores the stability and function of the joint in most patients. The level of evidence for this study is III.

Valoración clínica de la reconstrucción del ligamento cruzado anterior (LCA) con autoinjerto de hueso-tendón rotuliano-hueso (HTH) por portal medial

BackgroundThere is a lack of prospective series evaluating the post-operative outcome of patients with arthroscopic reconstruction of anterior cruciate ligament (ACL) with patellar bone-tendon-bone (PBTB), using the medial portal for perforation of the femoral tunnel. The objective of the study is to describe the functional outcome of arthroscopic ACL reconstruction with ipsilateral patellar BTB autograft through medial portal for treating anterolateral knee instability. Materials & methodsAn observational prospective cohort study was conducted with a one-year follow up of 48 patients with isolated ACL injury without associated intra-articular injuries, in whom arthroscopic reconstruction was performed with an ipsilateral BTB autograft through the medial portal. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) scale, and laxity was assessed with the KT-1000 arthrometer®. ResultsThe mean age of patients was 34.6 years, and 68.5% of patients had a post-operative grade of A or B according to the IKDC scale, and the objective post-operative stability measured with the KT-1000 arthrometer® was significantly better. DiscussionAfter one year follow up, ACL reconstruction through medial arthroscopic portal using ipsilateral BPTB autograft showed satisfactory results for the patient and good clinical results for the surgeon. Level of evidenceII.

KOOS and IKDC scales may be inadequate in evaluating patients with multiple ligament knee injuries: a systematic review

ImportanceStandardised, validated patient-reported outcome measures are crucial in understanding the impact of multiple ligament knee injury and surgery.AimEvaluate the validity and responsiveness of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score in patients with multiple ligament knee injuries through existing studies in the literature.Evidence ReviewA systematic review of the literature was performed using MEDLINE and Cochrane databases. The search terms ‘multiple ligament,’ ‘multiligament,’ ‘knee dislocation,’ and ‘combined ligament’ were used in conjunction with ‘KOOS’ or ‘IKDC’. Multiple ligament injury was defined as the disruption of ≥2 major knee ligaments. Validity was assessed through floor/ceiling effects, comparing scores between single and multiple ligament injuries, and correlation with Lysholm scores. Responsiveness was assessed by calculating effect sizes (ES) and standardised response means (SRM).Findings8 studies reported KOOS scores, and 45 studies reported IKDC scores. No studies specifically evaluated the validity or responsiveness of either measure in patients with multiligament knee injuries. Owing to a lack of available data, the validity and responsiveness of the KOOS could not be thoroughly evaluated. The IKDC may have a ceiling effect and indifference to the disparity between single and multiple ligament injuries, indicating poor content and construct validity. Correlations between IKDC and Lysholm scores ranged from 0.65 to 0.93. The IKDC demonstrated good responsiveness in this population, with ES and SRM ranging from 1.9 to 8.0 and 0.9 to 5.1, respectively.Conclusions and RelevanceThe KOOS and IKDC may be inadequate in evaluating patients with multiple ligament knee injuries. Future studies should consider using the Multiligament Quality of Life (MLQOL) questionnaire, a recently developed multiligament knee injury-specific instrument, when evaluating patients with multiple ligament knee injuries.

A dose response analysis of a specific bone marrow concentrate treatment protocol for knee osteoarthritis.

BackgroundPrior studies describing the treatment of symptomatic knee osteoarthritis with injections of bone marrow concentrate have provided encouraging results. The relationship between the cellular dose contained within the bone marrow concentrate and efficacy of the treatment, however, is unclear. In the present study we describe clinical outcomes for symptomatic knee osteoarthritis in relation to higher and lower cell concentrations contained within a bone marrow concentrate treatment protocol.MethodsData from an ongoing patient registry was culled to identify 373 patients that received bone marrow concentrate injections for the treatment of 424 osteoarthritic knee joints. The clinical scales for these patients were assessed at baseline and then tracked post-procedure at 1, 3, 6 and 12 months, and annually thereafter. Tracked outcomes included the numeric pain scale; a lower extremity functional questionnaire; an International Knee Documentation Committee scale; and a subjective improvement rating scale. Using pain and functional outcome measures, a receiver operating characteristic analysis was used to define an optimal clinical outcome threshold at which bone marrow nucleated cell count could be divided into either a lower or higher cell count group within a treatment protocol.ResultsThe lower and higher cell count groups were defined using a threshold of 4 × 108 cells. There were 224 and 185 knee joints treated in the lower (≤4 × 108) and higher (>4 × 108) cell count groups respectively. Most joints were diagnosed with early stage knee osteoarthritis. Both the lower and higher cell count groups demonstrated significant positive results with the treatment for all of the pain and functional metrics. The higher cell count group reported lower post treatment numeric pain scale values, in comparison with the lower cell count group (1.6 vs. 3.2; P < 0.001). No significant differences were detected for the other metrics, however.ConclusionsImproved function and reduced pain was observed in patients treated with a bone marrow concentrate protocol regardless of cellular dose; however, patients receiving a higher concentration of cells reported a better pain outcome in comparison with the lower dose group. These preliminary findings suggest that cell dose may be an important factor governing clinical outcomes in autologous bone marrow concentrate treatment of knee osteoarthritis. Further studies using a larger patient population may help elucidate these findings.

Resultados clínicos a corto plazo de la sutura meniscal en pacientes asociados a seguros laborales

ObjectiveTo analyze the clinical results of meniscus suture using the all-inside or inside-out technique, in a population associated with occupational safety. MethodA retrospective study conducted on accident patients with reparable vertical meniscus injuries and subjected to a Sequent® all-inside or inside-out meniscus suture. The patients were evaluated using the Lysholm and International Knee Documentation Committee (IKDC) scales. A total of 43 meniscus tears were repaired, with a mean follow-up of 19.86 months after the date of the surgery (range 6 months to 46 months). The mean age at the time of the surgery was 27.1 years (range16 years to 49 years). The internal meniscus was sutured in 12 cases (27.9%), in the lateral meniscus in 27 cases (62.7%), and in both menisci in 4 patients (9.3%). A simultaneous ligamentoplasty procedure was required in 14 patients due to an anterior cruciate ligament (ACL) injury. ResultsThe unsatisfactory postoperative Lysholm and IKDC scores observed in 3 patients were considered as technique failures. The success rate was 93.0%, while the failure rate of the meniscus suture was 7.0%. No superiority of results was obtained in the patients subjected to a simultaneous ligamentoplasty. The mean score on the Lysholm scale increased from 24.81 in the preoperative period to 91.51 (55-100) in the postoperative period, and an increase from 25.66 to 89.94 (45-100) was observed in the mean IKDC score. No complications were observed as regards the surgical technique. ConclusionsThe meniscus suture using the all-inside and inside-out techniques in a group of working patients showed functional improvements with a safe technique with few complications.