KOOS Quality Of Life Research Articles

Regression to the mean for physical function and quality of life in clinical trials for symptomatic knee osteoarthritis

ObjectiveTo estimate size of regression to the mean (RTM) for common patient-reported outcomes in trials for knee osteoarthritis (OA). DesignLongitudinal cohort study; we included participants of the Osteoarthritis Initiative who fulfilled typical inclusion criteria for enrolment in a trial. These included: age 40-79 years, symptomatic knee OA, Kellgren-Lawrence grade 2-3, use of pain medication more than half the days of a month in past 12 months, numerical rating scale pain of 4 to 9. We studied observed changes in WOMAC physical function and KOOS quality of life (QOL). ResultsWe identified 547 subjects who fulfilled inclusion criteria on at least one annual follow-up between year 1 and year 8. The mean level of physical function and QOL at each follow-up time point was similar, about 18, and about 51, respectively. However, at the time of theoretical inclusion in a trial, the mean levels in the same subjects were 23 and 43, respectively (both worse scores). The mean improvement in physical function between inclusion and 1 and 2 years later, respectively, was 2.5 (95% confidence interval 1.7 to 3.2) and 3.1 (2.3 to 3.8). The corresponding improvement in QOL was 2.7 (1.7 to 3.7) and 4.2 (3.1 to 5.3). ConclusionRTM in trials for knee OA is likely to explain improvement in physical function and QOL, not only in knee pain. RTM often misleads investigators to overinterpret effectiveness as RTM neither represents improvement from the intervention nor placebo effect from the intervention and its context.

Long-Term Outcomes of Arthroscopically Verified Focal Cartilage Lesions in the Knee: A 19-Year Multicenter Follow-up with Patient-Reported Outcomes.

Focal cartilage lesions (FCLs) are frequently found during knee arthroscopies and may impair quality of life (QoL) significantly. Several treatment options with good short-term results are available, but the natural history without any treatment is largely unknown. The aim of this study was to evaluate patient-reported outcome measures (PROMs), the need for subsequent cartilage surgery, and the risk of treatment failure 20 years after diagnosis of an FCL in the knee. Patients undergoing any knee arthroscopy for an FCL between 1999 and 2012 in 6 major Norwegian hospitals were identified. Inclusion criteria were an arthroscopically classified FCL in the knee, patient age of ≥18 years at surgery, and any preoperative PROM. Exclusion criteria were lesions representing knee osteoarthritis or "kissing lesions" at surgery. Demographic data, later knee surgery, and PROMs were collected by questionnaire. Regression models were used to adjust for and evaluate the factors impacting the long-term PROMs and risk factors for treatment failure (defined as knee arthroplasty, osteotomy, or a Knee injury and Osteoarthritis Outcome Score-Quality of Life [KOOS QoL] subscore of <50). Of the 553 eligible patients, 322 evaluated patients (328 knees) were included and analyzed. The mean follow-up was 19.1 years, and the mean age at index FCL surgery was 36.8 years (95% confidence interval [CI], 35.6 to 38.0 years). The patients without knee arthroplasty or osteotomy had significantly better mean PROMs (pain, Lysholm, and KOOS) at the time of final follow-up than preoperatively. At the time of follow-up, 17.7% of the knees had undergone subsequent cartilage surgery. Nearly 50% of the patients had treatment failure, and the main risk factors were a body mass index of ≥25 kg/m 2 (odds ratio [OR] for overweight patients, 2.0 [95% CI, 1.1 to 3.6]), >1 FCL (OR, 1.9 [CI, 1.1 to 3.3]), a full-thickness lesion (OR, 2.5 [95% CI, 1.3 to 5.0]), and a lower level of education (OR, 1.8 [95% Cl, 1.1 to 2.8]). Autologous chondrocyte implantation (ACI) was associated with significantly higher KOOS QoL, by 17.5 (95% CI, 3.2 to 31.7) points, and a lower risk of treatment failure compared with no cartilage treatment, microfracture, or mosaicplasty. After a mean follow-up of 19 years, patients with an FCL who did not require a subsequent knee arthroplasty had significantly higher PROM scores than preoperatively. Nonsurgical treatment of FCLs had results equal to those of the surgical FCL treatments except for ACI, which was associated with a better KOOS and lower risk of treatment failure. Full-thickness lesions, >1 FCL, a lower level of education, and a greater BMI were the main risk factors associated with poorer results. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Tibial Baseplate Migration Is Not Associated with Change in Patient-Reported Outcome Measures and Clinical Scores After TKA: A Secondary Analysis of 5 Radiostereometric Analysis Studies with 10-Year Follow-up.

Radiostereometric analysis (RSA) provides highly accurate data about the migration of a total knee arthroplasty (TKA) component. However, patient-reported outcome measures (PROMs) reflect the patients' perspective of their functional status, pain, and overall health after TKA. The aim of this study was to evaluate the association between tibial implant migration and change in postoperative PROMs and clinical scores, using data pooled from long-term follow-up RSA studies. Individual implant migration data were collected from 5 randomized RSA studies, including a total of 300 patients with 6 distinct TKA implant designs (all Stryker). Tibial implant migration (maximum total point motion [MTPM]) was evaluated with RSA at 3 months, 1 year, and 2, 5, 7, and 10 years postoperatively. The Knee Society Score (KSS)-Knee and KSS-Function and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were collected in all studies at the same follow-up times. Linear mixed-effects models, with adjustment for TKA implant design and patient characteristics, were used to analyze the data. The 3-month follow-up visit was used as the baseline to assess the association between implant migration and PROMs across the 10-year follow-up. No association between tibial implant migration and change in KSS-Knee (p = 0.384), KSS-Function (p = 0.737), KOOS-Symptoms (p = 0.398), KOOS-Pain (p = 0.699), KOOS-Activities of Daily Living (p = 0.205), KOOS-Sport and Recreation (p = 0.702), or KOOS-Quality of Life (p = 0.368) was found across the entire follow-up. Similar results were found when using the 2-year follow-up as the baseline, after which both cemented and uncemented implants are expected to have stabilized. Tibial baseplate migration was not associated with postoperative worsening in PROMs or clinical scores in patients who underwent TKA. These findings suggest that implant migration, as measured with RSA, measures a different parameter (i.e., implant-bone fixation) than PROMs (i.e., patient perception) and clinical scores. Therefore, to assess the performance and safety of TKA implant designs, RSA and PROMs cannot be used interchangeably during the postoperative follow-up of patients and evaluation of the fixation of knee implants. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Cultural adaptation and validation of the knee injury and osteoarthritis outcome score into Sinhala language in patients with primary knee osteoarthritis: a cross-sectional study

BackgroundKnee Injury and Osteoarthritis Outcome Score (KOOS) scale is a patient-reported outcome measurement tool. It evaluates both short- and long-term consequences of knee injury and primary osteoarthritis. This study aims to translate and validate the KOOS scale for a Sinhala-speaking Sri Lankan population.MethodsA cross sectional study was conducted in three hospitals. Four hundred and fifteen patients comprising 185 males and 227 females (3 subjects did not reveal their gender) with knee osteoarthritis (KOA) participated in the study. Seventy nine participants without KOA were recruited as controls. The functionality and quality of life level in patients and healthy participants were assessed using translated versions of the KOOS and Short Form-36 (SF-36) scales. Internal consistency of the instrument was assessed by Cronbach alpha. Construct validity and test-retest reliability were examined using the Intraclass Correlation Coefficient (ICC). Confirmatory Factor Analysis (CFA) was used to assess factorial validity.ResultsThe mean age (± sd) of the KOA subjects was 54.9 (± 9.2) years and for the control group was 49.2 (± 8.0) years. Majority of the respondents were female and Sinhalese in both groups. Internal consistency reliability was high (Cronbach’s alpha values ≥ 0.70). The test–retest reliability was excellent with the intraclass correlation coefficient for all subscales being above 0.90. Construct validity was assessed by the magnitude of the correlation coefficient between KOOS and SF-36 subscale scores. KOOS Pain scale moderately correlated with SF-36 bodily pain (Pearson’s r = 0.41). SF-36 physical function scores had a weak positive correlation with all KOOS subscales and SF-36 emotional wellbeing was not significantly correlated with KOOS Quality of Life (QoL) subscale. A five-factor Confirmatory Factor Analysis (CFA) model yielded a Comparative Fit Index (CFI) = 0.950, Tucker Lewis Index (TLI) = 0.946, Root Mean Square Error of Approximation (RMSEA) = 0.082 and Standardised Root Mean squared Residual (SRMR) = 0.072.ConclusionThe Sinhala translation of the KOOS scale is a reliable and valid instrument to assess KOA in a Sinhala-speaking Sri Lankan population. Studies to assess its use as a scale to evaluate responsiveness are recommended.

Responsiveness of the Various Short-Form Versions of the Knee Injury and Osteoarthritis Outcome Score Between 2 and 5 Years After Anterior Cruciate Ligament Reconstruction

Background: Various short-form versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) have been developed in an attempt to minimize responder burden. However, the responsiveness of these short-form measures in patients who have undergone anterior cruciate ligament (ACL) reconstruction has not been compared at midterm follow-up. Purpose: To determine the responsiveness of 3 short-form versions of the KOOS (KOOS-12, KOOS-Global, and KOOS-ACL) in patients who have undergone ACL reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: In 276 patients (149 male, 127 female), we administered the KOOS and a measure of overall knee function at both 2 and 5 years after ACL reconstruction. From the full KOOS, the following short-form versions were calculated: KOOS-12, KOOS-Global, and KOOS-ACL. Responsiveness was assessed using several distribution and anchor-based methods for each of the short-form versions. From distribution statistics the standardized response mean (SRM) and smallest detectable change (SDC) were calculated. Using the anchor-based method, the minimally important change (MIC) that was associated with an improvement in knee function was determined using receiver operating characteristic (ROC) analysis. Results: High ceiling effects were present for all measures. KOOS-Global scores increased significantly over time, whereas KOOS-12 and KOOS-ACL did not change. The KOOS-Quality of Life (QOL) subscale, which can be derived from both KOOS-Global and KOOS-12, also increased significantly between assessments. Both these increases were associated with a small (0.2-0.3) SRM. The MIC was smallest for KOOS-Global (3.2 points) and largest for KOOS-QOL (9.4 points), and, for all measures, the MIC was larger than the SDC at a group level. KOOS-Global was the only measure for which the mean difference between the 2- and 5-year assessments exceeded both the SDC (group level) and the MIC. Conclusion: Of the 3 short-form versions of the KOOS currently available, the KOOS-Global had the greatest responsiveness to change between the 2- and 5-year assessments after ACL reconstruction. High ceiling effects were present for all versions.

Weight loss enhances meniscal healing following transtibial pullout repair for medial meniscus posterior root tears.

This study investigated the impact of weight change on the success of transtibial pullout repair for medial meniscus (MM) posterior root tears (MMPRTs). The study included 129 patients diagnosed with MMPRTs who had undergone transtibial pullout repair. The patients were screened between July 2018 and November 2021. Patient-reported outcomes were assessed preoperatively and at 12 months postoperatively using the Knee injury and Osteoarthritis Outcome Score (KOOS). MM extrusion (MME) and ΔMME (postoperative MME - preoperative MME) were calculated preoperatively and at 12 months postoperatively using magnetic resonance imaging. Patients were divided into weight loss (body mass index [BMI] decrease of at least 0.5 kg/m2 after primary repair; n = 63) and weight gain (BMI increase of at least 0.5 kg/m2 ; n = 66) groups. Both groups had similar demographic variables and preoperative clinical scores; patient-reported outcomes significantly improved postoperatively. The weight loss group had significantly greater improvement in KOOS-quality of life (weight loss, 29.4 ± 23.7; weight gain, 23.9 ± 27.6; p = 0.034), lower postoperative MME (weight loss, 3.9 ± 1.7 mm; weight gain, 4.2 ± 1.2 mm; p = 0.043) and lower ΔMME (weight loss, 0.8 ± 0.8 mm; weight gain, 1.2 ± 0.9 mm; p = 0.002) than the weight gain group. Total arthroscopic healing scores (weight loss, 7.6 ± 1.0; weight gain, 7.2 ± 1.5; p = 0.048) and associated subscales, including anteroposterior bridging tissue width (weight loss, 4.0 ± 0.0; weight gain, 3.8 ± 0.7; p = 0.004) and MM posterior root stability (weight loss, 2.6 ± 0.7; weight gain, 2.4 ± 0.7; p = 0.041), significantly differed between the groups. Weight loss was associated with better meniscal healing and less MME progression after MMPRT repair, highlighting the significance of weight management in individuals undergoing meniscal surgery. These findings provide valuable insights into the clinical significance of weight loss in the success of transtibial pullout repair for MMPRTs. Level III.

Comparative Effects of High and Low Intensity Progress Resisted Exercises on Pain, Range of Motion and Functional Disability in Knee Osteoarthritis Patients with Sarcopenia: A Randomized Controlled Trial

Background: Osteoarthritis is the most common kind of arthritis, affecting millions of people. It develops because of the slow loss of the protective cartilage that cushions the ends of the bones over time. Although osteoarthritis may affect any joint, it is most often connected with joints in the hands, knees, hips, and spine. Objective: To compare the effects of high and low intensity progressive resisted exercises on pain, range of motion and functional disability in knee osteoarthritis patients with sarcopenia. Methods: It was a Randomized Controlled Trial. Data was collected from University of Lahore Teaching Hospital, physical therapy department. Group A- High Intensity Program and Group B- Low Intensity Program each had 42 patients in them. They were all male and female, between the ages of 35 and 65, and had osteoarthritis of different grades, according to Kallgren and Lawrence. The SARC-F questionnaire was used to find out if people had sarcopenia. The outcome measures were pain, functional disability, as well as range of motion. Results: Group A had a mean age of 58.47 years (SD = 4.22) and a mean symptom duration of 3.47 (SD = 1.82). In contrast, Group B had a slightly higher mean age of 58.8 years (SD = 3.11) and a mean symptom duration of 3.04 (SD = 1.68). At baseline, no significant differences were seen between Group A and Group B in terms of knee range of motion, KOOS pain, KOOS function, and KOOS quality of life. However, after 8 weeks, all variables showed significant differences (p&gt;0.05) except for knee flexion (p&gt;0.05). Conclusion: Low-intensity exercises showed greater improvements in pain, functional disability, quality of life, and range of motion compared to the high-intensity group among knee osteoarthritis patients with sarcopenia. Notably, knee flexion exhibited superior enhancement within the high-intensity exercise regimen.

Increased quadriceps muscle strength after medial meniscus posterior root repair is associated with decreased medial meniscus extrusion progression

BackgroundThis study aimed to assess quadriceps muscle strength after medial meniscus (MM) posterior root repair and determine its relationship with clinical scores and MM extrusion (MME).MethodsThirty patients who underwent pullout repair for MM posterior root tear and were evaluated for quadriceps muscle strength preoperatively and at 1 year postoperatively were included in this study. Quadriceps muscle strength was measured using the Locomo Scan-II instrument (ALCARE, Tokyo, Japan). MME and clinical scores (i.e., Knee Injury and Osteoarthritis Outcome Score [KOOS], International Knee Documentation Committee score, Lysholm score, Tegner score, and visual analog scale pain score) were evaluated preoperatively and at 1 year postoperatively, and second-look arthroscopy was performed at 1 year postoperatively. Wilcoxon's signed-rank test was used to compare each measure pre- and postoperatively. Pearson's correlation coefficient was used to assess the correlation with quadriceps muscle strength values. Multiple regression analysis was performed to identify factors associated with the change in MME (ΔMME).ResultsSecond-look arthroscopy confirmed continuity of the posterior root in all patients. The quadriceps muscle strength measured at 1 year postoperatively (355.1 ± 116.2 N) indicated significant improvement relative to the quadriceps muscle strength measured preoperatively (271.9 ± 97.4 N, p < 0.001). The MME at 1 year postoperatively (4.59 ± 1.24 mm) had progressed significantly relative to the MME preoperatively (3.63 ± 1.01 mm, p < 0.001). The clinical scores at 1 year postoperatively were improved significantly relative to the scores preoperatively (p < 0.001). The postoperative quadriceps muscle strength was correlated with ΔMME (correlation coefficient = -0.398, p = 0.030), and the change in quadriceps muscle strength was correlated with the KOOS-Quality of Life (correlation coefficient = 0.430, p = 0.018). Multiple regression analysis showed that the postoperative quadriceps muscle strength had a significant effect on ΔMME even when the body mass index and time from injury to surgery were included.ConclusionsAfter MM posterior root repair, patients with greater quadriceps muscle strength showed less MME progression. In addition, patients with greater improvement in quadriceps muscle strength had better clinical scores; therefore, continued rehabilitation aimed at improving quadriceps muscle strength after MM posterior root repair is recommended.Level of evidenceIV

Clinical and Patient-Reported Functional Outcome of Semitendinosus Autograft Anterior Cruciate Ligament Reconstruction With FiberTape® InternalBrace™ All-Inside Technique: A Prospective Study.

The purpose of this study is to report the early one-year clinical and patient-reported functional outcomes of semitendinosus autograft anterior cruciate ligament reconstruction with the FiberTape® InternalBrace™ all-inside technique. The patient-reported functional outcomes and clinical outcomes were analyzed prospectivelyfollowingthe treatment of 324 unilateral ACL rupture cases with the FiberTape® InternalBrace™ Technique. Patient-reported outcome measures (KOOS scores, WOMAC scores, VAS score, and IKDC score) and clinical examinations like pre-operative and post-operative pivot shift, Lachman test, and range of motion (ROM) were conducted. These tests and examinations were recorded for each patient before surgery and at 3, 6, and 12 months after surgery. Secondary outcomes like re-rupture, infection, synovitis, or limited range of motion were noted. The mean follow-up period was18±4.5 months (range: 12-24 months). Out of a total of 324 cases, 37 cases (11.4%) could not be followed up. 158 patients (55.1%) were male and 129 were female (44.9%). Preoperative mean KOOS pain value, KOOS symptoms, KOOS ADLs, KOOS sport and recreation, and KOOS quality of life were 77.05, 78.69, 84, 21, 89.7, and 57, respectively. All KOOS subsections increased significantly at one-year to 98.37, 99.09, 98.95, 99.02, and 99.30 (p<0.0001), respectively. Mean preoperative WOMAC pain, WOMAC stiffness, and WOMAC function were 76.4, 65.2, and 74.1 and increased significantly at one-year to 94.5, 89.6, and 98.2 (p<0.0001), respectively. There was a significant decrease in VAS for pain from 2.93 before surgery to 0.12 (p<0.0001) at one year. The IKDC score significantly changed from a pre-treatment value of 50.9 to 96.2 (94.5-97.8) at a follow-up of one year. The Lysholm score at 12-months was significant at 95 (93.1-96.9), p<0.05. Post-operative Lachman test values decreased significantly, which meant decreased laxity, from 1.98 (1.89-2.07) pre-operative to 1.60 (1.57-1.62) p<0.05 at one-year post-operative. At one-year follow-up, 276 patients (96%) had fully recovered. It was concluded that the FiberTape® InternalBrace™ technique for ACL reconstruction provides orthopedic surgeons with an effective alternative technique to conventional methods of surgery and also reduces the overall time to recovery for patients, thereby allowing them to return to sports faster. Level 4.

The Value of Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State for Commonly Used Patient-Reported Outcomes in Recurrent Patellar Instability Patients After Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer

To identify the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) for commonly used patient-reported outcomes (PROs) in recurrent patellar instability patients after medial patellofemoral ligament reconstruction (MPFLR) and tibial tubercle transfer (TTT), and to determine the impact of potential prognostic factors on the likelihood of achieving these values. From April 2015 to February 2021, patients who underwent MPFLR and TTT were retrospectively reviewed. PROs included Kujala, Knee Injury and Osteoarthritis Outcome (KOOS), Lysholm, International Knee Documentation Committee (IKDC) and Tegner score. Relevant anchor questions were provided. A distribution- or anchor-based method was adopted to determine the MCID, SCB and PASS. Minimal detectable change (MDC) was included to confirm the validity. Univariate regression analyses were conducted to determine the potential prognostic factors. 142 patients were included. The MCID were 9.1(Kujala), 11.1 (Lysholm), 0.9(Tegner), 9.9(IKDC), 9.0(KOOS-Pain), 10.8(KOOS-Symptoms), 10.0(KOOS-Activities of Daily Living (ADL)), 17.8(KOOS-Sports and Recreation (Sports/Rec)), and 12.7 (KOOS-Quality of Life (QoL)). The SCB were 14.5(Kujala), 12.5(Lysholm), 1.5(Tegner), 14.5(IKDC), 13.9(KOOS-Pain), 14.3(KOOS-Symptoms), 18.4(KOOS-ADL), 47.5(KOOS-Sports/Rec), 15.0(KOOS-QoL). The PASSs were 85.5(Kujala), 75.5(Lysholm), 3.5(Tegner), 73.2(IKDC), 87.5(KOOS-Pain), 73.2(KOOS-Symptoms), 92.0(KOOS-ADL), 77.5(KOOS-Sports/Rec), and 53.1(KOOS-QoL). All SCBs were valid except KOOS-QoL. All MCIDs were valid at the 95% confidence interval (CI) except KOOS scores, the majority of which were valid at the 90% CI. A younger age was an independent prognostic factor of reaching PASS for Lysholm, IKDC, Tegner and KOOS-ADL score. A higher baseline score was a negative prognostic factor for achieving MCID or SCB but had a slightly positive influence on the achievement of PASS. This study established the MCID, SCB, and PASS for commonly used PROs and confirmed their validity in recurrent patellar instability patients after MPFLR and TTT. Younger age and lower baseline scores were prognostic factors of achieving MCID and SCB, while patients with higher baseline scores were more likely to report satisfaction.

Paper 42: A Novel Machine Learning (ML) Algorithm to Predict Outcomes after Revision ACLR (rACLR) in the Multicenter Anterior Cruciate Ligament Reconstruction Study (MARS) Cohort

Objectives: The multicenter anterior cruciate ligament reconstruction study (MARS) Group has implicated several factors that influence revision anterior cruciate ligament (rACLR) outcomes. As machine learning (ML) becomes increasingly utilized in the orthopaedic literature, the application of ML methodology to MARS cohort data presents a valuable opportunity to translate data into patient-specific insights. This study sought to apply novel ML methodology to the MARS cohort data in order to determine 1) an optimal predictive model of rACLR graft failure and 2) features that are most predictive of rACLR graft failure in context of the predictive model. Methods: The MARS Group of 83 surgeons and 52 sites prospectively enrolled a cohort of patients undergoing rACLR. Patients were followed up at 2 and 6 years postoperatively regarding patient-reported outcomes (PROs), additional surgeries, and incidence of graft failure. Surgeon reported intraoperative findings and preoperative radiographic measures were obtained. Data was preprocessed and 381 demographic, clinical, and surgical features were used to build five machine learning models predictive of graft failure at 6 years postoperatively. Models used included traditional logistic regression (LR), XGBoost, Gradient Boosting, Random Forest, and a validated ensemble algorithm, AutoPrognosis (AP). Validated performance metrics for binary outcome prediction models were used to determine discriminative power and calibration. Individual feature importance was calculated for the highest performing models using partial dependence and perturbation-based feature importance. Results: The cohort included 831 patients who completed six year follow up, and 5.8% (n=48) of whom experienced graft failure. While all models had moderate to good concordance, AP demonstrated the highest discriminative power compared to other models (Model: AUROC | AP: 0.722 | Random Forest: 0.621 | Gradient Boosting: 0.654 | XGBoost: 0.690 | Logistic Regression: 0.630). The AP model was well-calibrated, with calibration scores similar to the other studied models (Model: Brier Score | AP: 0.054 | Random Forest: 0.054 | Gradient Boosting: 0.059 | XGBoost: 0.059 | Logistic Regression: 0.102). Features deemed important for AP differ from those for LR model performance. For AP, partial dependence feature importance calculations demonstrated the following top five contributors to model predictive ability: surgeon years of experience, prior femoral tunnel position measured via preoperative radiograph, compromised prior ACLR femoral tunnel position and size, and baseline patient age. Similarly, AP perturbation-based calculations showed the following top five features that contribute most to the AUROC performance: baseline patient age, current ACLR graft type, years since previous ACLR, prior ACLR femoral tunnel position, and prior tibial tunnel position on sagittal view preoperative radiographs. Perturbation-based calculations showed the following top five features that contribute most to the AUPRC performance: current ACLR graft type, baseline patient age, prior tibial tunnel position on sagittal view preoperative radiographs, previous ipsilateral medial meniscus repair, and baseline SF-36 subscale scores for patient vitality. Other leading contributors to model predictive ability included baseline PROs including SF-36 subscale scores for physical function, mental health and composite mental health, KOOS quality of life, WOMAC pain, and MARX activity rating scores. Conclusions: Of the studied models in this preliminary analysis, AP appears to most accurately predict rACLR graft failure. These findings build on prior studies, identifying key surgical, clinical, radiographic, and patient-reported factors contributing to the model’s ability to predict rACLR graft failure at 6 years postoperatively. Further work includes creation of a clinical risk calculator using important feature inputs, and the use of survival modeling to determine risk scores at various postoperative time points.

Effect of Lower Extremity Torsion on Clinical Outcomes After Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer for Recurrent Patellofemoral Instability

Background: Increased femoral torsion (FT) or tibial torsion (TT) has been suggested to be a potential risk factor for recurrent patellofemoral instability. However, the influence of increased FT or TT on the postoperative clinical outcomes of recurrent patellofemoral instability has rarely been investigated. Purpose: To assess the effect of increased FT or TT on postoperative results in patients with recurrent patellofemoral instability after combined medial patellofemoral ligament reconstruction (MPFLR) and tibial tubercle transfer, along with the influence of other risk factors. Study Design: Cohort study; Level of evidence, 3. Methods: Out of 91 patients, the study’s analyses included 86 patients with recurrent patellofemoral instability who were treated with MPFLR and tibial tubercle transfer and enrolled between April 2020 and January 2021. FT and TT were assessed using preoperative computed tomography images. According to the torsion value of FT or TT, patients were categorized into 3 groups for each of FT and TT: group A (<20°), group B (20°-30°), and group C (>30°). Patellar height, femoral trochlear dysplasia, and the tibial tuberosity–trochlear groove (TT-TG) distance were also assessed. Patient-reported outcome scores (Tegner, Kujala, International Knee Documentation Committee [IKDC], Lysholm, and Knee injury and Osteoarthritis Outcome Score [KOOS]) were evaluated pre- and postoperatively. Clinical failure of MPFLR was recorded. Subgroup analysis was conducted to evaluate the effect of increased FT or TT on the postoperative outcomes. Results: A total of 86 patients were enrolled with a median follow-up time of 25 months. At the final follow-up, all functional scores improved significantly. Patella alta, high-grade trochlear dysplasia, and increased TT-TG distance did not have any significant effect on the postoperative functional scores. Regarding FT, subgroup analysis indicated that all functional scores of group C were lower than those of groups A and B except the KOOS knee-related Quality of Life score. For TT, group C had lower scores than group A for all functional outcomes except Tegner and KOOS Quality of Life and lower scores than group B for Kujala, IKDC, KOOS (Symptoms and Sport and Recreation subscales), Tegner, and Lysholm scores. The comparison between group A and group B, whether for FT or TT, revealed no significant differences. Conclusion: For patients with recurrent patellofemoral instability, increased lower extremity torsion (FT or TT >30°) was associated with inferior postoperative clinical outcomes after combined MPFLR and tibial tubercle transfer.

Exercise Therapy for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

Exercise is an effective nonpharmaceutical therapy for knee osteoarthritis (KOA). To identify the most effective type of exercise therapy for KOA with regard to pain, stiffness, joint function, and quality of life. Systematic review; Level of evidence, 3. The PubMed, Web of Science, Embase, and Cochrane Library databases were searched, from inception to April 4, 2022. Included were randomized controlled trials that assessed the efficacy on KOA among 5 different exercise therapy groups (aquatic exercise [AE], stationary cycling [CY], resistance training [RT], traditional exercise [TC], and yoga [YG]) and compared with the control group. Outcomes among the groups were assessed with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), 6-minute walk test (6-MWT), visual analog scale (VAS) for pain, and Knee injury and Osteoarthritis Outcome Score (KOOS); weighted mean differences (WMDs) and 95% confidence intervals were calculated. Network meta-analyses comparing outcomes between all groups and with controls were performed, and group rankings were calculated using the surface under the cumulative ranking curve (SUCRA). A total of 39 studies (N = 2646 participants) were included. Most of the studies failed to blind participants and researchers, resulting in a high risk of performance bias. Significantly worse WOMAC-Pain scores were seen in controls compared with all exercise interventions except AE (WMD [95% CI]: CY, -4.45 [-5.69 to -3.20]; RT, -4.28 [-5.48 to -3.07]; TC, -4.20 [-5.37 to -3.04]; and YG, -0.57 [-1.04 to -1.04]), and worse scores were seen in controls compared with YG regarding WOMAC-Stiffness (WMD, -1.40 [95% CI, -2.45 to -0.34]) and WOMAC-Function (WMD, -0.49 [95% CI, -0.95 to -0.02]). According to the SUCRA, CY was the most effective for improving WOMAC-Pain (80.8%) and 6-MWT (76.1%); YG was most effective for improving WOMAC-Stiffness (90.6%), WOMAC-Function (77.4%), KOOS-Activities of Daily Living (72.0%), and KOOS-Quality of Life (79.1%); AE was the most effective regarding VAS pain (77.2%) and KOOS-Pain (64.0%); and RT was the most effective regarding KOOS-Symptoms (84.5%). All 5 types of exercise were able to ameliorate KOA. AE (for pain relief) and YG (for joint stiffness, limited knee function, and quality of life) were the most effective approaches, followed by RT, CY, and TC.

Internal Fixation of Unstable Osteochondritis Dissecans of the Knee: Long-term Outcomes in Skeletally Immature and Mature Patients

Background: Osteochondritis dissecans (OCD) is a disorder originating in the subchondral bone, leading to focal lesions with risk of fragmentation and secondary damage of the articular cartilage. It remains controversial if surgical treatment of such lesions is equally successful in skeletally immature and mature patients. Purpose: To determine (1) the long-term clinical success rate after internal fixation of unstable OCD in skeletally immature and mature patients based on physeal status, (2) if patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was conducted investigating skeletally immature and mature patients treated for unstable OCD lesions of the knee between 2000 and 2015. The healing rate was assessed by radiological imaging and clinical follow-up. Failure was defined as any definitive reoperation for the initially treated OCD lesion. Results: A total of 81 patients met inclusion criteria, including 25 skeletally immature patients and 56 patients with closed physes at the time of surgery. After a mean follow-up time of 11.3 ± 4 years, 58 (71.6%) patients had healed lesions, whereas the lesions failed to heal in 23 (28.4%) patients. No significant difference in risk of failure was observed based on physeal maturation status (hazard ratio, 0.78; 95% CI, 0.33-1.84; P = .56). Lateral versus medial condylar lesion location conferred an increased risk of failure (P < .05) for both skeletally immature and mature patients. Multivariate analysis of skeletal maturity status showed that a lateral femoral condylar location was an independent risk factor for failure (hazard ratio, 0.22; 95% CI, 0.1-0.5; P < .05). The mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] score and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery and remained high at the final follow-up (P < .05). The final scores (mean ± SD) at a mean follow-up of 135.8 months (range, 80-249 months) were IKDC, 86.6 ± 16.7; KOOS Pain, 88.7 ± 18.1; KOOS Symptoms, 89.3 ± 12.6; KOOS Activities of Daily Living, 89.3 ± 21.6; KOOS Sport and Recreation, 79.8 ± 26.3; and KOOS Quality of Life, 76.7 ± 26.3. Conclusion: The long-term results after internal fixation of OCD fragments show high rates of healing and sustainable subjective improvement of knee function and quality of life. A healing rate of 72% was noted at a mean follow-up of 11.3 years. The stage of skeletal maturity had no significant influence on the rate of failure. Lateral femoral condylar lesion location is an independent risk factor for failure in skeletally mature and immature patients.

Mild knee osteoarthritis predicts dissatisfaction after total knee arthroplasty: a prospective study of 186 patients aged 65 years or less with 2-year follow-up

Background and aimsThe incidence of total knee arthroplasty (TKA) is increasing, especially among younger working-age patients. However, dissatisfaction rates in this population are higher than among older patients. The aim of this study was to assess the rates of dissatisfaction and persistent pain after TKA and to evaluate those factors that predict these outcomes.Material and methodsIn total, 186 patients undergoing unilateral TKA aged 65 years or less were enrolled into this prospective observational study with 2-year follow-up. To assess the outcome, the visual analogue scales regarding satisfaction and persistent pain at rest and during exercise were used. In addition, the association between patients´ demographics, radiographic severity of knee osteoarthritis (OA), patient-reported outcome measures (PROMs) and dissatisfaction and persistent pain were tested by univariate logistic regression analysis. Mild OA was defined as Kellgren-Lawrence (KL) grade 2 and severe OA as KL grade 3–4. Furthermore, multiple logistic regression analysis was also conducted to test statistically significant relations.ResultsAfter 2 years, 12 % (n = 23) of patients were dissatisfied with the outcome of TKA, 27 % (n = 50) reported persistent pain during exercise and 10 % (n = 18) at rest. Patients with mild knee OA were significantly more dissatisfied (28.6 %) than patients with more severe OA (8.7 %) (p = 0.003). Younger patients had an increased risk for both dissatisfaction and persistent pain. Apart from KOOS Quality of Life, poor preoperative KOOS subscores were also predictive for these outcomes.ConclusionMild radiographic knee OA was the main predicting factor for dissatisfaction after TKA. Thus, performing TKA for such patients should be carefully considered. Furthermore, these patients should be informed about the increased risk for dissatisfaction and the same seems to apply to younger patients. Interestingly, when TKA is performed for patients with more severe knee OA, the satisfaction rates seem to be somewhat higher than those previously reported.Trial registrationThe study was retrospectively registered with ClinicalTrials.gov (registration number NCT03233620) on 28 July 2017.

OSTEOCHONDRAL ALLOGRAFTING IN THE SKELETALLY IMMATURE KNEE: HIGH RATES OF INCORPORATION AND EXCELLENT EARLY OUTCOMES

Background:While an excellent option for osteochondral defects in the adult knee, outcomes following fresh osteochondral allograft (OCA) the skeletally immature are limited. Purpose: To compare radiographic and patient reported outcomes (PROs) in mature and skeletally immature adolescents following OCA of the knee.Methods:An IRB-approved review of fresh size-matched OCA treatment of knee lesions in patients aged < 19 years within a pediatric sports medicine practice from 1/2006-3/2019 was completed. Following exclusion of patients with less than 12 months follow-up, demographics, lesion characteristics, reoperations, and PROs were evaluated. A novel grading scale (k= 0.832) was utilized to evaluate radiographic OCA incorporation: A=complete, B= >50%, or C= <50% healed.Results:Forty-four patients [15.5 years (9.6-19.8) treated with OCA of the distal femur or patella (LFC= 18, MFC=17, Trochlea=6, Patella=3), 24 with open and 20 with closed physes, with 2.2 year follow up (range 1-5.3 years) were evaluated. Overall average graft size was 4.76cm2 and did not differ significantly between groups. Thirty-nine patients underwent at least one prior procedure to the ipsilateral knee, most frequently for attempted osteochondral lesion healing (77%), followed by realignment (22.7%), and meniscal pathology (15.9%). Graft failure occurred in only one skeletally immature patient with a trochlear lesion.Those with open physes were more likely to demonstrate complete graft incorporation (66.6%, p=0.001). 21(88%) patients with open physes and 17(85%) patients with closed physes had radiographic healing grades of A or B one year post-operatively. There was no difference in healing grade based on graft size, depth, or location within the knee.There was no difference in pre-operative PROs or activity scores. At final follow-up, open physes OCA patients demonstrated better KOOS scores (KOOS daily living 97.0 vs 89.5, p=0.02; KOOS pain 95.7 vs 84.6, p= 0.04; KOOS quality of life 157.2 vs 59.6, p= 0.005). Final activity scores did not vary by skeletal maturity (Pedi-IKDC 75.8 vs 77.99; Pedi-FABS 17.2 vs 13.5,) or radiographic healing grade. Daily living and pain scores were better in those with more radiographic healing (KOOS daily living 98.6 vs 86,2, p= 0.02; KOOS pain 96.7 vs 82.3, p= 0.048).Conclusion:Fresh osteochondral allograft treatment in the young knee may be expected to yield good early results. Despite relatively large graft size, when indicated for patients with open physes, equivalent or improved healing and patient reported outcomes may be expected.

Low-Dose Perioperative Corticosteroids Can Be Administered Without Additional Morbidity in Patients Undergoing Bilateral Total Knee Replacement: A Retrospective Follow-up Study of a Randomized Controlled Trial.

Background: Short-term benefits of perioperative corticosteroid injections (CSIs) for bilateral total knee replacement (BTKR) include suppressed inflammation, improved knee motion, and reduced pain. Very little is known about the long-term benefits, complications, and safety of corticosteroids administered in the perioperative period. Purpose: We sought to compare 3-year follow-up outcomes of BTKR patients who received perioperative CSI with those who received placebo. We hypothesized that there would be no statistically significant differences in functional outcomes or adverse events based on whether or not CSIs were administered in the perioperative period. Methods: We conducted a retrospective review of chart and registry data of BTKR patients from a prior randomized controlled trial to compare outcomes in patients who received hydrocortisone vs placebo injections after BTKR (ClinicalTrials.gov: NCT01399268 and NCT01815918). Outcomes were compared at 6 and 12 weeks and at 1, 2, and 3 years. The Knee Injury and Osteoarthritis Outcome Scores (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate clinical outcomes. Cochran-Mantel-Haenszel tests were used to compare the risk of complications between treatments after adjustment for trial. When possible, summary relative risk estimates were calculated using the Mantel-Haenszel method. Results: No BTKR patients in the treatment group developed an infection. The risk of complications did not increase in patients who received CSI compared with those who received placebo. Patients in the CSI group experienced greater reductions in pain and stiffness, though these results were not statistically significant. There were no statistically significant differences in the KOOS-Symptoms, KOOS-Activities of Daily Living, KOOS-Sports, KOOS-Quality of Life, or WOMAC Function scores. Conclusions: Low-dose corticosteroids can be administered in selected patients who undergo BTKR without increasing the risk of adverse events. At 3-year follow-up, administration of low-dose corticosteroids did not result in superior clinical outcomes scores when compared with placebo.

Slope-Correction Osteotomy with Lateral Extra-articular Tenodesis and Revision Anterior Cruciate Ligament Reconstruction Is Highly Effective in Treating High-Grade Anterior Knee Laxity

Background: Both an elevated posterior tibial slope (PTS) and high-grade anterior knee laxity are often present in patients who undergo revision anterior cruciate ligament (ACL) surgery, and these conditions are independent risk factors for ACL graft failure. Clinical data on slope-correction osteotomy combined with lateral extra-articular tenodesis (LET) do not yet exist. Purpose: To evaluate the outcomes of patients undergoing revision ACL reconstruction (ACLR) and slope-correction osteotomy combined with LET. Study Design: Case series; Level of evidence, 4. Methods: Between 2016 and 2018, we performed a 2-stage procedure: slope-correction osteotomy was performed first, and then revision ACLR in combination with LET was performed in 22 patients with ACLR failure and high-grade anterior knee laxity. Twenty patients (6 women and 14 men; mean age, 27.8 ± 8.6 years; range, 18-49 years) were evaluated, with a mean follow-up of 30.5 ± 9.3 months (range, 24-56 months), in this retrospective case series. Postoperative failure was defined as a side-to-side difference of ≥5 mm in the Rolimeter test and a pivot-shift grade of 2 or 3. Results: The PTS decreased from 15.3° to 8.9°, the side-to-side difference decreased from 7.2 to 1.1 mm, and the pivot shift was no longer evident in any of the patients. No patients exhibited revision ACLR failure and all patients showed good to excellent postoperative functional scores (mean ± SD: visual analog scale, 0.5 ± 0.6; Tegner, 6.1 ± 0.9; Lysholm, 90.9 ± 6.4; Knee injury and Osteoarthritis Outcome Score [KOOS] Symptoms, 95.2 ± 8.4; KOOS Pain, 94.7 ± 5.2; KOOS Activities of Daily Living, 98.5 ± 3.2; KOOS Function in Sport and Recreation, 86.8 ± 12.4; and KOOS Quality of Life, 65.4 ± 14.9). Conclusion: Slope-correction osteotomy in combination with LET is a safe and reliable procedure in patients with high-grade anterior knee laxity and a PTS of ≥12°. Normal knee joint stability was restored and good to excellent functional scores were achieved after a follow-up of at least 2 years.

Single-Stage Autologous Chondrocyte-Based Treatment for the Repair of Knee Cartilage Lesions: Two-Year Follow-up of a Prospective Single-Arm Multicenter Study

Background: There is an unmet need for a single-stage cartilage repair treatment that is cost-effective and chondrocyte-based. Purpose: To evaluate the safety and preliminary efficacy of autologous freshly isolated primary chondrocytes and bone marrow mononucleated cells (MNCs) seeded into a PolyActive scaffold in patients with symptomatic cartilage lesions of the knee. Study Design: Case series; Level of evidence, 4. Methods: A total of 40 patients with symptomatic knee cartilage lesions were treated with freshly isolated autologous chondrocytes combined with bone marrow MNCs delivered in a biodegradable load-bearing scaffold. The treatment requires only 1 surgical intervention and is potentially a cost-effective alternative to autologous chondrocyte implantation. The primary chondrocytes and bone marrow MNCs were isolated, washed, counted, mixed, and seeded into a load-bearing scaffold in the operating room. Patients were followed up at 3, 6, 12, 18, and 24 months. Primary endpoints were treatment-related adverse events up to 3 months, adverse implant effects between 3 and 24 months, and the implant success rate at 3 months as measured by lesion filling. Results: Successful lesion filling (≥67% on magnetic resonance imaging) was found in 40 patients at 3 months and in 32 of the 32 patients analyzed at 24 months. Significant improvement over baseline was found for visual analog scale for pain from 3 months onward; Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain and KOOS-Activities of Daily Living from 6 months onward; for KOOS-Symptoms and Stiffness, KOOS-Quality of Life and International Knee Documentation Committee from 12 months onward; and for KOOS-Sport and Recreation from 18 months onward. Hyaline-like repair tissue was found in 22 of 31 patients available for biopsy. Arthralgia and joint effusion were the most common adverse events. Scaffold delamination and adhesions led to removal of the implant in 2 patients. Conclusion: The treatment of knee cartilage lesions with autologous primary chondrocytes and bone marrow MNCs, both isolated and seeded into a load-bearing PolyActive scaffold within a single surgical intervention, is safe and clinically effective. Good lesion fill and sustained clinically important and statistically significant improvement in all patient-reported outcome scores were found throughout the 24-month study. Hyaline-like cartilage was observed on biopsy specimen in at least 22 of the 40 patients. Registration: NCT01041885 (ClinicalTrials.gov identifier)

Preoperative Validation of the Patient-Reported Outcomes Measurement Information System in Patients With Articular Cartilage Defects of the Knee

To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF CAT) with current patient-reported outcome (PRO) instruments in patients with cartilage injuries of the knee. Patients scheduled for osteochondral autograft or allograft transplant, microfracture, autologous chondrocyte implantation, allograft cartilage resurfacing, and chondroplasty were prospectively enrolled in the study and completed PROMIS PF CAT, Knee Injury and Osteoarthritis Outcome Score (KOOS activities of daily living, pain, symptoms, sport, and quality of life), Short Form-36 Health Survey (SF-36 physical function [PF] and Physical Component Summary), and EuroQol-5 Dimension questionnaires. The Spearman correlation coefficient was used to compare instruments. Instrument correlations were defined as excellent (>0.7), excellent to good (0.61-0.69), good (0.4 to 0.6), and poor (<0.39), with significance defined as P < .05. A total of 293 knees in 275 patients (54.5% male) undergoing 319 cartilage procedures were analyzed. The most commonly performed cartilage procedure was chondroplasty (n= 118; 37.0%), followed by microfracture (n= 100; 31.3%). The mean age was 34.0 ± 14.7 and the mean body mass index was 30.0 ± 6.9. The PROMIS PF CAT had an excellent correlation with the SF-36 PF (r= 0.819; P < .001), SF-36 Physical Component Summary (r= 0.766; P < .001), KOOS activities of daily living (r= 0.733; P < .001), KOOS Sport (r= 0.709; P < .001), and EuroQol-5 Dimension (r= 0.752; P < .001) instruments; an excellent-good correlation with the KOOS pain (r= 0.662; P < .001), and KOOS quality of life (r= 0.640; P < .001) scores; and a good correlation with the KOOS symptoms (r= 0.519; P < .001) scale. The PROMIS PF CAT had no floor or ceiling effects and the smallest question burden (mean 4.17 ± 0.93 questions). Dimensionality analyses demonstrated that the smallest amount of unexplained variance was present in the PROMIS PF CAT (3.6%). The PROMIS PF CAT is an effective tool for preoperative outcome assessment in patients with cartilage defects of the knee. It correlates strongly with legacy PRO measures of physical function with no ceiling and floor effects and a minimal time burden for completion. Further study is warranted to determine postoperative performance and to evaluate the responsiveness of PROMIS to change within a patient. III; Prognostic retrospective comparative study.