Knee Injury And Osteoarthritis Outcome Score Quality Of Life Research Articles

Outcomes of Particulated Juvenile Articular Cartilage and Association With Defect Fill in Patients With Full-Thickness Patellar Chondral Lesions

Background: Cartilage restoration procedures for patellar cartilage defects have produced inconsistent results, and optimal management remains controversial. Particulated juvenile articular cartilage (PJAC) allograft tissue is an increasingly utilized treatment option for chondral defects, with previous studies demonstrating favorable short-term outcomes for patellar chondral defects. Purpose: To identify whether there is an association between defect fill on magnetic resonance imaging (MRI) with functional outcomes in patients with full-thickness patellar cartilage lesions treated with PJAC. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of prospectively collected data was conducted on patients treated with PJAC for a full-thickness symptomatic patellar cartilage lesion between March 2014 and August 2019. MRI was performed for all patients at 6, 12, and 24 months postoperatively. Patient-reported outcome measures (PROMs) were obtained preoperatively and at 1, 2, and >2 years postoperatively. Clinical outcome scores—including the International Knee Documentation Committee (IKDC) score, the Kujala, the Knee injury and Osteoarthritis Outcome Score–Physical Function Short Form (KOOS-PS), the Knee Injury and Osteoarthritis Outcome Score–Quality of Life (KOOS-QoL), and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS)—were analyzed and evaluated for a relationship with tissue fill on MRI. Results: A total of 70 knees in 65 patients (mean age, 26.6 ± 8.1 years) were identified, of which 68 knees (97%) underwent a concomitant patellar stabilization or offloading procedure. Significant improvements were observed on all postoperative PROM scores at the 1-, 2-, and >2-year follow-up except for the Pedi-FABS, which showed no significant difference from baseline. From baseline to the 2-year follow-up, the KOOS-QoL improved from 24.7 to 62.1, the IKDC improved from 41.1 to 73.5, the KOOS-PS improved from 35.6 to 15, and the Kujala improved from 52 to 86.3. Imaging demonstrated no difference in the rate of cartilage defect fill between the 3-month (66%), 6-month (72%), 1-year (74%), and ≥2-year (69%) follow-ups. No association was observed between PROM scores and the percent fill of cartilage defect on MRI at the 1- and 2-year follow-up. Conclusion: PROM scores were significantly improved at the 2-year follow-up in patients who underwent PJAC for full-thickness patellar cartilage defects. On MRI, a cartilage defect fill of >66% was achieved by 3 months in most patients. In our sample, PROM scores were not significantly associated with the defect fill percentage at the short-term follow-up.

Anterior cruciate ligament reconstruction: effect of graft type and gender on early to mid-term clinical outcomes.

Anterior cruciate ligament (ACL) rupture is a debilitating condition and often requires surgery to restore joint stability. Common autografts used for reconstruction include patella tendon and hamstring tendons. The primary aim of this study was to evaluate the early to mid-term clinical outcomes of ACL reconstruction using validated patient-reported outcome measures (PROMs). The secondary aim was to compare clinical outcomes between patella tendon and hamstring tendon autografts. The tertiary aim was to compare clinical outcomes between males and females. Patients with anACL rupture were evaluated before and after surgery using PROM scores which included Lysholm, Tegner, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Short Form-12 Item (SF-12) and EQ-5D-5L. A total of 87 patients were included in the study. All PROM scores significantly improved following surgery (p < 0.001) at a mean follow-up time of 28months (range 12 to 88months). The patella tendon subgroup (n = 27) had superior post-operative results as compared to the hamstring tendon subgroup (n = 60) for KOOS sport and recreation (p = 0.005), KOOS quality of life (p = 0.025), KOOS overall (p = 0.026), Tegner (p = 0.046) and IKDC (p = 0.021) scores. There was no significant difference of PROM scores between males (n = 60) and females (n = 27) (p > 0.05). ACL reconstruction significantly improves clinical outcomes for patients with symptomatic instability consequent to ACL rupture. Overall, patella tendon autograft resulted in better clinical outcomes as compared to hamstring tendon autograft following surgery. Gender did not influence clinical outcome following ACL reconstruction.

Greater changes in self-reported activity level are associated with decreased quality of life in patients following an anterior cruciate ligament reconstruction

ObjectiveTo determine the association between change in physical activity level, as defined as the change from pre-to post-operative Tegner Activity Scale, and quality of life (QOL) after anterior cruciate ligament reconstruction (ACLR), before patients are cleared for return to sport. Participants1198 participants (42.9% male; 18.7 ± 3.6 years; 7.1 ± 3.7 months post-ACLR). Main outcome measuresSurveys included Knee Injury and Osteoarthritis Outcome Score QOL (KOOS-QOL) subscale and Tegner Activity Scale. KOOS-QOL score ≥62.5 is considered as meeting a previously established patient acceptable symptom state. ResultsThe acceptable KOOS-QOL group reported a significantly smaller decrease in activity level from pre-injury to time of data collection (median: 2.00, IQR: 2.00) than the unacceptable KOOS-QOL group (median: 3.00, IQR: 3.00). Across the full cohort, for every one-point larger decrease in Tegner score from pre-to post-ACLR, there is a 52% increase in the odds of having an unacceptable KOOS-QOL score. For adolescents, the odds increase to 60% while the odds for adults were lower at 39%. ConclusionsFollowing ACLR, greater decreases in physical activity level are associated with poorer QOL for both adolescents and adults at short-term follow-up, and this effect is larger amongst adolescents.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021

Background: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR. Purpose/Hypothesis: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44. Results: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07). Conclusion: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

Intra-articular VEGF and MMP-1 are the Primary Drivers of Worse Baseline KOOS Symptoms and Quality of Life Subscores at Time of Knee Chondroplasty

Objectives: Biomarkers are a topic of interest in orthopaedics in the setting of osteoarthritis and patients undergoing knee arthroscopy for any reason. However, in patients undergoing knee arthroscopy for chondral defects, the influence of cytokines on patient pain and function is not fully understood. The purpose of this study is to investigate the concentrations of synovial inflammatory cytokines in patients undergoing arthroscopic chondroplasty for chondral defects in the knee and correlate those cytokine levels with baseline patient reported outcome measures (PRO’s) and defect characteristics. We hypothesized that the synovial cytokine environment will correlate with patient symptoms more so than baseline defect characteristics. Methods: Sixty patients 18-50 years old undergoing arthroscopic chondroplasty for knee cartilage defects were enrolled. Patients were assigned preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee International Knee Documentation Committee (IKDC) Subjective Knee Forms. Preoperative magnetic resonance images were used to calculate AMADEUS (Area Measurement And Depth Underlying Structure) scores.1 All patients received a successful synovial fluid aspiration just prior to initiation the arthroscopic procedure. The number of defects, total defect area, and ICRS grades were recorded based on intraoperative assessment. Patients with concomitant procedures beyond partial meniscectomy were excluded. Multiplex ELISA analyzed aspirations for: PDGF-BB, CCL-5/RANTES, MMP-3, MMP-1, EGF, VEGF, IL-1a, FGF-2, CCL-2, BMP-2, and aggrecan. Univariate correlation testing was used to assess significance between cartilage defect characteristics, PROs, and cytokine concentrations (Figure 1). The Akaike Information Criterion (AIC) was utilized to select the best-fit multivariate regression model using the 4 most significant independent variables for each cytokine (Figure 2). AIC best-fit modeling was repeated for each PRO that had at least two significant cytokine associations on univariate testing (Figure 3). Significance was set at P&lt;0.05. Results: MMP-1 had a positive correlation with number of defects treated (P=0.016) and negative correlation with KOOS quality of life (QOL) subscores (P=0.035; R2 =0.173). VEGF was positively correlated with defects treated (P=0.005) and negatively correlated with KOOS Symptoms scores (P=0.035; R2 =0.225). The treatment of multiple defects was an independent predictor of elevated IL-1a (P=0.002, R2 =0.202). CCL-2 was positively correlated with multiple defects (P=0.012) and negatively with KOOS QOL (P=0.016, R2 =0.173). Female sex was correlated with higher concentrations of MMP-3 (P=0.007, R2 =0.144), FGF (P=0.012, R2 =0.178), and BMP-2 (P=0.008; R2 = 0.169). BMP-2 was negatively correlated with KOOS Symptom (P=0.019). The primary driver of preoperative KOOS Symptoms scores on multivariate analysis was VEGF (P=0.023, R2 =0.120), influencing patient symptoms beyond defect characteristics. Similarly, KOOS QOL was independently correlated with MMP-1 concentration (P= 0.045, R2 =0.079), more so than ICRS grade (Figure 3). Conclusions: Multivariate regression analysis revealed that elevated MMP-1 was the primary driver of worse preoperative KOOS QOL scores, more so than defect characteristics such as the number of lesions treated. Similarly, worse preoperative KOOS Symptoms scores were more strongly correlated with elevated VEGF concentrations rather than defect ICRS grades. Our study demonstrated that synovial fluid cytokines appear to be the primary drivers of patients’ subjective assessments of their pain and function preoperatively.

Responsiveness of Patient-Reported Outcome Measures After Large Knee Articular Cartilage Transplantation: A Systematic Review and Meta-analysis.

Cartilage transplantation is commonly used to treat large (>4 cm2) articular cartilage defects of the knee. The 2 most common transplants are osteochondral allograft transplantation and autologous chondrocyte implantation. Several patient-reported outcome measures (PROMs) have been used to determine the efficacy of treatment, but it is unknown which measures are the most effective. To report the multiple PROMs used after large knee articular cartilage transplantation surgery and to compare the responsiveness between them. Meta-analysis; Level of evidence, 4. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the PubMed/MEDLINE and Web of Science databases was performed. A total of 181 articles met inclusion criteria. Patient and study characteristics were extracted, including pre- and postoperative means for PROMs. From the articles that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up, reported pre- and postoperative means and standard deviations; n = 131), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles. A total of 10,015 patients (10,093 knees; mean age, 34.8 years; mean body mass index, 26.1) were included in this study. The mean follow-up time was 58.3 months (range, 1.5-247.2 months), imaging findings were reported in 80 articles (44.2%), patient satisfaction was reported in 39 articles (21.5%), and range of motion was reported in 10 articles (5.5%). There were 58 unique PROM instruments identified, with the most used being the International Knee Documentation Committee (IKDC) score (n = 118; 65.2%), followed by Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (n = 58; 32.0%), KOOS Sport and Recreation (n = 58; 32.0%), KOOS Quality of Life (n = 57; 31.5%), KOOS Activities of Daily Living (n = 57; 31.5%), and KOOS Symptoms (n = 57; 31.5%). Overall, IKDC was found to have the greatest effect size (1.68) and the best responsiveness of the other PROMs, which include KOOS Pain (RE, 1.38), KOOS Symptoms (RE, 3.06), KOOS Activities of Daily Living (RE, 1.65), KOOS Sport and Recreation (RE, 1.44), Lysholm (RE, 1.76), and Tegner (RE, 1.56). The IKDC is the most responsive PROM after large knee articular cartilage transplantation surgery. The IKDC score is recommended for assessing outcomes after cartilage transplantation surgery.

Knee-Related Quality of Life Compared Between 20 and 35 Years After an Anterior Cruciate Ligament Injury Treated Surgically With Primary Repair or Reconstruction, or Nonsurgically

Background: Quality of life (QoL) is affected up to 5 years after an anterior cruciate ligament (ACL) injury. Knee impairment and osteoarthritis (OA) development increase over time, and this may affect QoL at a long-term follow-up. Purpose: To investigate changes in health- and knee-related QoL between 20 and 35 years after ACL injury and compare it between patients treated with or without ACL surgery, as well as to study how symptomatic OA (SOA) is associated with change in QoL. Study Design: Cohort study; Level of evidence, 2. Methods: Between 1980 and 1983, 139 patients with acute ACL rupture were allocated to surgical or nonsurgical treatment of the ACL. Both groups completed a structured rehabilitation program. Of those patients, 59 were followed for 20 and 35 years after ACL rupture. After 10 crossovers, 33 patients were treated with primary repair or ACL reconstruction, and 26 were treated without ACL surgery. Combined radiographic OA and knee symptoms at 35 years was defined as SOA. QoL was assessed at 20 and 35 years after injury with the Knee injury and Osteoarthritis Outcome Score QoL (KOOS-QoL) subscale (range, 1-100), ACL-QoL questionnaire (total score and 5 subscales; range, 1-100), European QoL–5 Dimensions Questionnaire, and visual analog scale. Results were analyzed with paired and independent-sample t tests and chi-square tests. Results: Knee-related QoL was impaired at both 20 and 35 years after ACL injury, and differences were dependent on the measurement outcome. In the total cohort, KOOS-QoL did not change but both total ACL-QoL score (7.1 points; 95% CI, 2.2-11.9) and 4 of 5 subscales (5-10 points) decreased (P < .05). No differences were found between treatment groups. QoL decreased overall in patients with SOA, with a 21-point difference within-group change in KOOS-QoL (SOA or non-SOA) between 20 and 35 years of follow-up (P = .001; Cohen d = 1.0). Conclusion: An ACL injury impairs knee-related QoL for up to 35 years, with no difference between treatment approaches (initial repair or later reconstruction compared with nonsurgical treatment). The deterioration decreases with longer follow-up. Clinicians should be aware of differences in QoL depending on the measurement outcome.

The efficacy of strength or aerobic exercise on quality of life and knee function in patients with knee osteoarthritis. A multi-arm randomized controlled trial with 1-year follow-up

ObjectiveTo evaluate the efficacy of strength exercise or aerobic exercise compared to usual care on knee-related quality of life (QoL) and knee function at 4 months and 1 year in individuals with knee osteoarthritis.MethodsA three-arm randomized controlled trial (RCT) compared 12 weeks of strength exercise or aerobic exercise (stationary cycling) to usual care supervised by physiotherapists in primary care. We recruited 168 participants aged 35–70 years with symptomatic knee osteoarthritis. The primary outcome was The Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL at 1 year. Secondary outcomes were self-reported function, pain, and self-efficacy, muscle strength and maximal oxygen uptake (VO2max) at 4 months and 1 year.ResultsThere were no differences between strength exercise and usual care on KOOS QoL (6.5, 95% CI -0.9 to 14), or for aerobic exercise and usual care (5.0, 95% CI -2.7 to 12.8), at 1 year. The two exercise groups showed better quadriceps muscle strength, and VO2max at 4 months, compared to usual care.ConclusionThis trial found no statistically significant effects of two exercise programs compared to usual care on KOOS QoL at 1 year in individuals with symptomatic and radiographic knee osteoarthritis, but an underpowered sample size may explain lack of efficacy between the intervention groups and the usual care group.ClinicalTrials.gov IdentifierNCT01682980.

Poster 242: Predictors of the Ten-Year Patient-Reported Outcome Measures After Collagen Meniscus Implant (CMI) for Partial Meniscus Deficiency

Objectives: Collagen Meniscus Implant (CMI) is considered an effective procedure for reducing knee pain and improving knee function after previous meniscectomy. Nevertheless, the current knowledge regarding the clinical results of CMI are limited to small case series at short- to mid-term follow-up studies. The goal of the present study was to evaluate clinical outcomes, reoperations, and failures of CMI at a minimum 10 years of follow-up. Methods: Consecutive patients who underwernt CMI at a single institution were screened for elegibility. Inclusion criteria for the present study were (1) Medial or Lateral CMI, (2) Isolated or combined procedure with ACL reconstruction, knee osteotomy or cartilage treatment, (3) follow-up between 10 and 15 years. Demographics and surgical details were obtained via chart review. Patients were asked if they were satisfied with the procedure and were evaluated with the Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, and Tegner score at the final follow-up. Survival analysis was performed with Kaplan-Meier curve, and clinical scores were analyzed based on the Patient Acceptable Symptom State (PASS). Results: A total of 92 patients (mean age, 42.8 years) were included in the analysis. A significant improvement in all the clinical scores was reported between the preoperative evaluation and the last follow-up. A chondropaty with outerbridge grade ≥III was associated with significantly overall lower clinical score, while a timing from meniscectomy to CMI implant to ≥5 years determined more pain at rest and lower score in the KOOS quality of life. Overall, 25% of patients did not achieved the PASS for Lysholm score and a percentage variable from 19% (KOOS Pain) and 40% (KOOS Symptoms) did not achieved the PASS in the KOOS subscales. Chondropaty with outerbridge grade ≥III was associated with an higher Risk of not achieving the PASS in all the KOOS subscales, while an age at surgery ≥45 years was resulted in a lower risk of not achieving PASS in the pain subscale. At the last follow-up 63% of patients returned to sport practice after CMI implantation, with 41% at the same or higher level. Finally, 80% of the patients were satisfied with the procedure Conclusions: CMI provided satisfactory results in terms of function, symptoms, sports and quality of life in 60% to 80% of the patients after more than 10 years of follow-up with clinical scores still higher compared to the preoperative evaluation. The cartilage status and the time from meniscectomy have shown to impact negatively on the outcomes, while an age &gt;45 years was associated with less pain. [Table: see text][Table: see text]

International Knee Documentation Committee (IKDC) Is the Most Responsive Patient Reported Outcome Measure After Meniscal Surgery

To report the variability in outcome measures after meniscal surgery and to compare responsiveness between patient-reported outcome measures (PROMs). A systematic search of the PubMed/MEDLINE and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 257 studies met inclusion criteria. Patient and study attributes were extracted, including pre- and postoperative means for PROMs. Of the studies that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up; n= 172), we compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in at least 10 articles. In total, 18,612 patients (18,690 menisci, mean age= 38.6 years, mean body mass index= 26.3) were included in this study. Radiographic measures were reported in 167 (65.0%) studies, range of motion was reported in 53 (20.6%) studies, and 35 different PROM instruments were identified. The mean number of PROMs in each article was 3.6 and 83.8% reported 2 or more PROMs. The most used PROMs were Lysholm (74.5%) and IKDC (51.0%). IKDC was found to be more responsive than other PROMs, which include Lysholm (RE= 1.03), Tegner (RE= 3.90), and Knee Injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) (RE= 1.12). KOOS Quality of Life (QoL) was also more responsive than other PROMs, such as IKDC (RE= 1.45) and KOOS ADL (RE= 1.48). Lysholm was more responsive compared with KOOS QoL (RE= 1.14), KOOS ADL (RE= 1.96), and Tegner (RE= 3.53). Our study found that IKDC, KOOS QoL, and Lysholm were the most responsive PROMs. However, because of the previously reported risks of either floor effects (KOOS QoL) or ceiling effects (Lysholm), the IKDC may offer a more complete psychometric profile when quantifying outcomes after meniscus procedures. To improve clinical outcomes, surgical decision-making, and research methodology, it is important to determine which PROMs are the most responsive after meniscal surgery.

Genicular artery embolization for early-stage knee osteoarthritis: results from a triple-blind single-centre randomized controlled trial

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure. A total of 59 participants with symptomatic Kellgren-Lawrence grade 2 knee OA were randomly allocated to TAE or a sham procedure. The intervention group underwent TAE of one or more genicular arteries. The control group received a blinded sham procedure. The primary outcome was knee pain at 12 months according to the Knee injury and Osteoarthritis Outcome Score (KOOS) pain scale. Secondary outcomes included self-reported function and quality of life (KOOS, EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), self-reported Global Change, six-minute walk test, 30-second chair stand test, and adverse events. Subgroup analyses compared participants who received complete embolization of all genicular arteries (as distinct from embolization of some arteries) (n = 17) with the control group (n = 29) for KOOS and Global Change scores at 12 months. Continuous variables were analyzed with quantile regression, adjusting for baseline scores. Dichotomized variables were analyzed with chi-squared tests. Overall, 58 participants provided questionnaire data at 12 months. No significant differences were found for the primary and secondary outcomes, with both groups improving following the procedure. At 12 months, KOOS pain scores improved by 41.3% and 29.4% in the intervention and control groups, respectively. No adverse events occurred. Subgroup analysis indicated that the complete embolization group had significantly better KOOS Sports and Recreation, KOOS Quality of Life, and Global Change scores than the control group; 76.5% of participants who received complete embolization reporting being moderately or much better compared to 37.9% of the control group. TAE might produce benefits above placebo, but only when complete embolization of all genicular arteries is performed. Further comparative studies are required before definitive conclusions regarding the effectiveness of TAE can be made. Level of evidence: I.

Patient-Reported Measures Associated with the Return to Pre-Injury Levels of Sport 2 Years after Anterior Cruciate Ligament Reconstruction.

The International Knee Documentation Committee Subjective Knee Form (IKDC2000) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) are knee-specific measures. However, their association with a return to sports after anterior cruciate ligament reconstruction (ACLR) is unknown. This study aimed to investigate the association between the IKDC2000 and the KOOS subscales and the return to the same pre-injury level of sport two years after ACLR. Forty athletes that were two years post-ACLR participated in this study. Athletes provided demographic information, filled out the IKDC2000 and KOOS subscales, and indicated whether they returned to any sport and whether they returned to the same pre-injury level (same duration, intensity, and frequency). In this study, 29 (72.5%) athletes returned to play any sport and eight (20%) returned to the same pre-injury level. The IKDC2000 (r: 0.306, p = 0.041) and KOOS quality of life (KOOS-QOL) (r: 0.294, p = 0.046) significantly correlated with the return to any sport, but it was age (r: -0.364, p = 0.021), BMI (r: -0.342, p = 0.031), IKDC2000 (r: 0.447, p = 0.002), KOOS-pain (r: 0.317, p = 0.046), KOOS sport and recreation function (KOOS-sport/rec)(r: 0.371, p = 0.018), and KOOS QOL (r: 0.580, p > 0.001) that significantly correlated with a return to the same pre-injury level. High KOOS-QOL and IKDC2000 scores were associated with returning to any sport, and high KOOS-pain, KOOS-sport/rec, KOOS-QOL, and IKDC2000 scores were all associated with returning to the same pre-injury level of sport.

Management of the Failed First Revision ACL Reconstruction: Clinical Outcomes of Nonsurgical Management Versus Second Revision ACL Reconstruction From the SANTI Group

Background: The optimum management strategy after failure of revision anterior cruciate ligament reconstruction (RACLR) is not clearly defined. The literature evaluating differences in outcomes between surgical and nonsurgical management is sparse. Purpose/Hypothesis: The purpose was to evaluate the outcomes of surgical versus nonsurgical management of failed first RACLR. It was hypothesized that the long-term clinical outcomes of second RACLR would be superior with respect to knee stability, return to sport, and patient-reported outcome measures when compared with nonsurgical treatment. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who experienced failure of first RACLR were evaluated. All participants followed the same rehabilitation protocol regardless of whether they underwent nonsurgical treatment or a second RACLR. Follow-up comprised regular clinical review and a standardized telephone interview at the end of the study period. Patient-reported outcome measures were recorded at the final follow-up. Results: A total of 41 patients with a mean follow-up of 104 ± 52.7 months (range, 40-140 months) were evaluated. Of these, 31 underwent a second RACLR, and 10 patients chose nonsurgical treatment. There was a high rate of return to sport in both groups, but patients undergoing second RACLR had significantly better Tegner (6.35 vs 4.8; P = .012), Lysholm (88.5 vs 78.3; P = .0353), Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (72.6 vs 56.3; P = .0490), and KOOS Sport and Recreation scores (81.4 vs 62.5; P = .0033). Significantly more patients undergoing second RACLR achieved the Patient Acceptable Symptom State for KOOS Sport and Recreation than those who underwent nonsurgical management (74.2% vs 30%; P = .015). The most important predictor of failure to achieve a good/excellent Lysholm score in multivariate analysis was nonsurgical management (P = .0095). Conclusion: Both second RACLR and nonsurgical management of failed first RACLR were associated with high rates of return to sport. However, second RACLR was associated with significantly better functional outcome scores with respect to Tegner, Lysholm, KOOS Quality of Life, and KOOS Sport and Recreation scores compared to nonsurgical management. In addition, nonsurgical treatment was the only significant predictor of failure to achieve a good/excellent Lysholm score at the final follow-up, and this was likely a function of inferior knee stability in that group.

OP0229 OSTEOARTHRITIS OF THE KNEE, INFLAMMATION, AND THE EFFECT OF ADALIMUMAB (OKINADA): A RANDOMIZED PLACEBO-CONTROLLED TRIAL

BackgroundCytokines such as tumor necrosis factor (TNFα) have been shown to elicit inflammatory and catabolic events in the joints of patients with osteoarthritis. Recent RCTs demonstrated that TNFα inhibition has no effect on pain and MRI-detected synovitis or bone marrow lesions in patients with erosive hand OA1-3. However, the progression of bone erosions was reduced in a subgroup of patients with more clinically swollen distal interphalangeal joints in one RCT1. Consequently, it remains possible that TNFα inhibition may have beneficial effects in specific subgroups of patients with a high inflammatory component.ObjectivesWe aimed to evaluate the efficacy and safety of a TNFα inhibitor, adalimumab (ADA), in a proof-of-concept study in patients with inflammatory OA of the knee.MethodsOKINADA was a 52-week, randomized, double-blind, placebo-controlled, parallel-group study done at 11 sites in Canada (NCT02471118). Eligible participants were adults (aged ≥18 years) with a diagnosis of OA of the index knee and classified according to American College of Rheumatology criteria, including radiological evidence of OA (Kellgren-Lawrence grades 2 or 3) with clinical signs of knee effusion. Subjects had persistent knee pain of ≥ one month duration with a pain score of ≥ 4 (0-10 NRS) in the index knee at screening and baseline despite conventional treatment with maximum tolerated acetaminophen and/or non-steroidal anti-inflammatory drug. Patients were randomly assigned (1:1) to receive subcutaneous 40 mg ADA every 2 weeks or placebo (PBO). Primary endpoint was the Outcome Measures in Rheumatology and Osteoarthritis Research Society International set of responder criteria (OMERACT-OARSI) at week 16 defined as: (1) improvement in pain or function ≥50% and an absolute change ≥20 mm; or (2) improvement of ≥20% with an absolute change ≥10 mm in at least two of the following three categories: pain, function, and patient’s global assessment. Secondary endpoints included: the Knee Injury and Osteoarthritis Outcome Score (KOOS) for the domains of pain, activities of daily living (ADL), OA symptoms, sport and recreation function (SRF), and knee-related quality of life (QoL), patient’s global assessment of disease status (PGAD), investigator global assessment of disease status (IGAD), and expanded Target Joint Assessment (TJA) score.ResultsA total of 59 patients were randomized (29 to PBO, 30 to ADA). The primary endpoint was not met: OMERACT-OARSI combined (ADA: 9 [30.0%] vs PBO: 7 [24.1%], p=0.62). For KOOS pain, ≥20% improvement was noted in 11 (36.7%) ADA vs 7 (24.1%) PBO patients (p=0.30), and ≥50% improvement in 5 (16.7%) ADA vs 6 (20.7%) PBO patients (p=0.69). There were no significant treatment-group differences in baseline to 16-week change in continuous secondary endpoints (ADA vs PBO: KOOS ADL 6.5 vs 8.4 (p=0.71), KOOS QoL 10.1 vs 7.4 (p=0.66), KOOS symptoms 7.8 vs 11.5 (p=0.42), KOOS SRF 5.8 vs 7.7 (p=0.76), PGAD -1.0 vs 0.1 (p=0.10), IGAD -1.5 vs -2.1 (p=0.30), TJA -2.4 vs -2.2 (p=0.87) or in lab markers (ESR, CRP). There were 11 withdrawals (4 ADA, 7 PBO) of which 2 were for adverse events (1 ADA, 1 PBO) and 2 for increasing knee pain (1 ADA, 1 PBO). No new safety signals were identified and there were no serious adverse events.ConclusionAlthough the treatment was safe, short-term treatment with anti-TNFα therapy does not appear to provide clinically meaningful improvements in OA symptoms in patients with established radiographic knee OA. Analyses of structural endpoints will be reported when results are available.

Reliability and Validity of the Knee Injury and Osteoarthritis Outcome Score in Patients Undergoing Unicompartmental Knee Arthroplasty

BackgroundThe Knee Injury and Osteoarthritis Outcome Score (KOOS) was developed to document outcomes from knee injury, including the impact of osteoarthritis on knee function. The purpose of this study is to determine the reliability and validity of the KOOS subscales for evaluating outcomes following unicompartmental knee arthroplasty (UKA). MethodsKOOS Pain, Activities of Daily Living (ADL), Sport, Symptoms, and Quality of Life (QoL) scores collected from 172 patients who underwent UKA were used in the analysis. KOOS subscales were tested for reliability and validity of scores through a Rasch model analysis. ResultsKOOS Sport, KOOS ADL, and KOOS QoL had good evidence of reliability with acceptable person reliability, person separation, and item reliability. For overall scale functioning, KOOS Pain, Symptoms, and ADL all had 1 question that did not have an acceptable value for infit or outfit mean square value. Questions in KOOS Sport and QoL all had acceptable values. There was a positive, linear relationship between the Short-Form 12 Physical Component Summary and the KOOS subscales which indicated good evidence of convergent validity. These associations were also seen when the cohort was separated in medial and lateral UKA. ConclusionTwo of the 5 KOOS subscales (KOOS Sport and KOOS QoL) were considered adequate in measuring outcomes, as well as reliability. The KOOS ADL had borderline values; however, it had adequate infit and outfit values. The KOOS Pain and Symptom score performed poorly in this analysis. For documenting outcomes following UKA, this study supports the use of KOOS ADL, Sport, and QoL.

Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee.

Background:While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied.Purpose:To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD).Study Design:Cohort study; Level of evidence, 3.Methods:Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed).Results:The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm2 and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; P = .002) and more commonly male (80% vs 35%; P = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; P = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; P = .04) and KOOS Quality of Life (87.0 vs 56.8; P = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion.Conclusion:FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.

The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis.

This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m2) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all P<.001) and SCB achievement (chi-square=26.02-53.24, all P<.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, P<.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [Orthopedics. 2021;44(5):299-305.].

Weight-bearing knee flexion angle better correlates with patient-reported outcome measures than non-weight-bearing condition in total knee arthroplasty: a three-dimensional analysis study

BackgroundThis study aims to elucidate and compare the relationship between the knee flexion angle and patient-reported outcome measures (PROM) in both non-weight-bearing (NWB) and weight-bearing (WB) conditions.MethodsThis retrospective cohort study included 61 knees (47 patients) who underwent total knee arthroplasty. The knee flexion angle was measured by three conditions: NWB in manual goniometer, NWB in fluoroscopic three-dimensional (3D) analysis and WB in the fluoroscopic 3D analysis. The PROM was evaluated by postoperative 2011 Knee Society Score (2011 KSS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Correlations between the knee flexion angle and PROM was analyzed using Spearman’s correlation coefficient. Additionally, whether the angular difference between NWB and WB correlated with the PROM or not was evaluated.ResultsThe NWB knee flexion angle in a goniometer, NWB in 3D analysis, and WB in 3D analysis were 124.6° ± 8.4°, 118.0° ± 10.5°, and 109.5° ± 13.3°, respectively. The angular difference was 8.5° ± 12.8°. No PROM correlation existed in NWB using a goniometer. Moreover, significant positive correlations in 2011 KSS symptoms (r = 0.35) and 2011 KSS functional activities (r = 0.27) were noted in NWB using 3D analysis. Significant positive correlations existed in 2011 KSS symptoms (r = 0.32), 2011 KSS functional activities (r = 0.57), KOOS pain (r = 0.37), KOOS activity of daily living (ADL; r = 0.45), KOOS sports (r = 0.42), and KOOS quality of life (r = 0.36) in WB using 3D analysis. Significant negative correlations were noted in 2011 KSS functional activities (r = − 0.45), KOOS ADL (r = − 0.30), and KOOS sports (r = − 0.38) in angular difference.ConclusionsThe WB knee flexion angle better correlated with PROM compared with NWB by evaluation of 3D analysis. The larger the angular difference existed between NWB and WB, the lower the PROM score.

Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates.

Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose was to compare ACL reconstruction failure rates between hospitals performing different annual surgical volumes. All patients from the Norwegian Knee Ligament Register having primary autograft ACL reconstruction between 2004 and 2016 were included. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1-12 (V1), 13-24 (V2), 25-49 (V3), 50-99 (V4) and ≥ 100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Secondary outcome measures included (1) mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) and Sport subsections from pre-operative to 5-year follow-up and (2) subjective failure defined as KOOS QoL < 44. Twenty thousand eight hundred and fifty patients met the inclusion criteria and 1195 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Revision rates were lower in the lower volume hospitals compared with the higher volume hospitals (p < 0.001). There was no clinically significant difference in improvement between pre-operative and 5-year follow-up KOOS scores between hospital volume categories, but a higher proportion of patients having surgery at lower volume hospitals reported a subjective failure. Patients in the lower volume categories (V1-3) were more often male and older compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries and participation in pivoting sports were most common in V5 compared with V1 (p < 0.001). Median operative time decreased as hospital volume increased, ranging from 90min at V1 hospitals to 56min at V5 hospitals (p < 0.001). Patients having ACL reconstruction at lower volume hospitals had a lower rate of subsequent revision surgery relative to higher volume hospitals. However, complications occurred more frequently, operative duration was longer, and the number of patients reporting a subjective failure of ACL reconstruction was highest at these lower volume hospitals. Level III.

Can We Predict Unplanned Intensive Care Unit Admission in Hip and Knee Arthroplasty?

AbstractPreoperative risk stratification remains important for both patient safety and cost-effective allocation of resources in total joint arthroplasty. Limited literature exists investigating risk factors for unplanned intensive care unit (ICU) admission following arthroplasty. Therefore, the purpose of this study was to assess a broader spectrum of factors that may increase the risk of ICU admission across multiple surgical settings. We retrospectively reviewed 18,169 patients who underwent a hip (40.7%) or knee (59.3%) arthroplasty procedure (primary: n = 13,384, 90%; revision: n = 1,485, 10%) between August 1, 2015, and January 31, 2019, across nine sites at a single institution. Patient demographics, laboratory data, surgical parameters, and preoperative scores on the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) were recorded. A univariate analysis was conducted to identify differences between patients who required an ICU admission and those with no ICU involvement. Logistic regression was then used to generate predicted risk of ICU Involvement. A total of 147 patients (0.99%) required an ICU admission. Increasing age, higher Charlson's comorbidity index, American Society of Anesthesiologists (ASA) class 3 or greater, elevated blood urea nitrogen (BUN), elevated creatinine, decreased preoperative hemoglobin level, general anesthesia, surgical setting, revision procedure, and lower baseline scores on the KOOS Quality of Life (QOL) subscale (17 vs. 22.5, p = 0.032), VR-12 physical component score (PCS; 24.4 vs 27.1, p = 0.001), and VR-12 mental component score (MCS; 45.9 vs. 49.6, p = 0.003) were associated with a statistically significant increase in the risk of ICU admission. As performance of arthroplasty shifts in both the setting of care and the complexity of patients, identifying patients most at risk of requiring higher acuity of care is important. Preoperative assessment of comorbidities, kidney function, surgical setting, KOOS QOL subscale score, and VR-12 scores may provide guidance for the improvement of value-based care pathways.