International Knee Documentation Committee Subjective Knee Form Research Articles

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction.

Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR). Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated. Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.). Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care. Level II.

Responsiveness and Minimal Clinically Important Difference of the Thai Version of the International Knee Documentation Committee Subjective Knee Form in Patients With Anterior Cruciate Ligament Injury.

The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) is a knee-specific patient-reported outcome (PRO) measure that is commonly used to evaluate patients with various knee disorders. The Thai version of the IKDC-SKF (Thai IKDC-SKF) was shown to have good validity and reliability; nonetheless, no data regarding its responsiveness are available. To evaluate the responsiveness of the Thai IKDC-SKF for assessing patients with anterior cruciate ligament (ACL) injury and determine the minimal clinically important difference (MCID) for this PRO measure. Cohort study (diagnosis); Level of evidence, 3. This prospective study included ACL-injured patients who were scheduled for ACL reconstruction (ACLR) at a single institution. The patients completed the Thai IKDC-SKF at the baseline and the 6-month postoperative follow-up. The global rating of change scale was an anchor question that evaluated patients' overall perception of a clinical change compared with their preoperative condition. The effect size and standardized response mean were calculated. The MCID was identified with an anchor-based approach by plotting a receiver operating characteristic curve and calculating the value that maximized the Youden index. Of 59 enrolled patients, 53 patients (89.8%) completed the preoperative and 6-month postoperative Thai IKDC-SKF. The mean (±SD) age of the participants was 32.3 ± 10.3 years, and 86.8% were men. The mean Thai IKDC-SKF score improved significantly from preoperatively to the 6-month follow-up (from 56.3 ± 14.9 to 70.8 ± 14.1, respectively; P < .001), with an effect size of 0.975 and a standardized response mean of 0.977. A receiver operating characteristic curve was generated to determine the ability of the Thai IKDC-SKF to distinguish between improved patients and unimproved patients, and the area under the curve was 0.80 (95% CI, 0.68-0.92), which was considered excellent. The MCID was 15.5, which yielded a sensitivity and specificity of 0.55 and 1, respectively. This study confirmed the responsiveness of the Thai IKDC-SKF for detecting a clinical change in ACL-injured patients after ACLR. The identified MCID of 15.5 can be used to calculate the significant clinical change and sample size in future studies.

Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group

Background: While various techniques have been described to augment the anterolateral side of the knee, such as lateral extra-articular tenodesis and anterolateral ligament (ALL) reconstruction (ALLR), it is unclear how they affect clinical outcomes. The aim of this study was to compare the results of 2 ALLR techniques for combined anterior cruciate ligament (ACL)/ALL reconstruction. Hypothesis: The graft rupture rate, complications, and patient-reported outcomes are similar between a reconstruction technique using a continuous gracilis graft (CG) and single femoral tunnel for ACL/ALL reconstruction, and one using a separate gracilis graft (SG) and independent femoral tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of data collected prospectively at 2 hospitals was conducted: one in which a CG is preferred when performing combined ACL/ALL reconstruction and the other in which an SG is preferred. The medical records at these 2 hospitals were searched to identify ACL-deficient patients who had undergone ACL/ALL reconstruction between 2015 and 2020. Eligible patients were between 18 and 60 years of age, had the reconstruction surgery done within 24 months of the injury, and had ≥2 years of follow-up. The eligible patients were contacted to gather outcomes, or their outcomes were collected in person during their last follow-up visit. Outcomes evaluated included graft rupture rate, complication rate, and Lysholm and International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores. Preoperative and intraoperative data were also evaluated. Results: A total of 237 patients were available for analysis in the GC group and 178 in the SG group with a mean follow-up of 3 years (CG: SD, 9.6 months; SG: SD, 8.1 months). The authors found a low rate of graft rupture (CG: 3.4%; SG: 2.8%; P = .785) and no difference between techniques. The complication rate was 6% in the CG group, while it was 10% in the SG group (P = .112). The mean value of the IKDC-SKF was similar between techniques (CG: 88.1; SG: 87.9; P = .267), and the mean Lysholm score was excellent in both sets of patients (CG: 90.0; SG: 92.4; P < .001). Conclusion: This study found little to no difference in the graft rupture rate, complication rate, and functional knee scores when using a CG or SG for ALLR during combined ACL/ALL reconstruction. Both techniques are equivalent and can be used for an anterolateral augmentation procedure in combination with ACL reconstruction.

Patient-reported Outcomes and Muscle Strength after a Physiotherapy-led Exercise and Support Brace Intervention in Patients with Acute Injury of the Posterior Cruciate Ligament: A Two-year Follow-up Study.

While outcomes of posterior cruciate ligament (PCL) injuries treated surgically are well described, prospective studies reporting outcomes of exercise interventions are lacking. The purpose of this study was to investigate changes in patient-reported outcomes of a physiotherapy-led exercise and support brace intervention in patients with acute injury of the PCL over a two-year follow-up period. Furthermore, this study sought to investigate changes in isometric knee muscle strength over an eight-month follow-up period, and finally to report conversion to surgical reconstruction over a two-year follow-up period. Case series study, prospective. Fifty patients with an acute injury of the PCL were treated with a brace and a physiotherapy-led exercise intervention and followed prospectively. Changes in patient-reported outcomes were measured with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS) from baseline (diagnosis) to two-year follow-up. Furthermore, changes in isometric knee flexion and extension strength were measured with a static strength dynamometer from 16 weeks after diagnosis to one-year follow-up. Conversion to surgery was prospectively extracted from medical records. Mean changes were analyzed with a mixed effects model with time as a fixed factor. The IKDC-SKF score improved 28 (95%CI 24-33) IKDC points from baseline to two-year follow-up. Isometric knee flexion strength of the injured knee increased 0.18 (95%CI 0.11-0.25) Nm/kg from 16 weeks after diagnosis to one-year follow-up, corresponding to an increase of 16%. In contrast, isometric knee extension strength of the injured knee did not change (0.12 (95%CI 0.00-0.24) Nm/kg, p=0.042). Over two years, seven patients converted to PCL surgical reconstruction. One and two-year follow-up were completed by 46 and 31 patients, respectively. The physiotherapy-led exercise and support brace intervention demonstrated clinically relevant improvements in patient-reported outcomes and knee flexion strength, and the risk of PCL surgical reconstruction was considered low within the first two years. 3b©The Author(s).

Rasch Calibration of the International Knee Documentation Committee Subjective Knee Form.

Among numerous knee-related patient-reported outcome measures, the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) has been used across a wide variety of knee pathologies. However, traditional validation procedures (classical test theory) and existing studies (estimating item parameters) have limitations in establishing the measurement properties of the IKDC-SKF. Rasch analysis reveals a strong validation approach to improve IKDC-SKF clinical interpretation with larger samples. To assess psychometric properties, including differential item functioning, of the IKDC-SKF as a patient-reported measure of knee function. Cross-sectional study. Secondary data. Data were extracted from the cloud-based orthopedic and sports medicine global registry Surgical Outcome System (Arthrex). A total of 1725 individuals who underwent an arthroscopic knee procedure and completed all items on the IKDC-SKF. Rasch analysis including model-data fit, rating scale's function, item-person map (distribution of item difficulty and person ability), and differential item functioning (sex and age groups) was used to evaluate the psychometric properties of the IKDC-SKF. Ten misfit items were found and removed. The 5-point Likert scale of the 9-item IKDC-SKF worked well. Item difficulty ranged from 0.58 to 0.81 logits, and person's knee function had ranged from -5.56 to 4.86 logits, with a wide distribution. The IKDC-SKF was found to function similarly for sex (male vs female) and age. Rasch analysis identified a unidimensional structure retaining 9 of the original IKDC-SKF items; however, a more comprehensive inventory is necessary to assess a wider range of knee function and improve measurement validity.

Untreated Injuries to the Anterolateral Capsular Structures Do Not Affect Outcomes and Kinematics after Anatomic Anterior Cruciate Ligament Reconstruction.

Injuries to the anterolateral complex (ALC) may contribute to increased rotatory knee laxity. However, it has not been evaluated whether such injuries affect in vivo kinematics when treated in situ. The purpose of this study was to determine the grade of ALC injury and its effect on kinematic and clinical outcomes of ACL-injured patients 24 months after anatomic ACL reconstruction. It was hypothesized that injury to the ALC would be significantly related to patient-reported outcomes (PROs) and in vivo knee kinematics during downhill running. Thirty-five subjects (mean age: 22.8 ± 8.5 years) participating in a randomized clinical trial to compare single- and double-bundle ACL reconstruction were included in the study. Subjects were divided into two groups based on the presence or absence of injury to the ALC, as determined on MRI scans performed within 6 weeks of injury. None of the patients underwent treatment for these ALC injuries. At 24 months, PROs, including the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS) and in vivo knee kinematics during downhill running, were obtained. Pivot-shift test results, PROs and in vivo knee kinematics were compared between groups with and without ALC injury using the Pearson's Chi Squared test and Mann-Whitney U test with significance set at p < 0.05. The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (49%) study participants. No significant differences were detected in PROs and in vivo kinematics between subjects with and without ALC injury (n.s.). The findings of this study demonstrate that MRI evidence of an ALC injury does not significantly affect in vivo knee kinematics and PROs even in individuals with a high-grade ALC injury. Injuries to the ALC as observed on MRI might not be a useful indication for an anterolateral procedure.

Long-term Quality of Life in Patients After ACL Reconstruction With Concomitant Meniscal Injury Treatment: Patient-Reported Outcomes at Minimum 10-Year Follow-up

Background: Long-term studies of patients after anterior cruciate ligament (ACL) reconstruction with or without concomitant meniscal tear treatment are limited. Purposes: To (1) report postoperative outcomes after anatomic ACL reconstruction with a hamstring autograft, (2) investigate how concomitant treatment of meniscal injury could affect these outcomes, and (3) evaluate the association between quality of life and activity levels at a minimum 10-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients treated with a unilateral, anatomic ACL reconstruction between 2005 and 2011 were investigated. The following patient-reported outcome measures (PROMs) were reported for the overall sample as well as a subsample of patients with meniscal injury: International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee score, Tegner activity scale, 5-level EQ-5D (EQ-5D-5L), and patient satisfaction. Sex, age, body mass index (BMI), and meniscal injury treatment (meniscectomy vs meniscal repair) were examined as patient-specific risk factors regarding long-term activity and quality of life. Results: Overall, 106 patients, 90 men (85%) and 16 women (15%), were enrolled in the study, with a mean follow-up of 13.2 years. The ACL retear rate was 2.8%. The mean scores were 80.6 ± 16.7 (IKDC-SKF), 87.4 ± 15.0 (KOOS), 90.5 ± 11.5 (Lysholm), 5.6 ± 1.9 (Tegner), and 91.8 ± 14.5 (EQ-5D-5L). The majority (90.6%) of patients considered their knee state satisfactory during follow-up. When compared with patients who underwent meniscal repair, patients who underwent meniscectomy had statistically significantly lower scores on all PROMs except for the Tegner and EQ-5D-5L ( P &lt; .05 for all). The mean difference between the 2 groups was ≥7 points on all PROM scores. Patient sex, age, and BMI did not affect PROM scores. There was a statistically significant, strong positive correlation between quality of life and activity. Conclusion: Patients had few or no symptoms and considered their knee state satisfactory 13.2 years after anatomic ACL reconstruction. Patients with concomitant meniscal tears having undergone meniscal repair had improved PROMs compared with those treated with meniscectomy. Finally, participation in activities of daily living and sports was interrelated with quality of life and was not affected by patient age, sex, or BMI.

Return to Sport After Multiligament Knee Injury in Young Athletes.

While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI). To assess the level of and factors associated with RTS after MLKI in young athletes. Case series; Level of evidence, 4. We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL-Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries. A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels. Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.

Improved Outcomes After Reinforced Radial Meniscus Repair Augmented With Bone Marrow Aspirate Concentrate

To assess clinical outcomes of patients who have undergone surgical repair of radial meniscal tears with reinforced suture bar (rebar) technique augmented with bone marrow aspirate concentrate. This is a retrospective study of a single fellowship-trained sports medicine surgeon's experience on all patients who underwent a reinforced repair (rebar) of a radial meniscus tear from November 2016 to 2018, with a minimum of 12-month follow-up. Lysholm scores, IKDC (International Knee Documentation Committee) Subjective Knee Form scores, and Tegner scalewere collected postoperatively at periods for at least 1 year and retrospectively studied. Patients were followed for an average of 36.3 ± 25.0 months [range: 12.0-69.0 months]. Pain scores improved from 6.1 ± 2.1 to 0.4 ± 1.4 at 1 year (P < .001). IKDC Subjective Knee Form scores improved from 63 ± 26 to 90 ± 13 (P= .021). Lysholm scores improved from 64 ± 28 to 94 ± 9 (P= .025). Based on a calculated minimal clinical important difference (MCID) of 1.5, 100% of patients had improvement above the MCID. In addition, 88% of patients had a 1-year IKDC Subjective Knee Form score above the patient acceptable symptomatic state. Preoperative Tegner activity scale improved from 3 ± 1.5 to 8 ± 2.6 (P= .007). Patients returned to their preinjury activity with little difference in the Tegner activity scale when we compared preinjury and 1-year postoperative (8.1 ± 1.3 vs 8.0 ± 2.6 respectively, P= .317). The rebar repair technique for radial meniscus tears, with bone marrow aspirate concentrate augmentation, showed improved outcomes in both pain and function at minimum follow-up of 12 months. Patients were able to return to a high preinjury activity level by 1 year, and 100% of patients had improvement above the MCID and 88% met patient acceptable symptomatic state. Level IV, therapeutic case series.

Remnant Preservation of the Primary Vertical Graft in Revision Anterior Cruciate Ligament Reconstruction.

The remnant preservation of a primary vertical graft in revision anterior cruciate ligament reconstruction (ACLR) can benefit anteroposterior stability. However, studies that address this concept are rare. To evaluate clinical outcomes of remnant preservation of primary vertical graft in revision ACLR. Cohort study; Level of evidence, 3. A total of 74 patients with revision ACLR were included in this retrospective study. Remnant preservation revision ACLR was performed only in patients with primary vertical grafts. The patients were divided into 2 groups according to whether the primary remnant vertical graft was preserved (remnant group; n = 48) or absent or sacrificed (no-remnant group; n = 26). The remnant group was further divided according to the degree of remnant tissue: sufficiently preserved subgroup (graft coverage, ≥50%; n = 25) and insufficiently preserved subgroup (graft coverage, <50%; n = 23). Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective form, Lysholm score, Tegner activity scale, manual laxity tests, and side-to-side difference in anterior tibial translation on Telos stress radiographs. The mean time to final follow-up was 40.7 ± 16.8 months. The remnant group showed more improved results in the postoperative Lachman test and Telos side-to-side difference than did the no-remnant group (P = .017 and .016, respectively). The post hoc test revealed that the side-to-side difference in laxity in the sufficiently preserved subgroup significantly outperformed that in the no-remnant group (P = .001), although no significant difference existed between the insufficiently preserved and no-remnant subgroups (P = .850). The postoperative IKDC subjective form, Lysholm score, and Tegner activity scale did not show significant differences between the 2 groups (P = .480, .277, and .883, respectively). The remnant preservation of the primary vertical graft in revision ACLR may result in better anteroposterior stability. However, subjective outcomes in the remnant group did not exceed that of the no-remnant group. The subgroup analysis revealed that only sufficiently preserved remnants demonstrated better anteroposterior stability.

Validity and Reliability of the Thai Versions of the Lysholm Knee Scoring Scale and Tegner Activity Scale.

Functional or quality of life questionnaires are important tools in clinical investigations. The Lysholm Knee Scoring Scale and Tegner Activity Scale are knee-specific questionnaires that are widely used to assess knee function. To translate both questionnaires into Thai and to assess the validity and reliability of the Thai versions of the Lysholm and adjusted Tegner scales. Cohort study (diagnosis); Level of evidence, 3. The Lysholm and Tegner scales were translated into Thai by using the forward-backward translation protocol. Because cultural modifications were made to the sports used to measure activity on the Tegner scale, the authors of this study refer to the Thai version as the "Thai adjusted Tegner scale." The reliability and validity of the translated scales were evaluated by obtaining the responses of 60 consecutive patients (mean age, 40.5 years; 34 male, 26 female); the patients also completed the Thai version of the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Criterion validity was tested by correlating the scores from both translated questionnaires with those from the Thai IKDC-SKF, while reliability was assessed by measuring test-retest reliability and internal consistency. The Thai Lysholm scale showed a strong correlation with the Thai IKDC-SKF (r = 0.89), while the Thai adjusted Tegner scale showed a moderate correlation with the Thai IKDC-SKF (r = 0.60). The intrarater and test-retest reliability measures were excellent for the Thai Lysholm (intraclass correlation coefficient [ICC], 0.94 and 0.98, respectively) and moderate to good for the Thai adjusted Tegner (ICC, 0.73 and 0.86, respectively). The internal consistency for the Thai Lysholm was acceptable at all the time points (Cronbach alpha, 0.71-0.73). The Thai Lysholm and Thai adjusted Tegner scales adequately retained the characteristics of the original versions. They can be considered reliable instruments for Thai patients with knee-related problems.

Changes in subjective knee function and psychological status from preoperation to 6 months post anterior cruciate ligament reconstruction

PurposeTo determine characteristic changes in subjective knee function, kinesiophobia, and psychological readiness to return to sports between scores taken before anterior cruciate ligament reconstruction (ACLR) and those taken 6 months post-ACLR.MethodsThirty-two participants (median age, 20.0 years) were included. Subjective knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). The Tampa Scale for Kinesiophobia (TSK-11) and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale were used to evaluate kinesiophobia and psychological readiness to return to sport, respectively. Questionnaires were administered 1 day before surgery and at 6 months post-ACLR. A positive change was defined as an increase in IKDC-SKF and ACL-RSI scores and a decrease in TSK-11 score. The change in each score from pre-ACLR to 6 months post-ACLR was analyzed using a paired t-test. The percentage change in scores was calculated, and the correlations of the percentage change in the TSK-11 and ACL-RSI scores and that in the IKDC-SKF score were analyzed.ResultsAll scores differed significantly positively from pre-ACLR to 6 months post-ACLR. The proportion of participants whose scores did not change positively from pre-ACLR to 6 months post-ACLR was higher for the TSK-11 (38.0%) and ACL-RSI (38.0%) than for the IKDC-SKF (6.3%). No correlation was observed between the percentage change in the IKDC-SKF score and that in the TSK-11 or ACL-RSI scores from pre-ACLR to 6 months post-ACLR.ConclusionsChanges in subjective knee function and psychological status from pre-ACLR and 6 months post-ACLR may not be interdependent.

Bilateral changes in knee joint laxity during the first year after non-surgically treated anterior cruciate ligament injury

ObjectivesAnalyse changes in knee laxity between 3, 6, 12 and 24 months after non-surgically treated ACL injury and to analyse associations between knee laxity and knee function, self-reported knee stability, ACL-Return to Sport after Injury (ACL-RSI), fear and confidence at different timepoints during recovery. DesignProspective cohort study. Participants125 patients (67 males, mean age 25.0 ± 7.0 years) with acute ACL injury. Main outcomeLaxity was measured using KT-1000 arthrometer. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Confidence and fear were assessed with questions from the ACL-RSI scale. Subjectively knee stability was assessed using SANE. ResultsKnee laxity increased bilaterally from 3 to 12 months, and in the non-involved knee from 3 to 24 months (p˂0.05), although mean change was below 1 mm. Side-to-side difference in knee laxity was correlated with IKDC-SKF (r = −0.283) and knee stability in rehabilitation/sport activities (r = −0.315) at 6 months, but not with confidence/fear. ConclusionKnee laxity increased bilaterally during the first year after non-surgically treated ACL injury, though, the mean change in knee laxity was below 1 mm and the clinical significance is unknown. Knee laxity was weakly associated with knee function and perceived knee stability. Level of evidenceLevel II Trial registrationNCT02931084

Translation, cross-cultural adaptation and reliability of the International Knee Documentation Committee (IKDC) subjective knee form and the tampa scale for kinesiophobia (TSK) into Hebrew.

The International Knee Documentation Committee-Subjective Form (IKDC-SF) is one of the most used measures for evaluating the quality of life among people experiencing knee pain but is not yet available in Hebrew. Similarly, the Tampa Scale for Kinesiophobia (TSK), used to evaluate fear of movement, is not available in Hebrew. This study aimed to determine the reliability and construct validity of the Hebrew IKDC-SF and TSK among people experiencing chronic knee pain. Translation and cultural adaptation of the IKDC-SF and TSK questionnaires, followed by test-retest reliability within a two-week interval. We report on internal consistency, construct validity, and the psychometric properties of both questionnaires. Both questionnaires showed high internal consistency (Cronbach's α = 0.85 and 0.89, respectively) and test-retest reliability, expressed by the Intra-Class Correlation Coefficient (ICC = 0.89 and 0.80 respectively). The standard error of measurement, group smallest real difference and minimal detectable change for the IKDC-SF were 4.66, 9.13, and 12.91 points, and 3.64, 7.13, and 10.08 points for the TSK, respectively. We demonstrated that the Hebrew version of the IKDC-SF and TSK is reliable and valid for assessing QoL, function, and kinesiophobia among people experiencing chronic knee pain.

Four Distinct 5-Year Trajectories of Knee Function Emerge in Patients Who Followed the Delaware-Oslo ACL Cohort Treatment Algorithm

Background: Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist. Purpose: (1) To identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation. Study Design: Cohort study; Level of evidence, 3. Methods: We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (<6 months after the 5-week program), 11% delayed ACLR (>6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation. Results: Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory. Conclusion: We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories’ validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

Cutoff Value for the Patient Acceptable Symptom State of the Thai IKDC Subjective Knee Form in Patients After Primary ACL Reconstruction.

Background:The Patient Acceptable Symptom State (PASS) cutoff is the value on a patient-reported outcome measure beyond which patients consider themselves to be “feeling well.” There are limited data regarding the PASS threshold for non-English versions of the International Knee Documentation Committee–Subjective Knee Form (IKDC-SKF).Purpose:To establish the PASS cutoff for the Thai version of the IKDC-SKF for patients undergoing primary anterior cruciate ligament reconstruction (ACLR) and to identify factors to achieve PASS after surgery.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Included in this study were patients aged 18 to 50 years who had undergone primary unilateral ACLR between January 2016 and February 2020. After enrollment, patients completed the Thai IKDC-SKF and answered the anchor question for determining the PASS.Results:Questionnaires were sent to 321 patients, of whom 173 (53.9%) responded. The vast majority (156 patients; 90.2%) considered themselves to have achieved the PASS. This group of patients had significantly higher IKDC scores than did those who did not have an acceptable symptom state (79.6 ± 14.2 vs 60.7 ± 16.5; P < .001). The receiver operating characteristic curve of the IKDC score for predicting the PASS had an area under the curve of 0.82 (95% CI, 0.72-0.91). The optimum PASS cutoff of the Thai IKDC-SKF was a score of 74.2 (sensitivity, 0.72; specificity, 0.82). Factors that provided favorable odds for achieving the PASS were the use of a hamstring tendon autograft (odds ratio, 4.1; 95% CI, 1.5-20.6) and the absence of a patellofemoral chondral lesion (odds ratio, 3.8; 95% CI, 1.03-14.1).Conclusion:For patients undergoing ACLR, the cutoff for the PASS of the Thai version of the IKDC-SKF was a score of 74.2. Two surgery-related factors provided favorable odds for achieving the PASS: the use of a hamstring tendon autograft and the absence of a patellofemoral chondral lesion.

Choice of Patient-Reported Outcome Measures for Midterm Assessment After Anterior Cruciate Ligament Reconstruction Surgery

Background: Patient-reported outcome measures (PROMs) have become increasingly popular for assessing subjective elements of a patient's condition. Two frequently used knee-related PROMs after anterior cruciate ligament reconstruction (ACLR) surgery are the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS). However, completing the full versions of both measures represents a considerable responder burden. Purpose: To compare a variety of KOOS short forms with each other as well as the IKDC-SKF in a large sample of ACLR patients between 2 and 6 years after surgery. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: The KOOS and IKDC-SKF were administered between 2 and 6 years (mean, 3 years) after ACLR surgery to a cohort of 832 patients (men, n = 489; women, n = 343). Two single-item assessment numerical evaluations were also completed for knee function and satisfaction. The following short form versions were calculated from the full KOOS: the KOOS-12 short form, KOOS–Physical Function Short form (KOOS-PS), KOOS–Joint Replacement Short form (KOOS-JR), and KOOS–Global. Descriptive statistics were calculated for all PROMs and associations between measures were explored using nonparametric (Spearman rho) correlations. Floor or ceiling effects were considered present if >15% of patients reported the worst (floor effect) or best (ceiling effect) possible score. Age and sex comparisons were also made for each PROM. Results: Ceiling effects were present for all KOOS short form versions. They were highly evident for the KOOS-JR and KOOS-PS (37%-44%), but they were only marginally above the threshold for the KOOS-12 and KOOS–Global (16%). The KOOS-12 and KOOS–Global had the highest correlation with the IKDC-SKF but only explained 58% to 59% of the variance in scores. The KOOS-12 and KOOS–Global were very highly correlated (ρ = 0.98). Only moderate correlations were seen between the single-item assessments and the IKDC-SKF or various KOOS short forms. There was a negligible association between patient age and PROM scores, but there was no significant sex difference for any of the PROMs. Conclusion: The IKDC-SKF together with either the KOOS–Global or KOOS-12 may provide a comprehensive range of knee-related PROMs with minimized responder burden at 2 to 6 years after ACLR.

Creating Crosswalks for Knee Outcomes After ACL Reconstruction Between the KOOS and the IKDC-SKF.

Anterior cruciate ligament (ACL) registries do not all use the same patient-reported outcome measures, limiting comparisons and preventing pooling of data for meta-analysis. Our objective was to create a statistical crosswalk to convert cohort and registry mean Knee Injury and Osteoarthritis Outcome Scores (KOOS) to International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores and vice versa to allow these comparisons. Data from 3 ACL registries were pooled (n = 14,412) and were separated into a training data set (70% of the sample) or a validation data set (30% of the sample). The KOOS and the IKDC-SKF scores were available prior to the operation and at 1, 2, and 5 or 6 years postoperatively. We used equipercentile equating methods to create crosswalks in the training data set and examined accuracy in the validation data set as well as bootstrapping analyses to assess the impact of sample size on accuracy. Preliminary analyses suggested that crosswalks could be attempted: large correlations between scores on the 2 measures (r = 0.84 to 0.94), unidimensionality of scores, and subpopulation invariance were deemed sufficient. When comparing actual scores with crosswalked scores in the validation data set, negligible bias was observed at the group level; however, individual score deviations were variable. The crosswalks are successful for the group level only. Our crosswalks successfully convert between the KOOS and the IKDC-SKF scores to allow for a group-level comparison of registry and other cohort data. These crosswalks allow comparisons among different national ligament registries as well as other research cohorts and studies; they also allow data from different patient-reported outcome measures to be pooled for meta-analysis. These crosswalks have great potential to improve our understanding of recovery after ACL reconstruction and aid in our ongoing efforts to improve outcomes and patient satisfaction, as well as to allow the continued analysis of historical data.

Translation, Cross-Cultural Adaptation, Validity, and Reliability of the Indonesian Version of the IKDC Subjective Knee Form.

Background:No questionnaire is currently available for use in patients with anterior cruciate ligament (ACL) injuries in an Indonesian population. The most-used questionnaire in clinical research for these patients is the International Knee Documentation Committee (IKDC) Subjective Knee Form, as its psychometric properties are considered to be excellent.Purpose:To translate the IKDC into Indonesian and assess its validity for use in Indonesian-speaking patients with ACL injuries.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:After a forward-and-backward translation procedure and cross-cultural adaptation, the validity and reliability of the questionnaire were investigated. The responses of ACL injury patients on 3 questionnaires, the Indonesian-IKDC (I-IKDC), 36-Item Short Form Health Survey, and Kujala Anterior Knee Pain Scale, were compared. Following consensus-based standards for the selection of health measurement instruments guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement error were determined. The Bland-Altman method was used to explore absolute agreement.Results:Of 253 ACL injury patients, 106 (42%) responded to the invitation. Construct validity was considered good, as all predefined hypotheses on correlations between the I-IKDC and other scores were confirmed. Reliability proved excellent, with a high test-retest correlation (intraclass correlation coefficient = 0.99). Bland-Altman analyses showed no systematic bias between test and retest. Internal consistency was good (Cronbach α = .90). There were no floor or ceiling effects. Standard error of measurement was 2.1, and the minimal detectable change was 5.8 at the individual level and 0.7 at the group level.Conclusion:The I-IKDC, as developed, appeared to be a good evaluation instrument for Indonesian patients with ACL injuries.

Femoral Nerve Blockade Does Not Lead to Subjective Functional Deficits After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) ranks among the most common surgeries performed in civilian as well as military orthopedic settings. Regional anesthesia, and the femoral nerve block (FNB) in particular, has demonstrated efficacy in reducing postoperative pain and opioid use after ACLR, however concerns linger about possible impaired functional outcomes. The purpose of the current investigation was to assess International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores at 6 to 12 months after ACLR in patients who did (FNB) and did not (NoFNB) receive a perioperative FNB. All patients undergoing unilateral ACLR in the study period were reviewed in this institutional process improvement analysis. The primary outcome was prospectively collected IKDC-SKF scores obtained at 6-12 months post-surgery. Demographic and surgical information collected as potential covariates included age, sex, body mass index (BMI), preoperative IKDC-SKF score, use of an FNB, use of another (not femoral nerve) block, American Society of Anesthesiologists (ASA) score, graft type (auto vs. allograft), concomitant meniscus or cartilage procedures, tobacco use, tourniquet time, and primary vs. revision surgery. Assuming a 1:2 ratio of patients who did not vs. did receive FNBs and a clinically meaningful difference of 7 points on the IKDC-SKF, 112 patients were required for 80% power. A regression model averaging approach examined the relationships between covariates and postoperative IKDC-SKF scores. One hundred nineteen patients met inclusion criteria (FNB 79 and NoFNB 40). The cohorts were significantly different in several factors including BMI, ASA level, graft type, and other peripheral nerve blocks, which were controlled for through regression modeling. Regressions with model averaging examined the relationship between treatment groups and postoperative IKDC-SKF scores, along with other potential predictor variables. Estimated adjusted marginal differences in postoperative IKDC-SKF scores from the best-fitting model revealed a very small 0.66-point mean (P = .86) difference between NoFNB and FNB groups that was not statistically significant. Those who reported tobacco use had a 10.51 point (P = .008) lower mean postoperative IKDC-SKF score than those who did not report tobacco use. Every 1-point increase in the preoperative IKDC-SKF score was associated with a 0.28-point (P = .02) increase in the postsurgical IKDC-SKF score. Active tobacco use may negatively impact short-term subjective patient-reported outcomes after ACLR, as reported by the IKDC-SKF. Lower preoperative scores are also associated with significantly lower postoperative IKDC-SKF scores while the use of a FNB was not associated with lower postoperative scores. The negative association between tobacco use and patient-reported functional outcomes after ACLR lends further support to tobacco cessation programs within the military.