International Knee Documentation Research Articles

Poster 239: Advanced Patellofemoral Chondromalacia Does Not Affect Outcomes After Meniscal Root Repair

Objectives: Meniscal root tears have been shown to accelerate cartilage breakdown and increase the risk of total knee arthroplasty (TKA) if left unaddressed. Unfortunately, many patients with meniscal root tears already have associated chondromalacia which can impact surgical outcomes. The presence of advanced chondromalacia in the medial or lateral compartmentsof the knee is a known contraindication to performing meniscal root repair; however, the effect of advanced patellofemoral chondromalacia on meniscal root outcomes is not known. The purpose of this study was to compare the outcomes of meniscal root repair in patients with and without advanced patellofemoral chondromalacia (PFC). Methods: A retrospective review of prospectively collected data of patients undergoing meniscal root repair by a single surgeon was conducted between January 2016 and December 2019. Patients were included if they had undergone an isolated posterior medial or lateral meniscal root repair. The meniscal root repair was performed using a transtibial suture technique. Patients were placed into one of two groups depending on the amount of patellofemoral chondromalacia present at the time of surgery. Patients with Outerbridge grade 0-2 were placed in the Minimal Patellofemoral Chondromalacia (MPFC) Group. Patients with Outerbridge 3-4 changes found the time of surgery were placed in the Patellofemoral Chondromalacia (PFC) Group. Patients with Outerbridge 3-4 changes found in the medial or lateral compartment were excluded from the study. Lysholm Knee Scoring Scale and the International Knee Documentation (IKDC) Subjective Knee Form were collected preoperatively, 6,12 and 24 months after surgery. Clinical outcomes followed included recurrent meniscal tear, conversion to total knee arthroplasty, knee arthrofibrosis requiring manipulation under anesthesia/lysis of adhesions and infection. PASS and MCID were determined using data on meniscal repairs in other literature. Continuous data was compared using two-tailed student-T test while categorical data was compared utilizing chi-square testing. Results: A total of 27 patients made up the PFC group and 54 in the MPFC group. There was no difference between the groups with regards to age, sex, BMI or laterality of the procedure. The PFC group had 26 medial and 1 lateral meniscal root repairs. The MPFC group had 51 medial and 3 lateral repairs. The average Outerbridge score of the patella for the PFC group was 3.2 compared to 1.8 in the MPFC group (p<.001). The Outerbridge score for the trochlea in each group was 3.4 vs. 1.6 for the PFC and MPFC groups respectively (p<.001). No difference was identified between the Outerbridge score for the medial compartment for the PFC and MPFC groups (1.48 vs 1.46 respectively) or the lateral compartments (0.48 vs. 0.61 respectively). Lysholm and IKDC scores rose significantly over the pre- operative value at all time points in the study for both groups. No difference was seen between the two groups for the Lysholm or IKDC scores at any timepoint during study. PASS rates for IKDC between the two groups were similar with 6,12 and 24-month PASS rates being 66.7%, 87.5% and 81.4% respectively for the PFC group and 62.9%, 77.8% and 85.2% for the MPFC group. There was also no difference between the groups with regards to the percentage of patients reaching MCID for IKDC. The PFC group showed the percentage of patients reaching MCID to be 81.5%, 100% and 92.6% at the 6,12, and 24 month time points respectively while the MPFC group showed the percentage of patients reaching MCID to be 75.9%, 88.9% and 94.4% at the 6,12 and 24 month postoperative time points respectively. There was 1 (3.7%) recurrent tear in the PFC group and 3 (5.6%) in the MPFC group (p=.72). One patient (3.7%) in the PFC and none of the MPFC group were converted to TKA by the 2-year follow up (p=.15). Each group had 1 patient develop arthrofibrosis requiring MUA/LOA. There were no infections in the PFC group and one in the MPFC group which was a superficial wound infection that resolved after a course of oral antibiotics. Conclusions: In our series, the presence of advanced patellofemoral chondromalacia did not lead to inferior short-term outcomes in patients undergoing meniscal root repair compared to patients without patellofemoral chondromalacia. IKDC and Lysholm scores were similar between the PFC and MPFC group at all time points while scores for both groups were significantly higher than preoperative levels at all time points. The ability to reach MCID and PASS for IKDC was not significantly different between the two groups. In addition, there was not a significant difference between the two groups in the number of recurrent tears, conversion to total knee arthroplasty or complications identified. Our results show meniscal root repair can be performed in patients with severe patellofemoral chondromalacia with similar results as patients undergoing root repair without severe patellofemoral chondromalacia. Patellofemoral chondromalacia should not be considered a contraindication to meniscal root repair.

Quadriceps Tendon Ruptures in Middle-Aged to Older Patients: A Retrospective Study on the Preoperative MRI Injury Patterns and Mid-Term Patient-Reported Outcome Measures

(1) Quadriceps tendon rupture (QTR) is a rare pathology, usually occurring in elderly patients with comorbidities, requiring surgical therapy. The aim of this study was to analyze rupture patterns and concomitant injuries using preoperative magnetic resonance imaging (MRI) and to evaluate patient-reported outcome measures. (2) In this retrospective cross-sectional study, 113 patients with QTR were screened and rupture patterns/concomitant injuries (n = 33) were analyzed via MRI. Clinical outcome was assessed in 45 patients using the International Knee Documentation (IKDC) and Lysholm score with a mean follow-up of 7.2 (±5.0) years. (3) The evaluation of preoperative MRIs showed multiple ruptures of subtendons in 67% with concomitant knee injuries in 45%. The most common associated pathology detected using MRI was pre-existing tendinosis (31.2%). Surgical refixation demonstrated good results with a mean post-operative IKDC score of 73.1 (±14.1) and mean Lysholm score of 84.2 (±16.1). Patient characteristics and individual radiologic rupture patterns did not significantly affect the clinical outcome of patients. (4) Acute QTRs are complex injuries with common involvement of multiple subtendons. MRI imaging can be useful for achieving an accurate diagnosis as pre-existing tendinosis as well as concomitant injuries are common, and might be useful for providing an individual surgical strategy and improving outcomes.

Autologous Osteochondral Grafts Result in Improved Clinical Outcomes in Patients With Early Knee Osteoarthritis

PurposeTo determine whether autologous osteochondral grafts improve clinical outcomes in early knee osteoarthritis (EKOA) and whether the grafts prevent progression of radiographic joint degeneration.MethodsIn this study, we identified patients older than 40 years with EKOA having no traumatic events, with grade 0, 1, or 2 on the Kellgren-Lawrence (KL) classification and more than grade 3 of cartilage degeneration according to the International Cartilage Repair Society scale. Recipient sites were as follows: 14 patellofemoral (PF3) joint, 18 medial femoral condyle (M1), and 6 lateral femoral condyle (L2). Japanese Orthopedic Association (JOA) score and International Knee Documentation (IKDC) subjective score (SUB) were examined as clinical outcomes.ResultsThe study included 31 knees in 31 patients who underwent autologous osteochondral grafts for EKOA and more than two years follow-up. The sample included 15 men and 16 women. The mean operative age was 56.0 years, and the mean follow-up period was 76 months (range, 24-170 months). In the preoperative period, JOA and SUB were 73.9 and 49.5, respectively. At follow-up, the JOA and SUB scores were 93.7 and 84.5, respectively. The differences were statistically significant. Progression of KL classification occurred in 0% of the PF3 group, 17% of the L2 group, and 33% of the M1 group. The outcomes of the M1 group significantly became worse (P = .0381) than those of the L2 and the PF3 groups, and the PF3 group significantly maintained good clinical outcomes (P = .0334).ConclusionAutologous osteochondral grafts for degenerated cartilage improved clinical outcomes of EKOA even if the recipient had cartilage degeneration, and not trauma. The PF3 group maintained significantly good clinical outcomes, and the M1 group became significantly worse.

The correlation between patient reported outcomes and biomarkers for knee osteoarthritis

Background: Novel non-operative treatment modalities, including injections of genetically engineered chondrocytes (GEC), have been developed to target the inflammatory pathways implicated in knee osteoarthritis (OA). Patient reported outcome measures (PROMs) have been the cornerstone of knee OA diagnostics and are frequently used to quantify treatment efficacy but their subjective nature limits their utility. However, inflammatory biomarkers of knee OA provide quantitative data but are less commonly used to assess the severity and progression of OA. Therefore, the purpose of this study was to correlate PROMs with biomarkers in knee OA. Specifically, we compared International Knee Documentation (IKDC) scores with serum C-terminal telopeptide of type I collagen (sCTX-I), urine C-terminal telopeptide of type II collagen (uCTX-II), and joint space width (JSW) in patients receiving GEC injections or placebo injections for knee OA. Methods: A multi-center, double-blinded, randomized, placebo-controlled study was conducted between November 2013 and August 2015. A total of 163 patients were enrolled and randomized to receive GEC injections or placebo injections in a 1:1 ratio of treatment to control. The PROMs assessed were IKDC scores which evaluated three domains: symptoms, sports and daily activity, and difference in knee function. The biomarkers assessed were sCTX-I, uCTX-II, and JSW. Outcomes were measured at baseline as well as at 6, 9, and 12 months after the injections. Scatter plots were created to graphically represent the correlations. Pearson’s correlation coefficients were utilized to determine associations between IKDC scores and each of the three biomarkers. Results: Significant correlations were identified between PROMs and inflammatory biomarkers of knee OA at 6, 9, and 12 months post-treatment with GEC injections. In the GEC cohort, as IKDC scores improved, improvements in sCTX-I levels were also observed. Correlations between IKDC scores and sCTX-I levels were statistically significant at 9 months (r=−0.42, P Conclusions: Newer treatment options for knee OA target the inflammatory pathways that mediate the destruction of bone and cartilage. Inflammatory biomarkers are an objective alternative to assess the severity and progression of OA. This study found significant correlations between an established PROM (IKDC scores) and inflammatory biomarkers in knee OA (sCTX-I, uCTX-II, and JSW). For newer non-operative treatment modalities, such as GEC injections, inflammatory biomarkers of knee OA should be utilized to evaluate the severity and progression of knee OA.

The correlation between patient reported outcomes and biomarkers for knee osteoarthritis

Background: Novel non-operative treatment modalities, including injections of genetically engineered chondrocytes (GEC), have been developed to target the inflammatory pathways implicated in knee osteoarthritis (OA). Patient reported outcome measures (PROMs) have been the cornerstone of knee OA diagnostics and are frequently used to quantify treatment efficacy but their subjective nature limits their utility. However, inflammatory biomarkers of knee OA provide quantitative data but are less commonly used to assess the severity and progression of OA. Therefore, the purpose of this study was to correlate PROMs with biomarkers in knee OA. Specifically, we compared International Knee Documentation (IKDC) scores with serum C-terminal telopeptide of type I collagen (sCTX-I), urine C-terminal telopeptide of type II collagen (uCTX-II), and joint space width (JSW) in patients receiving GEC injections or placebo injections for knee OA. Methods: A multi-center, double-blinded, randomized, placebo-controlled study was conducted between November 2013 and August 2015. A total of 163 patients were enrolled and randomized to receive GEC injections or placebo injections in a 1:1 ratio of treatment to control. The PROMs assessed were IKDC scores which evaluated three domains: symptoms, sports and daily activity, and difference in knee function. The biomarkers assessed were sCTX-I, uCTX-II, and JSW. Outcomes were measured at baseline as well as at 6, 9, and 12 months after the injections. Scatter plots were created to graphically represent the correlations. Pearson’s correlation coefficients were utilized to determine associations between IKDC scores and each of the three biomarkers. Results: Significant correlations were identified between PROMs and inflammatory biomarkers of knee OA at 6, 9, and 12 months post-treatment with GEC injections. In the GEC cohort, as IKDC scores improved, improvements in sCTX-I levels were also observed. Correlations between IKDC scores and sCTX-I levels were statistically significant at 9 months (r=−0.42, P Conclusions: Newer treatment options for knee OA target the inflammatory pathways that mediate the destruction of bone and cartilage. Inflammatory biomarkers are an objective alternative to assess the severity and progression of OA. This study found significant correlations between an established PROM (IKDC scores) and inflammatory biomarkers in knee OA (sCTX-I, uCTX-II, and JSW). For newer non-operative treatment modalities, such as GEC injections, inflammatory biomarkers of knee OA should be utilized to evaluate the severity and progression of knee OA.

DOES THE USE OF A “HYBRID” GRAFT ALTER GRAFT FAILURE RATES OR OUTCOMES IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? A SYSTEMATIC REVIEW AND META-ANALYSIS

Background The use of hamstring autografts less than 8.0mmin size to reconstruct anterior cruciate ligament (ACL) injuries is associated with a higher risk of graft failure. A hybrid graft consisting of hamstring autograft tendons supplemented by allograft tendon to create a more robust graft has been proposed as an alternative treatment option in patients with small hamstring graft size. Multiple studies have shown inconsistent results for ACL reconstructions with hybrid grafts. This meta-analysis was designed to examine the rates of graft failure and clinical outcome measures for hybrid grafts in primary ACL reconstructions. Methods A search was performed of PubMed, MEDLINE and Google Scholar using the terms “Anterior Cruciate Ligament” OR “ACL” combined with “reconstruction” and “hybrid.” Two authors reviewed the papers, and outcomes were subdivided into autograft and hybrid graft. Chi Square with Yates Correction was used to determine the correlation between failure and type of graft for all patients, as well as for the subanalysis done for patients less than 18 years old and patients greater than 18 years old. Chi Square with Yates Correction and unpaired t-test were used to compare the demographic characteristics of the two groups. Unpaired t-test was used to evaluate for differences in subjective outcome scores. Results A total of 9 studies met the inclusion criteria. Only one study included a comparison of hybrid grafts with autografts and allografts, and as such, the allograft data was excluded from the analysis. Overall a total of 506 patients were treated with autografts with an average age of 26.7 +/- 10.8 years; and a total of 453 patients were treated with hybrid grafts with an average age of 28.33 +/-10.4 years. All patients had minimum follow up of 2 years with average follow up of 38.2 months. There was no significant difference in sex between the two groups (p = 0.07). There were significantly more females in the hybrid group compared to the autograft group (48% versus 42%, respectively p = 0.02). There was no significant difference in failure rates for the autograft or hybrid graft subgroups (p = 0.92). International Knee Documentation (IKDC) scores and Lysholm scores were significantly higher in the autograft group than the hybrid graft group (p = 0.02 and p < 0.01, respectively). There was no significant difference in Tegner Activity scores (p =0.68). On further subgroup analysis, there was no difference in failure rates for autografts vs hybrid grafts with subgroup analysis for both patients under 18 years of age and patients over 18 years of age (p = 0.78 and p = 0.24, respectively). Conclusions Supplementation of hamstring autograft with allograft tissue to form a “hybrid graft” did not alter the graft failure rate. But, the use of hybrid graft was associated with worse subjective outcome scores as measured by IKDC and Lysholm scores. Level of Evidence Level IV (A meta-analysis of Level II, III, and IV studies)

Outcome measures in clinical ACL studies: an analysis of highly cited level I trials.

Clinical research in the area of anterior cruciate ligament (ACL) injury has shown substantial growth during the last decade. This was accompanied by the establishment of a wide range of outcome measures used to address the demands of clinical studies. The aim of this study was to evaluate outcome measures reported byhighly cited level I trials in ACL research and identify factors influencing citation metrics. The database of the Institute for Scientific Information (ISI) was utilized to screen journals under the subject categories "Orthopaedics", "Sports Sciences", "Radiology" and "General medicine" for the 50 most cited level I ACL trials based on predefined inclusion criteria. Metadata, citation metrics and outcome measures were extracted for each article. Frequencies of reported outcome measures were calculated, and a multiple linear regression model applied to identify factors influencing citation metrics. Two independent outcome measures demonstrated an influence on acquisition of citations including: 1-report of the pivot-shift test and 2-inclusion of the Knee Injury and Osteoarthritis Outcome (KOOS) score. Furthermore, highly cited ACL trials frequently reported KT-1000 measures of anterior translation, range of motion (ROM), graft failure, Lysholm, Tegner and subjective International Knee Documentation (IKDC) scores. This analysis reflects on the outcome measures utilized in highly cited level I trials impacting the field of ACL research. It also identifies factors likely to influence acquisition of citations. This is of both clinical and academic relevance when choosing appropriate measures for post-operative outcome evaluationafter ACL surgery. I.

Morbid Obesity Is Associated With Fear of Movement and Lower Quality of Life in Patients With Knee Pain-Related Diagnoses

To compare fear of movement in patients with different body mass index (BMI) values referred for rehabilitative care of the knee and to examine whether this fear contributed to self-reported knee-related function. We hypothesized that fear of movement would be elevated with increasing BMI and that fear would correspond with lower self-report knee-related function and lower quality of life (QOL). Retrospective cross-sectional study. Outpatient therapy clinic affiliated with a tertiary care hospital. Patients with knee pain diagnoses (n = 278) were stratified into 4 BMI groups (in < or =25 kg/m(2) nonobese; 25-29.9 kg/m(2) overweight; 30-39.9 kg/m(2) obese; > or =40 kg/m(2) morbidly obese). The Tampa Scale of Kinesiophobia (TSK; fear of movement), International Knee Documentation (IKDC; knee function), and Short-Form 8 (SF-8; QOL) scores were main outcomes. Pain and straight leg raise test scores also were collected. After review of the medical records, descriptive statistics and nonparametric tests were performed, and TSK, QOL, and SF-8 scores were compared. Hierarchical regression modeling determined the contribution of TSK scores to the variance of IKDC scores. Pain scores were greatest in the nonobese group and lowest in the morbidly obese group (7.5 +/- 2.6 points vs 4.8 +/- 3.1 points; P < .05). TSK scores in morbidly obese patients were greater than in nonobese patients (27.1 +/- 7.7 points vs 22.0 +/- 6.6 points; P = .002). The SF-8 mental-physical subscores were 27% to 32% lower in the morbidly obese than nonobese patients (both P < .0001). IKDC scores were lower in the morbidly obese than nonobese patients (32.1 +/- 19.2 points vs 50.9 +/- 23.8 points; P = .0001). Pain severity and TSK scores contributed 28.6% and 7.1% to the variance of the IKDC scores (overall R(2) = 68.6). Morbid obesity is associated with elevated fear of movement. Pain was the strongest predictor of IKDC scores, and fear of movement enhanced this predictive value of the regression model. Despite lower absolute pain severity in the morbidly obese group, this fear may influence IKDC scores in this population. Morbidly obese patients might benefit from rehabilitation activities that reduce fear of movement to optimize participation in rehabilitation activity.

The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries.

The MOS 36-item short-form health survey is a generic, patient-based health assessment tool. It has been used to assess functional outcome for many medical conditions, both acute and chronic. The use of this survey in evaluating the effects of treatment of any specific disease or injury allows comparison of treatments across a broad spectrum of disease categories. The purpose of this study was to see if this assessment tool could 1) be used to identify those patients requiring anterior cruciate ligament reconstruction, 2) detect changes in the patients with treatment over time, and 3) correlate with the commonly used knee assessment scales. The short-form health survey could not identify those patients requiring anterior cruciate ligament reconstructive surgery. However, it did show important and significant changes with treatment (surgical and nonsurgical) over time. There was a significant correlation between the short-form health survey and the Lysholm and International Knee Documentation Committee scores during this study. The addition of the MOS 36-item short-form health survey to our traditional knee ligament evaluation tools is encouraged. Its use will permit the orthopaedic community to demonstrate the value of our treatment of anterior cruciate ligament injuries to health care planners and generalist physicians.

Assessing the limits of knee motion

Ten patients were examined clinically by 11 experienced knee surgeons and with three measurement devices (Genucom, Knee Signature System, and KT-1000). Nine of the 10 patients examined had sustained documented intraarticular ligament disruptions including eight ACL disruptions and five posterior cruciate ligament disruptions. The eight patients with ACL injuries had undergone reconstructive surgery. The clinical examination test sequence was performed as described by the International Knee Documentation Committee. Testing results were reported as estimated degrees of angulation or millimeters of displacement. Testing results were divided into two groups based on the index minus nonindex knee difference. Eighteen displacement tests were performed on each knee by each examiner. The index minus nonindex knee difference was greater than 3 mm in 16% of the tests. Only 1 of the 198 displacement tests performed on the subject who did not have a ligament disruption was recorded as an index minus nonindex difference greater than 3 mm. There was appreciable difference between measurements recorded by different examiners, particularly anterior/posterior measurements in patients who had sustained combined anterior and posterior cruciate ligament injuries. There is a need to rigorously evaluate limits of motion tests that are used to develop treatment plans and report the results of ligament surgery.