KOOS QOL Scores Research Articles

EARLY POST-OPERATIVE CLINICAL OUTCOMES IN PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY COMPARING IN-PERSON CLINIC VERSUS TELEHEALTH-DELIVERED REHABILITATION PROGRAM: A NON-INFERIORITY TRIAL

INTRODUCTION AND AIMS Rehabilitation following total knee arthroplasty (TKA) is essential to mitigate delay in physical recovery and facilitate optimum patient outcomes. Telehealth is emerging as a cost-effective and efficacious delivery method. The aim of this study was to investigate the early post-operative outcomes of patients following a telehealth-delivered rehabilitation program (Tele) compared with those following conventional outpatient rehabilitation (Clinic) in patients following TKA. METHODS A single-blinded, randomized controlled non-inferiority trial was conducted, with 108 participants scheduled for primary TKA randomly allocated to a 6-week, telehealth-delivered rehabilitation program (n=54) or a 6-week supervised, in-person rehabilitation program (n=54). Knee flexion range of motion (KF-ROM) and the Quality of Life subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-QOL) were collected pre-surgery and 7-weeks post-surgery. A linear mixed-effect model was used to assess differences between groups over time for both outcome measures. Change in KOOS-QOL of greater than 10 points was used to establish minimally clinically important change (MCIC), with chi square analyses used to assess between-group differences. RESULTS Baseline KF-ROM measures were 124.1° and 122.2° for telehealth-delivered and in-person groups respectively; and 108.7° and 111.6° at 7-week post-surgery. KOOS-QOL scores were 32.7 and 33.3 at baseline for the respective groups; and 60.9 and 62.9 at week-7. There were no significant differences in between group changes over time for both KF-ROM (mean difference = -2.9°, 95% CI = -7.7 to 1.8; p=0.226) and KOOS-QOL (mean difference = -2.1, 95% CI: -10.0 to 5.9; p=0.611). Chi square analyses revealed no differences between groups meeting the MCIC (Tele = 71%; Clinic = 79%) in KF-ROM (X2 = 0.78, p = 0.377). CONCLUSION Short term outcomes following TKA are not different between telehealth-delivered and conventional supervised rehabilitation. Telehealth may provide an effective rehabilitation option for patients undergoing TKA.

Outcome of Single-stage Multi-ligament Reconstruction: A Retrospective Observational Study

Introduction: Multi-ligament injuries of the knee can cause significant functional impairment. It is uncommon, and treatment is still controversial. The main controversies are around staged versus single-stage surgery. There is scanty literature on the functional outcome of the single-stage multi-ligament reconstruction. Moreover, less is known about the outcomes following single-stage multi-ligament reconstruction in the context of Nepal. We have been practicing single-stage reconstruction for multi-ligament injuries for the last few years at our center. This study was conducted to evaluate the functional outcome after single-stage multi-ligament reconstruction in our setup. Methods: The records of 75 patients who underwent single-stage multi-ligament reconstruction were retrospectively reviewed. All the patients were interviewed by telephone and face-to-face using set questionnaires. The KOOS QoL, Lysholm, and IKDC scores were used to evaluate outcomes. The data analysis was done using SPSS 20. Student’s t-test and Chisquared test were used to calculate the p-value for parametric and nonparametric variables. p-value of less than 0.05 was considered to be significant. Results: The mean age of patients who underwent multi-ligament reconstruction was 36.63 years. Among 75 patients, 51 were males, and 24 were females. 50 (66.7%) had RTA, 20 (26.7%) had fall injuries, 3 (4%) had a sports injury, and 2 (2.7%) had other injuries. The mean KOOS QoL, Lysholm, and IKDC scores were 71.19, 85.85, and 75.92, respectively. Conclusion: This study found that more than 77% of patients undergoing single-stage multi-ligament reconstruction have good to excellent outcomes. KeyWords: KOOS QOL score, Lysholm score, IKDC score, RTA.

Impact of end-stage knee osteoarthritis on perceived physical function and quality of life: A descriptive study from Jordan.

Of the present study was to evaluate the impact of end-stage knee OA on patient's perception of their functional abilities and quality of life (QoL) using the self-reported questionnaire; the Knee Injury and Osteoarthritis Outcome Score (KOOS), and to determine the contribution of knee pain on patient's perceived outcomes. Patients with end-stage knee OA who are on the waiting list for total knee arthroplasty were recruited in this cross-sectional study. Patients were asked to fill out the KOOS questionnaire. Knee pain for both sides was quantified on a continuous scale from 0-10. Age, and anthropometric data were recorded. Descriptive statistics were calculated for patients' characteristics, and for the scores of each KOOS subscale. Hierarchical linear regression models were created to determine the contributions of knee pain on two KOOS subscales; the function in daily living (KOOS-ADL), and the knee-related quality of life (KOOS-QoL). Patients in this study scored low across KOOS subscales (27.7% - 54.2%) with the QoL subscale being the lowest. After accounting for age and BMI, hierarchical linear regressions revealed that knee pain in both sides were determinants of self-perceived KOOS-ADLs, while only knee pain in the most-affected side significantly contributed to lower KOOS-QOL scores. End-stage knee OA negatively impact the patients' perceived function and quality of life. Patients' KOOS scores were similar to those reported in other countries, with QoL being the domain most affected. Our findings demonstrate that the level of knee pain has a determinant effect on our patients' perceptions of functional abilities and QoL. As waiting-list patients, addressing knee pain with a targeted regimen prior to TKA, as well as increasing patient's awareness about knee pain management, may improve/ or minimize deterioration in perceived functional ability and QoL while awaiting TKA.

Paper 49: Demographic and Clinical characteristics of patellar instability patients from prospective JUPITER (Justifying Patellar Instability Treatment by Early Results) cohort.

Objectives:The purpose of this study is to provide an objective analysis of patient demographics and clinical features for the young patients with patellar instability. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to better describe demographic and clinical characteristics and predictors of clinical outcomes in the young patellar instability population.Methods:21 surgeons from 12 institutions enrolled patients between 10-30 years of age who presented with at least one documented patellar dislocation episode. Radiographs and MRI were evaluated for all patients at baseline to confirm patellar dislocation and skeletal maturity status. Patient demographics, dislocation history, physical exam characteristics and baseline validated patient reported outcome (PRO) scores were collected and analyzed. Conservative versus operative treatment was based on treating physician’s preference following standard of care guidelines. The cohort was divided between first-time vs recurrent dislocators and between conservative vs operative treatment.Results:At the end of enrollment in December 2020, a total of 1722 knees with patellar instability were enrolled. The mean age of the cohort was 17.7 years, 62.4% were female. 306 were skeletally immature. 59% of knees reported that they had more than 1 dislocation. ). 71% knees were enrolled in the operative group and 29% in the conservative group. For patients with recurrent dislocation, 89.7% were treated operatively and 10.2% were treated conservative (p<0.001). Operative treatment was indicated in 42.9% of first-time dislocators; 50% were due to presence of an osteochondral fracture. The recurrent and operative group patients were noted to have a higher percent of positive physical exam findings than first-time and conservative group patients on the affected knee (J-sign [p<0.001], apprehension [p<0.001], crepitus [p=0.041]) and the contralateral knee (except for the crepitus test [p=0.648]). The recurrent group was nearly twice as likely to be ligamentously lax (Beighton score of 5 or greater) compared to first-time dislocators (p<0.001). Baseline PROs varied with the recurrent group having lower Pedi-FABS (p=0.001) and KOOS-QoL (0.008) scores and higher Kujala (0.009), KOOS ADL (0.008), KOOS Sports (<0.001), and Pedi-IKDC (0.014) scores than the first-time dislocator group.Conclusions:Based on large prospective cohort of JUPITER group, operative management was indicated in 42.9% of first-time dislocators and 89.7% of recurrent dislocators. Besides osteochondral fracture, recognition of risk factors (young age, contralateral dislocation, anatomic risk factors) may account for higher rates of operative treatment after first-time dislocation. Recurrent dislocators were more likely to have positive physical exam findings on both knees and lower activity scores. However, the knee specific outcome scores were higher in patients with recurrent dislocations which may reflect adaptive mechanisms to improve function. This prospective study provides insights related to demographic information, clinical presentation and baselines PROs of patients with patellar instability. These baseline characteristics would help to identify the at-risk population and compare outcomes in a longitudinal fashion.

CLINICAL EFFECTIVENESS OF TRANS-ARTICULAR VERSUS RETRO-ARTICULAR DRILLING OF STABLE OSTEOCHONDRITIS DISSECANS OF THE KNEE: A, PROSPECTIVE RANDOMIZED CONTROLLED TRIAL BY THE ROCK STUDY GROUP

Background:The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent athlete. Standard of care for conservative treatment, include activity modification and weight bearing protection. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness.Hypothesis/Purpose:The study hypothesis was that trans-articular (TAD) and retro-articular drilling (RAD) would demonstrate similar rates of healing, times to return to sports, and patient-reported outcome scores (PROs).Methods:Skeletally immature (n=113) patients presenting with radiograph indicated stable OCD of the MFC who did not demonstrate healing despite a minimum of 3 months of non-operative treatment were prospectively enrolled and randomized to TAD or RAD, for which 17 surgeon-investigators (at 14 centers, representing all major regions in the U.S.). Serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were due to lesion instability detected at the time of surgery,Results:Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, with the two groups being of similar age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant difference between TAD and RAD was detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD. 71% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 58% RAD patients at a mean of 1.06 years.Conclusion:While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement being achieved much sooner. While PROs were similar between drilling techniques, revision surgery rates were more than twice as common with RAD compared with TAD but the overall risk was low and the Absolute Risk was only 6%.

Trans-articular versus Retro-articular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Randomized Controlled Trial by the ROCK Multicenter Study Group

Objectives:The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent athlete. The standard of care for primary treatment is non-operative, and includes rest/activity modification and often weight bearing protection or bracing. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness. The study hypothesis was that retro-articular drilling (RAD), the slightly newer technique, would not be inferior to trans-articular (TAD), with regard to rate of healing, time to return to sports (RTS), and patient-reported outcome scores (PROs).Methods:Skeletally immature (n=113) patients presenting with MRI-confirmed stable OCD of the MFC who did not demonstrate substantial healing after a minimum of 3 months of non-operative treatment were prospectively enrolled by one of seventeen surgeon-investigators (at 14 centers, representing all major geographic regions in the U.S.) and randomized to TAD or RAD. Post-operatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were closed out at time of surgery due to lesion instability detected during arthroscopy. Power analysis determined that in order to detect a difference in 2-year IKDC score between RA and TA groups with 80% power, sample sizes of 37 subjects per group would be required if the true standard deviation were 15. This analysis was based on conducting an independent samples Student’s t-test with alpha set to 5%.Results:Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, respectively, with the two groups being similar in age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant differences between TAD and RAD were detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD (p=0.40). 73% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 60% RAD patients at a mean of 1.21 years.Conclusions:While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement and RTS being achieved much sooner. PROs were similar between drilling techniques. Significantly higher powered studies are needed to better elucidate the greater revision surgery rates in RAD compared with TAD, but overall risk is low and absolute risk only 6%. The current data support either drilling technique, which may be technically simpler, without the need for fluoroscopy, with TAD, and may be more protective of the chondral articular surface with RAD.

DESCRIPTIVE EPIDEMIOLOGY STUDY OF THE JUSTIFYING PATELLAR INSTABILITY TREATMENT BY EARLY RESULTS (JUPITER) COHORT

Background:Patellar instability is a common injury in young patients and can lead to significant morbidity and arthritis. Its management is controversial. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population.Purpose:To describe the formation of JUPITER and provide a descriptive, epidemiologic analysis of patient demographics and clinical features of the patients in this prospective cohort.Methods:After training and institutional review board approval, surgeons began enrolling patients between 10-30 years of age who sustained a patellar dislocation. Patient demographics, dislocation history, physical exam characteristics, and PROMs were collected.Results:By January 1, 2019, 28 surgeons from 12 sites had prospectively enrolled 661 patients (677 knees) with patellar instability. 62% were female and mean age was 15.8 years. 447 knees (66%) were in the operative group and 230 (34%) in the non-operative group. 55% of knees reported that they had more than 1 dislocation (operative group 73%; non-operative group 27%, p<0.001). Operative treatment was indicated in 39% of first-time dislocators and 85% of recurrent dislocators (p<0.001).Recurrent and operative group patients had more positive physical exam findings than first-time and non-operative group patients on the affected knee (p<0.05 for J-sign, apprehension, crepitus) and the contralateral knee (p<0.05 J-sign, apprehension). The recurrent group was nearly twice as likely to be ligamentously lax (Beighton score 5 or greater) compared to first-time patients (p<0.001).Baseline PROMs varied with the recurrent group having lower Pedi-FABS (p=0.001) and KOOS-QoL (0.008) scores and higher Kujala (0.009), KOOS ADL (0.008), KOOS Sports (<0.001), and Pedi-IKDC (0.014) scores than the first-time dislocator group.Conclusions:The JUPITER Group has been able to accumulate the largest prospectively collected patellar instability database to date. Over half of patients in this group reported they sustained more than one dislocation. Operative management was indicated in 39% of first-time dislocators, 50% of which had sustained an osteochondral fracture, and 85% of recurrent dislocators. Recurrent dislocators were more likely to have positive physical exam findings on both the affected and contralateral knee.

Midterm clinical and functional outcomes after isolated double bundle anatomic MPFL reconstruction in patients with patellofemoral instability

The purpose of this study was to demonstrate midterm outcomes after isolated double bundle anatomic MPFL reconstruction in a young patient cohort. Between 2014 and 2016; 24 knee joints of 23 patients were operated and evaluated in our retrospective study. The time and duration of the patients' complaints, preoperative and postoperative knee range of motion, extent of patellofemoral pain and episodes of lateral patellofemoral instability were evaluated. Functional outcomes were evaluated with Kujala, IKDC, KOOS-QoL and Tegner activity scores. Patellar height was analysed radiographically using the Caton–Deschamps index. Patients were also asked if they were satisfied with the operation. The mean age of the patients during index surgery was 16.7 ± 8.4 years. 87 % of our patients was satisfied with the surgery. The average Kujala score increased from 72 to 96 (p

DESCRIPTIVE EPIDEMIOLOGY STUDY OF THE JUSTIFYING PATELLAR INSTABILITY TREATMENT BY EARLY RESULTS (JUPITER) COHORT

Background: Patellar instability is frequently seen in young patients and can lead to significant disability and arthritis. Its management is controversial. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to obtain sufficient subjects to better describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population. The purpose of this study is to describe the formation of JUPITER and provide preliminary descriptive analysis of patient demographics and clinical features for the initially enrolled patients in this prospective cohort. Methods: After training and institutional review board approval, surgeons began enrolling patients from the 10-25 years age group who sustained a patellar dislocation or subluxation event. Information regarding patient demographics, dislocation history, physical exam characteristics, and baseline validated patient reported outcome scores were collected. Results: As of May 31, 2018, 20 surgeons from 9 different sites had prospectively enrolled a total of 406 patients (142 male, 262 female, 2 not listed; average age 15.1 years old). 269 patients were enrolled in the operative group and 137 patients in the non-operative group. 54.7% of patients reported that they had had greater than 1 dislocation (71.7% in the operative group; 20.4% in the non-operative group). The mean number of recurrent dislocations was 7.6 (Mean operative group 8.3 vs. non-operative group 3.5). 58.7% of first time dislocators were indicated for non-operative treatment while 13.1% of recurrent dislocators were indicated for non-operative treatment (95% CI: 39.1-55.3%, p&lt;0.0001). At the time of first dislocation, 46.3% of participants reported they were participating in a sporting activity, 10.1% were walking, 6.2% were running, 2% were on stairs, and 31.3% reported other activity. 16.7% of the operative group versus 21.2% of the non-operative group reported a contact injury at the time of first dislocation. 32.5% required a manual reduction. Of those who sustained a recurrent dislocation, 5.4% reported a contact injury while 82.4% reported non-contact injury and 9.9% were unsure. 20.7% reported a family history of patellar dislocation. On physical exam, 51.2% (190/369) of patients were noted to have a positive J sign in the involved knee (78.4% mild, 21.2% severe). 35.2% (126/358) were noted to have Beighton hypermobility scores greater than 4. In a multivariable logistic regression model, more severe J-sign was associated with higher odds of redislocation (OR=2.76, 95% CI: 1.60-4.75, p&lt;0.0001) and higher Beighton scores approached significance (OR=1.10, 95% CI: 1.00 -1.20, p=0.06). Pedi-FABS scores (12.5 vs 14.9, p=0.02) and KOOS QOL scores (35.5 vs 41.5, p=0.01) were significantly lower in those who experienced more than one redislocation. Kujala scores were higher in the recurrent dislocators (60.1 vs 55.3, p=0.04). Conclusions: The JUPITER Group has been able to accumulate the largest prospectively collected patellar instability database to date. Over half of patients in this group reported they sustained more than one dislocation. Almost 60% of first time dislocators were indicated for nonsurgical management while only 13% of recurrent dislocators were indicated for non-operative management. Over 80% of recurrent dislocations occurred during a non-contact event. Pedi-FABS scores and KOOS QOL scores were significantly lower in those who experienced more than one redislocation.

Lateral cartilage defects and medial subchondral surface ratio are associated with knee-related disability.

We sought to determine the relationship between (i) full-thickness cartilage defects and tibiofemoral subchondral surface ratio (SSR) and (ii) disability and quality of life in patients with mild radiographic osteoarthritis (OA) (Kellgren-Lawrence grade 2) or without radiographic OA (Kellgren-Lawrence grades 0 or 1)? A total of 642 participants from the Osteoarthritis Initiative (OAI) with baseline knee MRIs and a Kellgren-Lawrence grade 2 or less on both bilateral screening radiographs were included. The independent relationship was assessed between (i) full-thickness cartilage defect presence and tibiofemoral SSR and (ii) Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life (QOL), KOOS function in sports and recreation (KOOS-sport/rec), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability score after adjustment for relevant confounders with multivariate regression modeling. The prevalence of medial full-thickness defects was 10.4% (67/642) and lateral was 18.1% (116/642). Lateral defect presence was associated with worse KOOS-QOL (beta -3.61 SE 1.04; p = 0.001), KOOS-sport/rec (beta -4.70 SE 1.38; p = 0.001) and WOMAC-disability scores (beta 0.02 SE 0.01; p = 0.001); these associations were not influenced by defect size. A larger medial compartment SSR was associated with worse KOOS-QOL (beta -27.20 SE 6.80; p < 0.001), KOOS-sports/rec (beta -22.30 SE 9.01; p = 0.01) and WOMAC-disability scores (beta 0.16 SE 0.04; p < 0.001). In older adults with little to no radiographic osteoarthritis, lateral full-thickness cartilage defects, irrespective of size, and a larger medial compartment tibiofemoral SSR are potential sources of knee-related symptoms that are not appreciated on standard radiographs. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:378-385, 2019.

Medial meniscal and chondral pathology at the time of revision anterior cruciate ligament reconstruction results in inferior mid-term patient-reported outcomes.

Anterior cruciate ligament (ACL) injuries are frequently not isolated injuries and damage to the menisci and articular cartilage surfaces is common. The concomitant presence of meniscal and chondral damage has the potential to influence patient outcomes following ACL reconstruction surgery and especially following revision ACL reconstruction where these findings are more common. However, study results regarding the mid-term outcome have been inconsistent. The purpose of this study was to compare mid-term patient-reported outcomes and return to sport in patients with and without meniscal and chondral pathology at the time of revision ACL reconstruction surgery. A cohort of 180 patients (131 males, 49 female) with a mean age of 25.3 (SD 7.8) years participated at an average follow-up time of 4.6 (SD 1.3) years after revision ACL reconstruction surgery. All patients completed the IKDC Subjective, Marx Activity, KOOS-Quality of Life (QOL) and Single Numerical Assessment (SANE) scores. In addition, patients were asked to indicate the highest level of sport to which they had returned following their revision surgery. Any further injuries to either knee were also documented. Patients were grouped according to whether or not they had medial or lateral meniscal pathology at the time of revision surgery; and whether or not they had > 50% depth chondral damage (ICRS 3 or 4). All outcomes were compared between these groupings. Patients with medial meniscal pathology had significantly lower Marx, KOOS-QOL and SANE scores than patients without. There were no differences in any outcome score between patients with and without lateral meniscal pathology. Patients with ICRS 3 or 4 chondral pathology had significantly lower scores on all patient-reported outcomes as well as a lower rate of return to the same level of pre-injury sport. The presence of more severe chondral damage at the time of revision ACL reconstruction has a negative impact on functional outcomes, activity levels and return to sport rates. In addition, the presence of medial meniscal pathology was associated with significantly lower functional and quality of life scores than patients without pathology. These findings provide important clinically relevant data on the outcomes following revision ACL reconstruction with concomitant chondral and meniscal injury. III.

Outcomes of Meniscal Allograft Transplantation in the Pediatric Athlete

Objectives:Meniscal allograft transplantation (MAT) has a successful clinical track record in adults. The results of MAT in children have not been reported. The goal of this study was to report the results of MAT with minimum 2-year follow-up in this unique population.Methods:After IRB approval, all patients under the age of 16 undergoing MAT between 1999 and 2011 and having > 2 year clinical follow-up were identified from a prospectively collected database. Demographic data including age, height, weight, BMI and prior surgery were collected. Functional outcome scores were collected pre-operatively and at 6 months, 1 year, 2 years and final follow up. Differences between scores at each time point were compared using a mixed model repeated measures ANOVA. All re-operations were documented.Results:17 patients met inclusion criteria. Mean age was 14.9 +/- 1.4 years (range 11 - 16). 10/17 patients had undergone prior knee surgery. 59% were female and 41% were male. The average BMI was 23.4 +/- 5.9. Concomitant procedures included 7 ACI, 1 ACI biopsy and one ACL reconstruction. All patients were available for follow-up at an average of 38 +/- 30 months (range 24 - 122). Surgery resulted in significant improvements in KOOS pain, KOOS ADL, KOOS sport and KOOS QOL scores (Figure 1). Similar improvements were seen in Lysholm, IKDC subjective, WOMAC pain, WOMAC function, and SF-12 physical scores. 3/17 (18%) patients underwent subsequent surgical intervention, however only one (6%) required a graft meniscectomy. One patient required a plica excision, and the other a combined ACL reconstruction and ACI. No complications were found in this population.Conclusion:MAT results in predictable improvements in functional outcomes in the pediatric athlete. Most of these improvements were sustained at an average follow up of 38 months. The meniscal re-operation rate was low (6%) and no complications were reported.

Effect of High-Grade Pre-operative Knee Laxity on Outcomes of Anterior Cruciate Ligament Reconstruction

Objectives:Knee laxity in the setting of suspected anterior cruciate ligament (ACL) injury is frequently assessed through physical examination using the Lachman, pivot-shift, and anterior drawer tests. The degree of laxity noted on these examinations may influence treatment decisions and prognosis. We hypothesized that increased pre-operative knee laxity (Grade 3+ pivot-shift, Lachman > 10mm, or anterior drawer greater than 10mm) are associated with increased risk of revision ACL reconstruction and poorer patient-reported outcomes at two years post-operative.Methods:From an ongoing prospective cohort study, 1394 patients that underwent primary isolated ACL reconstruction within 3 months of injury with autograft tissue without medial collateral, lateral collateral, or posterior cruciate injury requiring treatment or prior contralateral ACL injury were identified. Demographic data, physical examination findings under anesthesia at the time of ACL reconstruction, information regarding meniscus status and treatment, and pre-operative and 2 year post-operative International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score Knee Related Quality of Life subscale (KOOS-QOL), and Marx activity scores were collected. Patients reported by the operating surgeons as having a Lachman or anterior drawer examination at least 10mm greater than the contralateral side were classified as having a high grade Lachman or anterior drawer respectively. Patients reported by the operating surgeon as having a 3+ pivot-shift were classified as having a high-grade pivot-shift. Patients demonstrating high-grade laxity on any of these examinations were classified as having high-grade pre-operative knee laxity. Multiple logistic regression modeling was used to evaluate whether having high-grade pre-operative laxity was associated with increased odds of undergoing revision ACL reconstruction within 2 years of the index procedure, controlling for patient age, sex, activity level, and graft type. Multiple linear regression modeling was used to evaluate whether having high-grade pre-operative laxity was associated with poorer IKDC or KOOS-QOL scores at 2 years post-operative, controlling for patient age, sex, BMI, and smoking status, baseline score, activity level, graft type, and the presence and treatment of meniscal tears.Results:Two year revision data were available for 1333 patients (95.4%) and patient-reported outcomes were available for 1205 patients (86.4%). High-grade pre-operative laxity was noted in 395 patients (29.6%), including high grade pivot-shift in 24.9%, high-grade Lachman in 11.5%, and high-grade anterior drawer in 8.1%. ACL graft revision was performed in 59 patients (4.4%). The mean post-operative IKDC score was 84.1 ± 14.4 and the mean KOOS-QOL score was 75.1 ± 20.4. The presence of high grade pre-laxity was not associated with increased odds of ACL graft revision (OR=1.47, 95% CI: 0.85 - 2.55, p = 0.17). Similarly, the presence of high-grade pre-laxity was not associated with any difference in post-operative IKDC (β = -0.33, p = 0.71) or KOOS-QOL (β = -0.51, p = 0.70).Conclusion:The presence of high-grade pre-operative knee laxity as assessed by physical examination under anesthesia (Grade 3+ pivot-shift, Lachman > 10mm, or anterior drawer greater than 10mm) is not associated increased odds of revision ACL surgery or poorer patient-reported outcome scores at 2 years following ACL reconstruction.

Return to sport and quality of life in people with knee symptoms 5–20 years following anterior cruciate ligament reconstruction

Introduction:Anterior cruciate ligament reconstruction (ACLR) can result in psychological and physical impairments that impact on participation in desired activities and sports. To date, no study has explored the impact of sports restrictions on quality of life (QOL) in people with knee symptoms following ACLR. The aims of this study were to (i) quantify QOL; and (ii) explore relationships between participant characteristics, sport-related factors and QOL 5–20 years following ACLR. Methods: We conducted a cross-sectional analysis on 139 individuals with knee pain, stiffness or activity limitations 5–20 years following ACLR. Participants were recruited from surgical records of four experienced orthopaedic surgeons. All patients aged 18–55 years who had a hamstring or patellar-tendon autograft ACLR 5–20 years ago were invited to participate. People with significant comorbidities and those not fluent in English were excluded. Participants completed the Anterior Cruciate Ligament QOL Questionnaire (ACL-QOL), Knee injury andOsteoarthritis Outcome Score (KOOS) and a demographics questionnaire. KOOS and ACL-QOL scores range from 0 (worst) to 100 (best). KOOS cut-off criteria were applied to ensure all participants were symptomatic. Spearman rank correlations explored relationships between participant characteristics, return to sports information and QOL. Results: A total of 139 participants completed the questionnaires at a mean 9 years (range 5–20) following ACLR. Participants had a mean age of 38 years (range 20–55), a mean BMI of 27 (range 19–43) and 42% were female. Participants scored a mean 55±20on theKOOS-QOL subscale and57±21on theACL-QOL. The most impaired ACL-QOL itemswere sport/recreational frustrations (33±31), playing sport under caution (36±35) and fear of contact sports (35±37). The least impaired ACL-QOL subscale was workrelated concerns (78±22). Returning to sport at a lower level (27%) or not returning to sport (34%) was correlated with poor KOOSQOL scores (r=0.32, p<0.01). Reporting the knee as the reason for not returning to the same level of sport (77%) was correlated with competitive needs not being met (r=0.25, p=0.01) and poor knee confidence (r=0.20, p=0.05). Pain-free sport or exercise participation was considered preferable (78%) to pain-free participation in work (2%), family (15%) or social activities (5%). Discussion: The ability to participate in sport and exercise appear to be a high priority and is associatedwith QOL impairment in peoplewith knee symptoms 5–20 years after ACLR. Knee-related QOL was considerably lower than population norms. Addressing knee confidence, sport-related concerns, frustrations and fearsmay assist in improving QOL following ACLR.

ACL-RSI and KOOS Measures Predict Normal Knee Function after ACL-SPORTS Training

Objectives:After anterior cruciate ligament reconstruction (ACLR) athletes commonly report increased fear of re-injury and below normal knee function. Implementing a post-operative training protocol (ACL-SPORTS Training) to improve patient perceived knee function, may improve short term outcomes after surgery. Identifying pre-training measures that predict normal knee function after training may allow us to determine who may respond to the treatment intervention. The purpose of this study was to identify which pre-training patient reported measures of fear of re-injury and knee function predict normal knee function after ACL-SPORTS Training.Methods:Thirty subjects (13 normal knee function, 17 below normal knee function) with an isolated ACLR, who participated in jumping, cutting and pivoting activities ≥ 50 hrs/yr prior to their injury, were included in this study. Study enrollment required ≥ 80% quadriceps strength, minimal knee joint effusion and ≥ 12 weeks after surgery. Subjects were randomized to two treatment groups. The standard care group received 10 training sessions including quadriceps strengthening exercises, ACL injury prevention exercises and agility drills. The perturbation group received all standard care exercises augmented with perturbation training. Pre-training patient reported measures of fear of re-injury included the Tampa Scale of Kinesiophobia (TSK-11) and the ACL-Return to Sport after Injury (ACL-RSI). Knee function was measured with the Knee injury and Osteoarthritis Outcome Score (KOOS4), as a mean of the pain, symptoms, sports and recreation, and quality of life subscales. Each subscale (KOOS-pain, KOOS-symptoms, KOOS-ADLs, KOOS-sport/rec, KOOS-QoL) was also assessed individually. After the training program was completed, self-reported knee function was measured with the International Knee Documentation Committee subjective knee form (IKDC 2000). Age- and sex-matched normative values were determined based on the top 15th percentile of healthy measures. A binary logistic regression was used to determine which variables significantly predicted normal knee function after training.Results:There was no difference between those who achieved normal knee function and those with below normal knee function for age at the time of surgery (p=0.78), BMI at post-training testing (p=0.71), sex (p=0.13) or time from surgery to post-training testing (p=0.12) and treatment group did not significantly predict normal knee function after training (p=0.96). Higher pre-training ACL-RSI and KOOS4 scores significantly predicted 37.5% and 38.6% of the variance of achieving normal knee function, respectively. Together higher pre-training scores predicted 49.5% of the variance. Of the individual KOOS subscales, higher pre-training KOOS-pain, KOOS-symptoms, KOOS-ADLs, and KOOS-QoL scores significantly predicted 23.8%, 35.9%, 39.5% and 35.6% of the variance of achieving normal knee function, respectively.Conclusion:Prior to this ACL-SPORTS training protocol higher ACL-RSI, KOOS4, KOOS-pain, KOOS-symptoms, KOOS-ADLs and KOOS-QoL subscales were able to predict which individuals achieved normal knee function after this treatment protocol. Identifying individuals who do not achieve normal knee function after training may allow us to identify a subgroup of patients that require additional interventions to achieve normal knee function.