Knee Injury And Osteoarthritis Outcome Score Subscales Research Articles

Similar short-term KOOS between open-wedge high tibial osteotomy and total knee arthroplasty in patients over age 60: A propensity score-matched cohort study.

The purpose of the present study was to evaluate improvement in the Knee Injury and Osteoarthritis Outcome Score (KOOS) after open-wedge high tibial osteotomy (HTO) in comparison with total knee arthroplasty (TKA) in cohorts over age 60 matched by pre-operative age, gender, body mass index (BMI), hip-knee-ankle angle (HKAA), KOOS sub-scores, and osteoarthritis (OA) grade. Propensity score matching was performed between 162 HTO patients and 134 TKA patients. When calculating the propensity score by multivariate logistic regression analysis, the following pre-operative confounders were included: age, gender, BMI, HKAA, KOOS sub-scores, and OA grade. Consequently, a total of 55 patients were included in each group. The Student's t-test was used to analyse differences in the post-operative KOOS sub-scores between groups. After propensity score matching, all matched pre-operative valuables were identical, with no significant differences between the HTO and TKA groups. None of the post-operative KOOS sub-scores at 1 year after surgery showed a significant difference between the HTO and TKA groups. Both groups demonstrated significant and comparable post-operative improvement in every KOOS sub-score. In patients over age 60, there was no significant difference in short-term pain relief and improvements in activity and quality of life between HTO and TKA after propensity score matching including pre-operative age, KOOS sub-scores, and OA grade. HTO is a joint preservation procedure that is valid for knee OA even in individuals over age 60.

Arabic version of the International Knee Documentation Committee Subjective Knee Form (IKDC): Translation and validation.

In order to administer the International Knee Documentation Committee Subjective Knee Form (IKDC) questionnaire to Arabic speakers, a rigorous process of cross-cultural adaptation and validation is required in order to reach equivalence between the original publication and target version of the questionnaire. The main aim of this study is to translate and culturally adapt the IKDC into Arabic to suit the Arabic population. The secondary aim is to assess the Arabic version of the IKDC in order to test the psychometric characteristics (reliability, validity and dimensionality). The translation process has been carried out according to cross-cultural adaptation guidelines in accordance with the American Orthopaedic Society for Sports Medicine guidelines with forward/backward translations and pre-testing. The Arabic IKDC, Knee injury and Osteoarthritis Outcome Score (KOOS), RAND-36-Item Health Survey (RAND-36) questionnaire, and visual analogue scales (VAS) of pain were tested in 105 ACLR patients. Test-retest reliability, internal consistency, construct validity and content validity were evaluated. The test-retest reliability proved excellent with a high value for the intraclass correlation coefficient (r= 0.95). The internal consistency was strong (Cronbach's α= 0.91). Good construct validity by the strong correlations between similar component of the KOOS subscales, Rand-36 subscales and VAS, and good content validity with absence of floor and ceiling effects. The Arabic version of the IKDC is a valid and reliable instrument for Arabic patients with ACLR. However, further research is required with a more varied knee sample in order to enable generalisation to a wider population.

Matrix-Induced Autologous Chondrocyte Implantation (MACI) is Largely Effective and Provides Significant Improvement in Patients With Symptomatic, Large Chondral Defects: A Systematic Review and Meta-Analysis.

The purpose of this study was to perform a meta-analysis for long-term patient-reported outcome (PRO) measures in Matrix-induced Autologous Chondrocyte Implantation (MACI) patients using the Knee Injury and Osteoarthritis Outcome Score (KOOS) model. A literature search under the PubMed/Medline and Embase databases was conducted. Statistical significance was determined between the mean pre- and postoperative scores at each time point (1-, 2-, and 5-years). Cohen's d analysis was used to measure the effect size (ES) in each group when compared to preoperative measurements to determine clinical responsiveness. KOOS subscales at all long-term postoperative follow ups measured in this study showed significant (p-value < 0.001) improvement when compared to preoperative scores. Furthermore, apart from KOOS sports and recreation (KOOS-SR) at 1-year postoperative follow up that showed a medium ES (ES, 0.761), all other KOOS subscales at long-term follow up periods showed a large (>0.8) ES on mean preoperative KOOS. Review of the literature demonstrate an absence of large meta-analyses for long-term PRO measures with the MACI procedure. It was found that all subscales were largely responsive when evaluated at >2 years after surgery. Based on these results, MACI is an effective treatment option for patients with symptomatic, full-thickness cartilage defects about the knee.

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.

Comparison of Knee Function and Activity Level Between Bilateral and Unilateral ACL Reconstruction: A Matched-Group Analysis With Minimum 5-Year Follow-up.

Background:There is a lack of knowledge regarding knee function and activity level after bilateral anterior cruciate ligament reconstruction (ACLR) at midterm follow-up.Purpose:To compare activity level, patient-reported knee function, and quality of life in patients with bilateral ACLR and matched controls with unilateral ACLR at a minimum 5-year follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with bilateral ACLR who were aged ≤40 years and had a second ACLR performed between 2010 and 2015 were identified in the authors’ local database. Surgical data and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted. The patients were sent a letter with questionnaires including the KOOS, EuroQol 5-Dimensions (EQ-5D), and EuroQol visual analog scale (EQ-VAS) and were asked study-specific questions by telephone regarding activity level and knee function at a minimum 5-year follow-up. For every patient with bilateral ACLR, a control matched for age ±2 years, sex, year ACLR was performed, and preinjury activity level or sport at the time of injury were identified in the database.Results:A total of 98 patients (mean age ± SD, 33.3 ± 7.3 years) with bilateral ACLR and 98 patients with unilateral ACLR (mean age ± SD, 33.1 ± 7.7 years) were included. The mean postoperative follow-up was 7.6 ± 1.8 years (from the second ACLR) for patients with bilateral ACLR and 7.8 ± 1.7 years for patients with unilateral ACLR. Patients with bilateral ACLR reported lower scores on all KOOS subscales, the EQ-5D, and the EQ-VAS at follow-up (P < .05). There was no difference in activity level between the groups at follow-up, but patients with bilateral ACLR were less satisfied with their activity level and knee function (P < .05).Conclusion:Patient-reported knee function and health-related quality of life were inferior in patients with bilateral ACLR compared with patients with unilateral ACLR. Patients with bilateral ACLR cannot expect the same knee function and quality of life as patients with unilateral ACLR.

Predictors of Disparities in Patient-Reported Outcomes before and after Arthroscopic Meniscectomy.

The purpose of this study is to identify predictors of disparities in patient-reported outcome measures (PROMs) before and after arthroscopic meniscectomy. Knee injury and Osteoarthritis Outcome Score (KOOS) was used in this study. All patients who underwent single-knee arthroscopic meniscectomy from January 2012 to March 2018 performed by a single surgeon at an academic safety-net hospital were identified. We excluded patients who had undergone ipsilateral previous knee surgery, bilateral meniscectomy, or concomitant ligament, cartilage, or osteotomy procedures, and those with severe radiographic osteoarthritis in the operated knee, missing preoperative data, or military insurance. Data abstracted from medical records included demographics (age, sex, race, insurance type), clinical characteristics (body mass index, Charlson comorbidity index, and Kellgren-Lawrence [KL] grade), procedure codes, and KOOS assessed before and 90 days after surgery. Multivariable analyses investigated the associations between patient characteristics and the KOOS Pain, other Symptoms, and Function in activities of daily living (ADL) subscales. Among 251 eligible patients, most were female (65.5%), half were of nonwhite race (50.2%), and almost one third were insured by Medicaid (28.6%). Medicaid and black race were statistically significant (p < 0.05) predictors of worse preoperative values for all three KOOS subscales. Medicaid insurance also predicted a lower likelihood of successful surgery, defined as meeting the 10-point minimal clinically important difference, for the KOOS symptoms (p < 0.05) and KOOS ADL (p < 0.05) subscales. Compared with patients without definitive evidence of radiographic osteoarthrosis (KL grade 1), those with moderate radiographic osteoarthritis (KL grade 3) were less likely to have a successful surgical outcome (p < 0.05 for all subscales). Worse preoperative KOOS values predicted worse postoperative KOOS values (p < 0.001 for all subscales) and a lower likelihood of surgical success (p < 0.01 for all subscales). Insurance-based disparities in access to orthopaedic care for meniscus tears may explain worse preoperative PROMs and lower success rates of meniscectomy among Medicaid patients. Patients with meniscus tears and radiological and/or magnetic resonance imaging evidence of osteoarthritis should be carefully evaluated to determine the appropriateness of arthroscopic meniscectomy.

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

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

Midterm outcome and strength assessment after quadriceps tendon refixation with suture anchors

PurposeQuadriceps tendon ruptures (QTR) occur predominantly in middle-aged patients through violent eccentric contraction that occurs either when trying to regain balance or during a fall on the hyperflexed knee. The aim of this study was to quantify midterm postoperative results, including strength potential measured via standardized strength tests following acute (< six weeks) quadriceps tendon refixation using suture anchors.MethodsAll consecutive patients with QTR who underwent surgical suture anchor refixation between 2012 and 2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Tegner Activity Scale (TAS), Lysholm score, International Knee Documentation Committee subjective knee form (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, return to work rates, and Visual Analog Scale (VAS) for pain. Additionally, a standardized clinical examination and an isometric strength assessment of knee extension and flexion were performed.ResultsA total of 17 patients (median age 61.0 [25–75% IQR 50.5–72.5]) were available for final assessment at a mean follow-up of 47.1 ± SD 25.4 months. The majority of patients were male (82.4%) and most injuries occurred due to a fall on the hyperflexed knee (76.5%). The average time interval between trauma and surgery was 12.7 ± 7.5 days. Patients achieved a moderate level of activity postoperatively with a median TAS of 4 (3–5.5) and reported good to excellent outcome scores (Lysholm score: 97 (86.5–100); IKDC: 80.7 ± 13.5; KOOS subscales: pain 97.2 (93.1–100), symptoms 92.9 (82.5–100), activities of daily living 97.1 (93.4–100), sport and recreation function 80 (40–97.5) and knee-related quality of life 87.5 (62.5–100). All patients were able to fully return to work and reported little pain [VAS: 0 (0–0)]. No postoperative complications were reported. Strength measurements revealed a significant deficit of knee extension strength in comparison to the contralateral side (p = 0.011).ConclusionSuture anchor refixation of acute QTR leads to good functional results and high patient satisfaction without major complications. Isometric knee extension strength, however, may not be fully restored compared to the unaffected side.

Superior Outcome of Early ACL Reconstruction versus Initial Non-reconstructive Treatment With Late Crossover to Surgery: A Study From the Swedish National Knee Ligament Registry

Background: Although comparable clinical and functional outcomes have been reported after nonsurgical and surgical anterior cruciate ligament (ACL) treatment, few studies have investigated the effects of early versus late ACL reconstruction with initial rehabilitation. Purpose: To determine patient-reported knee function in patients who initially undergo nonreconstructive treatment after an ACL injury but who later choose to undergo ACL reconstruction as compared with (1) patients undergoing ACL reconstruction close to the index injury and (2) patients treated nonreconstructively at 1 to 10 years of follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Results from the Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted from the Swedish National Knee Ligament Registry for patients treated with nonreconstruction, early ACL reconstruction, and initial nonreconstruction but subsequent ACL reconstruction (crossover group). The KOOS4 (a mean of 4 KOOS subscales) was analyzed cross-sectionally at baseline and at the 1-, 2-, 5-, and 10-year follow-ups. Additionally, the Patient Acceptable Symptom State (PASS) was applied to all KOOS subscales from baseline to the 10-year follow-up. Results: A total of 1,074 crossover, 484 nonreconstruction, and 20,352 early ACL reconstruction cases were included. The crossover group reported lower KOOS4 values than the group undergoing early ACL reconstruction at baseline and at all follow-ups (mean difference [95% CI]): baseline, −6.5 (−8.0 to −5.0); 1 year, −9.3 (−10.9 to −7.7); 2 years, −4.8 (−6.3 to −3.2); 5 years, −6.1 (−8.8 to −3.4); and 10 years, −10.9 (−16.3 to −5.2). Additionally, a smaller proportion of the crossover cohort achieved a PASS on KOOS subscales at baseline and through the 1-, 2-, 5-, and 10-year follow-ups as compared with the early ACL reconstruction cohort. No differences were observed between crossover and nonreconstruction cases on either the KOOS4 or the PASS at any follow-up. Conclusion: A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction.

10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy.

Background:Good-to-excellent midterm results after high tibial osteotomy (HTO) to treat medial compartment cartilage defects or osteoarthritis (OA) have been published, but little is known about long-term survival rates in terms of conversion to total knee arthroplasty (TKA) using angular stable internal plate fixation.Purpose:To determine TKA-free survival rates and functional and radiological outcomes at 10 years after HTO. A subgroup analysis of patients who underwent combined HTO and autologous cartilage implantation (ACI) was also performed.Study Design:Case series; Level of evidence, 4.Methods:Included were 125 patients with a mean follow-up of 9.90 ± 2.25 years; 90 patients underwent HTO for medial OA, and 35 patients underwent ACI and HTO for medial focal cartilage defects. Functional outcome measures included visual analog scale (VAS) for pain, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and KOOS4 (average of 4 KOOS subscales: Pain, Symptoms, Sport, and Quality of Life). Radiological outcomes included lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle.Results:Overall, 16 patients required conversion to TKA at a mean 86.75 ± 25.73 months (10-year survival rate, 87.2%). Only 2 patients in the HTO+ACI subgroup required a conversion to TKA (10-year survival rate, 94.3%). The complication rate for all patients was 8.8%. In both the HTO and HTO+ACI subgroups, VAS pain levels decreased and Lysholm scores increased significantly from pre- to postoperatively (P < .001). A higher preoperative Tegner score led to a significantly lower risk for conversion to TKA (P = .001), and a preoperative body mass index of ≥35 was associated with a significantly higher risk (P = .019), as was female sex (P = .046). Radiological parameters remained within physiological ranges. The postoperative joint line conversion angle did correlate with postoperative functional outcome but not with TKA conversion.Conclusion:Long-term results of HTO for medial compartment OA or cartilage defects with underlying varus deformity were good to excellent. In particular, patients who underwent HTO+ACI presented excellent long-term survival rates. HTO, therefore, delays or prevents TKA implantation, especially in young, active patients with medial compartment damage.

An anti-inflammatory diet intervention for knee osteoarthritis: a feasibility study

BackgroundKnee osteoarthritis has an inflammatory component that is linked to pain and joint pathology, yet common non-surgical and non-pharmacological interventions (e.g., exercise, calorie restricting diets) do not typically target inflammation. We aimed to evaluate the feasibility of a telehealth delivered anti-inflammatory diet intervention for knee osteoarthritis.MethodsThis 9-week single-arm feasibility study recruited participants aged 40–85 years with symptomatic knee osteoarthritis (inclusion criteria: average pain ≥4/10 or maximal pain ≥5/10 during past week). All participants received a telehealth-delivered anti-inflammatory dietary education intervention involving 1:1 consultations at baseline, 3- and 6-week follow-up. The diet emphasised nutrient-dense wholefoods and minimally processed anti-inflammatory foods and discouraged processed foods considered to be pro-inflammatory. The primary outcome of feasibility was assessed via: i) eligibility, recruitment and retention rates; ii) self-reported dietary adherence; iii) adverse events; and iv) treatment satisfaction. Post-intervention interviews evaluated the acceptability of the dietary intervention delivered via telehealth. Secondary outcomes included changes in self-reported body mass, Knee injury and Osteoarthritis Outcome Score (KOOS), health-related quality of life (EuroQoL-5D), analgesic use and global rating of change. Worthwhile effects were determined by the minimal detectable change (MDC) for all five KOOS-subscales (pain, symptoms, activities of daily living, sport/recreation, quality of life) being contained within the 95% confidence interval.ResultsForty-eight of seventy-three (66%) individuals screened were eligible and 28 enrolled over 2 months (82% female, mean age 66 ± 8 years, body mass index 30.7 ± 4.8 kg.m−2). Six participants withdrew prior to final follow-up (21% drop-out). Of those with final follow-up data, attendance at scheduled telehealth consultations was 99%. Self-reported adherence to diet during the 9-week intervention period: everyday = 27%, most of time = 68% and some of time = 5%. Two minor adverse events were reported. Change scores contained the MDC within the 95% confidence interval for all five KOOS subscales. Suggestions to improve study design and limit drop-out included an initial face-to-face consultation and more comprehensive habitual dietary intake data collection.ConclusionThis study supports the feasibility of a full-scale randomised controlled trial to determine the efficacy of a primarily telehealth-delivered anti-inflammatory dietary education intervention in adults with symptomatic knee osteoarthritis.Trial registrationACTRN12620000229976 prospectively on 25/2/2020.

Correlation of patient-reported numbness around surgical scars with patient-reported outcome measures and joint awareness after knee replacement: a cohort study

BackgroundKnee replacement is a very effective and indispensable treatment option for end-stage knee arthritis, and the number of cases has been increasing worldwide. A replaced knee joint without patient joint awareness is thought to be the ultimate goal of artificial knees. Joint awareness reportedly correlates with patient satisfaction. Although numbness around a replaced knee is a minor but common problem, its effect on postoperative outcome is controversial. Joint awareness also is sensitive to subtle abnormalities of the joint, so it must be negatively affected by numbness. Although numbness is minor, it cannot be ignored to further improve knee replacement outcomes. This study investigated the relationship between patient-reported numbness and other patient-reported outcome measures (PROMs), including joint awareness, and kneeling. We developed a numbness score based on a 5-point Likert scale on frequency of numbness, with an intraclass correlation coefficient of 0.76 and higher scores indicating less numbness.MethodsThe numbness score, New Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score-12 (FJS-12), and other clinical and radiological data from 311 patients (394 primary knee replacements) were analyzed. Kneeling ability was evaluated by using kneeling-specific items in the KSS (KSS-Kneeling).ResultsNo numbness was found in 170 knees (43.1%), and some degree of numbness was found in the remaining 224 knees (56.9%). The numbness score showed weak-to-moderate correlations with KSS-Symptoms (r = 0.44), KSS-Satisfaction (r = 0.41), KSS-Activities (r = 0.29), and all KOOS subscales (r = 0.23–0.44), and FJS-12 (r = 0.42). Multiple regression analyses suggested that midline incision positively affected the numbness score over the anteromedial incision (p = 0.04) and that a better numbness score (p = 0.001), male sex (p < 0.0001), and better postoperative knee flexion angle (0.04) positively affected kneeling.ConclusionsThe numbness score positively correlated with PROMs and positively affected kneeling. Knee replacements performed via an anteromedial incision may be at higher risk for numbness.

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

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

Subsequent surgery after primary ACLR results in a significantly inferior subjective outcome at a 2-year follow-up

PurposeTo analyze minimal important change (MIC), patient-acceptable symptom state (PASS) and treatment failure after reoperation within 2 years of primary ACL reconstruction and compare them with patients without additional surgery.MethodsThis is a retrospective follow-up study of a cohort from a single-clinic database with all primary ACLRs enrolled between 2005 and 2015. Additional surgery within 2 years of the primary ACLR on the ipsilateral knee was identified using procedural codes and analysis of medical records. Patients who completed the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire preoperatively and at the 2-year follow-up were included in the study. MIC, PASS and treatment failure thresholds were applied using the aggregate KOOS (KOOS4) and the five KOOS subscales.ResultsThe cohort included 6030 primary ACLR and from this 1112 (18.4%) subsequent surgeries were performed on 1018 (16.9%) primary ACLRs. 24 months follow-up for KOOS was obtained on 523 patients (54%) in the reoperation group and 2084 (44%) in the no-reoperation group. MIC; the no-reoperation group had a significantly higher improvement on all KOOS subscales, Pain 70.3 vs 60.2% (p < 0.01), Symptoms 72.1 vs 57.4% (p < 0.01), ADL 56.3 vs 51.2% (p < 0.01), Sport/Rec 67.3 vs 54.4% (p < 0.01), QoL 73.9 vs 56.3% (p < 0.01). PASS; 62% in the non-reoperation group reported their KOOS4 scores to be satisfactory, while only 35% reported satisfactory results in the reoperated cohort (p < 0.05). Treatment failure; 2% in the non-reoperation group and 6% (p < 0.05) in the reoperation group considered their treatment to have failed.ConclusionPatients who underwent subsequent surgeries within 2 years of primary ACLR reported significantly inferior outcomes in MIC, PASS and treatment failure compared to the non-reoperated counterpart at the 2-year follow-up. This study provides clinicians with important information and knowledge about the outcomes after an ACLR with subsequent additional surgery.Level of evidenceIII.

Concomitant full-thickness cartilage lesions do not affect patient-reported outcomes at minimum 10-year follow-up after ACL reconstruction

PurposeTo compare patients with a concomitant full-thickness cartilage lesion and anterior cruciate ligament (ACL) injury to patients with an isolated ACL injury at 10–15 years post ACL reconstruction.MethodsThis is a longitudinal follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the index study in 2007. The study group consisted of 30 patients that underwent ACL reconstruction and had a concomitant, isolated full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grade 3–4). Each study patient was matched with two control patients who underwent ACL reconstruction but had no cartilage lesions (ICRS grade 1–4) (n = 59). At a median follow-up of 10.2 years (range 9.9–15.6), 65 patients (74%) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was the main outcome measure, resulting in 23 pairs after matching.ResultsAt a follow-up of 10–15 years after ACL reconstruction, no significant differences in KOOS were found between patients with a concomitant full-thickness cartilage lesion and patients without cartilage lesions. There was also no significant difference between the two groups when comparing the change over time in KOOS scores from preoperative to follow-up. Both groups showed significant improvement in all KOOS subscales from preoperative to follow-up, except for in the Symptoms subscale for the control group. The greatest improvement was in the QoL subscale for the study group.ConclusionACL-reconstructed patients with a full-thickness cartilage lesion did not report worse outcomes at 10–15 years after surgery compared with patients with an isolated ACL injury. Our findings support that there is no long-term negative effect of a concomitant cartilage lesion in an ACL-reconstructed knee. These findings should be considered when discussing treatment and informing about the expected long-term outcome after ACL reconstruction to patients with such combined injuries.Level of evidenceII.

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.].

Articular Cartilage and Meniscus Predictors of Patient-Reported Outcomes 10 Years After Anterior Cruciate Ligament Reconstruction: A Multicenter Cohort Study

Background: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving. Hypothesis/Purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years. Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral (P < .01) and medial (P < .05) compartments and previous medial meniscal surgery (7% of knees; P < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales. Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.

Postoperative Bone Marrow Lesions (BMLs) Are Associated with Pain Severity in Patients Undergoing Open Wedge High Tibial Osteotomy (OWHTO).

The purpose of the study was to investigate the relationship between postoperative bone marrow lesions (BMLs) and pain severity in patients undergoing open wedge high tibial osteotomy (OWHTO). We reviewed the patients undergoing OWHTO between April 2018 and April 2020. The demographic and clinical data of patients were collected. Clinically, VAS and Knee injury and Osteoarthritis Outcome Score (KOOS) were used to assess pain level and functional outcomes of patients. The MRI Osteoarthritis Knee Score (MOAKS) was used to assess the total BMLs size in medial tibiofemoral (MTF), lateral tibiofemoral (LTF), and patellofemoral (PF) joints. 98 patients were enrolled in the study, including 57 male and 41 female patients. The VAS scores improved significantly from 6.1 ± 0.8 to 1.5 ± 0.9 (p < 0.001), and all subscales of KOOS improved significantly after surgery (p < 0.001). There were no significant differences between the pre- and postoperative total BML size of PF and LTF joints (p > 0.05). We observed significant improvements in the total BML size of MTF joint (p < 0.001). The VAS scores and KOOS pain scores improved better in patients without postoperative MTF joint BMLs (p < 0.001). Postoperative MTF joint BMLs were correlated with postoperative VAS (p < 0.001) and KOOS pain (p < 0.001). Our study demonstrates that MTF joint BMLs improved significantly after OWTHO. We confirmed that the presence of postoperative MTF joint BMLs are strongly associated with pain severity. The greater the improvement in postoperative MTF joint BMLs, the less pain. Our findings provide valuable understandings of OWHTO in the treatment of knee osteoarthritis (KOA) and potential future directions for KOA treatment approaches.

Superior Improvements in Knee Pain and Function with a Novel Synthetic Medial Meniscus Replacement Implant Compared to Non-surgical Care in Subjects with Knee Pain Following Partial Meniscectomy: Two-year Results from Two Prospective US Clinical Trials

Objectives:Arthroscopic partial meniscectomy (APM) is the most common surgical treatment for symptomatic, irreparable meniscal tears that do not improve with non-surgical care. For many patients, APM is associated with improvements in knee pain and function, but a subset of patients reports persistent or recurrent knee pain 1-2 years after APM surgery. Current treatment options for post-APM knee pain are limited, especially for patients considered too young for knee replacement. The polymeric medial meniscus implant mimics the biomechanical function of the natural medial meniscus and is intended to provide relief from pain and improved function in subjects with knee pain following APM. Two FDA-regulated clinical trials were conducted in the United States and pooled for analysis, to assess superiority of a synthetic medial meniscus implant to non-surgical care in treating persistent or recurrent knee pain following previous partial meniscectomy. The hypothesis was that the meniscus implant is superior to non-surgical care for improvements in composite measures of knee-related pain, function, and quality of life at 2 years of follow-up.Methods:242 patients (176 investigational, 66 control) were treated in 2 prospective, concurrent clinical trials in the U.S.: a randomized controlled superiority trial (RCT) comparing the medial meniscus implant to non-surgical care (control) and a single-arm, implant-only trial. Eligible subjects had persistent knee pain and one or more previous partial meniscectomies at least 6 months before trial entry. Treated subjects returned for follow-up visits at 1.5 months, 6 months, 1 year, and 2 years. Patient-reported knee pain, function, and quality of life were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The primary patient-reported outcomes were 2 KOOS subscales: KOOS Pain and KOOS Overall. KOOS success was defined as subjects who achieved either (1) KOOS Pain ≥86.1 at 2 years and KOOS Overall ≥86.2 at 2 years or (2) a ≥20-point improvement from baseline to 2 years in KOOS Pain and KOOS Overall, with KOOS Pain ≥40 at 2 years. Treatment cessation was defined as any subject who discontinued the per-protocol treatment by permanent implant removal (implant group) or any surgical procedure on the index knee (control group). Implant subjects who underwent subsequent surgical procedures on index knees (e.g. implant exchange) remained in the trial. The two treatment groups were well-matched, except for baseline KOOS Sports and Recreation. Statistical analyses adjusted for high vs low baseline KOOS Sports and Recreation using 2-factor analysis of variance (ANOVA) for continuous variables and 2x2 logistic regression for dichotomous variables.Results:Sixteen subjects (6.6%; 14 control, 2 implant) were lost to follow-up or withdrew from the study over 2 years. The magnitude of improvement from baseline to 2 years was significantly greater in the implant group compared to control for 5 of 6 KOOS subscales (Figure 1), including the primary outcomes of KOOS Overall and KOOS Pain (Figure 1A,B). The proportion of subjects who achieved KOOS success was significantly higher in the implant group (63.4%) than the control group (27.9%), which remained true with or without the adjustment for baseline KOOS Sports and Recreation (P<.0001 in each case). Treatment cessation through 2 years was less frequent in the implant group (10.5%) compared to the control group (17.3%), but the difference was not statistically significant (P=.19).Conclusions:Two-year results from 2 prospective, concurrent, US clinical trials demonstrate that the synthetic meniscus implant provides superior relief from post-APM knee pain when compared to treatment with non-surgical care alone. In addition, the magnitude of change from baseline to 2 years in the primary patient-reported outcomes and the rate of KOOS success significantly favored the implant group compared to the control group. Subjects in the implant group tended to discontinue treatment at a lower rate compared to subjects in the control group, but the difference was not statistically significant. Subjects treated with the implant who underwent a device exchange or repositioning procedure were able to continue treatment therapy with the medial meniscus implant. Overall, the implant group experienced superior improvements and outcomes at 2 years compared to subjects receiving non-surgical care alone.

A Single-Blinded Randomized Controlled Trial of Mesenchymal Stem Cell Therapy for the Treatment of Osteoarthritis of the Knee with Active Control.

Background: Osteoarthritis is most prevalent in the knee and drives the growing incidence of total knee arthroplasty. There is a need to explore non-surgical treatment options to increase the portfolio of alternatives available. The study aimed to determine the clinical response to an autologous bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) intra-articular injection compared to an active comparator. Methods: The study was a prospective, single-blinded, randomized controlled pilot study. Participants with diagnosed knee osteoarthritis were allocated to one of two treatment groups to receive a BMAC injection immediately followed by a PRP injection or a single injection of Gel-One® crosslinked hyaluronate (HA). Outcomes were assessed at 3, 6, and 12 months post-treatment. Results: Significant improvements were observed in both treatment groups for all Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales with the exception of the symptoms assessment at 12 months in the HA group. BMAC KOOS scores peaked at 12 months, while HA KOOS scores generally peaked at 6 months. The gap in mean scores at 12 months in favor of the BMAC group did not reach statistical significance. Secondary outcomes included a greater reduction in pain at 12 months in the BMAC group (-3.13 points; 95% CI: -3.96, -3.29) compared to the HA group (-1.56 points; 95% CI: -2.59, -0.53; p= 0.02) via the numeric pain rating scale. Conclusions: Results demonstrate that both treatment groups experienced clinically and statistically significant improvement across the KOOS subscales. While BMAC has shown promise in the treatment of knee OA, there is a need for multi-center investigations with larger sample sizes, an extended follow-up, and placebo-based control. ClinicalTrials.gov Identifier: NCT02958267.