Marx Activity Research Articles

Anterior cruciate ligament repair with Independent Suture Tape Reinforcement: a case series with 2-year follow-up.

The treatment of acute anterior cruciate ligament (ACL) ruptures with a repair technique has recently regained interest. A novel ACL repair technique was described using Independent Suture Tape Reinforcement with 2-year follow-up results. Forty-two consecutive patients with an acute ACL rupture undergoing repair using this technique were followed up for a minimum of 2years. Patients with mid-substance, distal ACL ruptures, poor ACL tissue quality or retracted ACL remnants as well as patients with multi-ligament injuries were excluded. Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and the Marx Activity scale were collected by online questionnaires. Two-year postoperative patients were asked by telephone if they had experienced a rerupture. All the KOOS subscales improved significantly in comparison to the preoperative score. The largest improvement of all scores was seen at 3months postoperatively which is significant in all cases. The KOOS sport and recreation showed a meaningful change and the largest improvement of the KOOS subscales at 3months postoperatively, as well as the highest total improvement at 1year postoperatively compared to preoperatively. The VAS-pain and VR-12 physical score improved significantly, however the Marx activity scale decreased significantly in comparison to preoperative scores. Two patients reported a rerupture (4.8%, CI 1.7-11.2%). This is the first case series that described the 2-year follow-up results of patients with an acute, proximal ACL rupture, treated with the Independent Suture Tape Reinforcement repair technique. A meaningful KOOS sport and recreation change and significant improvements in the KOOS, VAS-pain and VR-12 physical scores as well as a significant decrease of the Marx activity scale in comparison to preoperative scores are demonstrated. Two of the 42 patients (4.8%) reported an ACL rerupture. Repair with this technique could be clinically relevant as a treatment option for patients with an acute, proximal ACL rupture which is not retracted and of good tissue quality. IV.

Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series

ABSTRACTObjectives: There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.Methods: A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.Results: A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17–43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4–15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.Conclusions: Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.

Effect of High-Grade Preoperative Knee Laxity on 6-Year Anterior Cruciate Ligament Reconstruction Outcomes

Background: Knee laxity in the setting of anterior cruciate ligament (ACL) injury is often 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. Hypothesis: Increased preoperative knee laxity is associated with increased risk of revision ACL reconstruction, increased risk of contralateral ACL reconstruction, and poorer patient-reported outcomes at 6 years postoperatively. Study Design: Cohort study; Level of evidence, 2. Methods: 2333 patients who underwent primary isolated ACL reconstruction without additional ligament injury were identified. Patients reported by the operating surgeons to have an International Knee Documentation Committee (IKDC) grade D Lachman, anterior drawer, or pivot shift examination were classified as having a high-grade laxity. Multiple logistic regression models were used to evaluate whether having high-grade preoperative laxity was predictive of increased odds of undergoing subsequent revision or contralateral ACL reconstruction within 6 years of the index procedure, controlling for patient age, sex, body mass index, Marx activity level, sport, graft type, medial meniscal treatment, and lateral meniscal treatment. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was predictive of poorer IKDC or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life (KOOS-QOL) scores at 6 years postoperatively, after controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscal status. Results: In total, 743 of 2325 patients (32.0%) were noted to have high-grade laxity on at least 1 physical examination test. High-grade Lachman was noted in 334 patients (14.4%), high-grade pivot shift was noted in 617 patients (26.5%), and high-grade anterior drawer was noted in 233 patients (10.0%). Six-year revision and contralateral ACL reconstruction data were available for 2129 patients (91.6%). High-grade prereconstruction Lachman was associated with significantly increased odds of ACL graft revision (odds ratio [OR], 1.76; 95% CI, 1.10-2.80, P = .02) and contralateral ACL reconstruction (OR, 1.68; 95% CI, 1.09-2.69; P = .019). High-grade prereconstruction pivot shift was associated with significantly increased odds of ACL graft revision (OR, 1.75; 95% CI, 1.19-2.54, P = .002) but not with significantly increased odds of contralateral ACL reconstruction (OR, 1.30; 95% CI, 0.89-1.87; P = .16). High-grade prereconstruction laxity was associated with statistically significantly lower 6-year IKDC (β = −2.26, P = .003), KOOS-QOL (β = −2.67, P = .015), and Marx activity scores (β = −0.54, P = .020), but these differences did not approach clinically relevant differences in patient-reported outcomes. Conclusion: High-grade preoperative knee laxity is predictive of increased odds of revision ACL reconstruction and contralateral ACL reconstruction 6 years after ACL reconstruction. Poorer patient-reported outcome scores in the high-grade laxity group were also noted, but the difference did not reach a level of clinical relevance.

Younger age and greater preoperative function predict compliance with 2-year follow-up visits after ACL reconstruction: an analysis of the PIVOT multicentre trial

ObjectivesThe purpose of this investigation was to identify clinical and demographic variables that may predict compliance, defined as patient follow-up at 1-year and 2-year postoperative appointments, after anterior cruciate ligament reconstruction (ACLR).MethodsA total of 107 patients undergoing primary ACLR across four centres were prospectively followed for 2 years. Demographic and clinical data were recorded preoperatively and postoperatively, including patient-reported outcomes such as the Marx Activity Rating Scale, Cincinnati Occupational Rating Scale (CORS), International Knee Documentation Committee Subjective Knee Evaluation Form and Activities of Daily Living Scale (ADLS). Compliance was retrospectively defined using the presence or lack of outcome measures at 1-year and 2-year postoperative visits. Univariate analysis was done to compare demographic and clinical variables between compliant and non-compliant patients at 1-year and 2-year follow-up. Significant variables were entered into a logistic regression model. Significance was set at p<0.05.ResultsThe overall rate of compliance at 1-year and 2-year postoperative appointments was 83.2% (89/107) and 57.0% (61/107), respectively. Regression analysis showed that residence in Kobe, Japan compared with Pittsburgh, USA (OR 10.28; 95% CI 1.0003 to 105.28), and ‘very strenuous’ (OR 16.74; 95% CI 3.21 to 87.43) and ‘strenuous’ (OR 18.78; 95% CI 2.01 to 175.78) preinjury activity level were independent factors associated with compliance at 1-year follow-up. At 2 years follow-up, younger age (OR 0.95; 95% CI 0.91 to 0.997), and greater preoperative score on CORS (OR 1.03; 95% CI 1.01 to 1.06) and on ADLS (OR 1.04; 95% CI 1.01 to 1.07) were independently associated with compliance.ConclusionWhile patients with greater level of strenuous activity were more likely to follow-up after ACL surgery at 1 year, patients who were younger and had higher preoperative function measured by CORS and ADLS were more likely to follow-up at 2 years. Differences in follow-up rates among the USA, Italy, Sweden and Japan may highlight important cultural, socioeconomic and infrastructural differences across international healthcare systems. Orthopaedic surgeons may consider the results of this study during preoperative discussion with their patients and design of future ACL clinical research trials.Level of evidenceLevel III, prospective cohort.

Tunnel Bone Grafting in Revision Anterior Cruciate Ligament Reconstruction Cruciate Ligament Reconstruction

Objectives:Bone grafting of lytic or malpositioned tunnels may be required in ACL revision reconstructive surgery. Little is known of the characteristics of these patients and the impact of this practice on the results following revision ACL reconstruction (rACLR). The purpose of this study was to report the differences in preoperative characteristics, surgical assessment, and 2-year outcomes for rACLR patients undergoing tunnel bone grafting procedures.Methods:1205 patients who underwent rACLR were enrolled in the Multicenter ACL Revision Study (MARS) consortium between 2006 and 2011, comprising the prospective cohort. Two-year questionnaire follow-up was obtained on 989 (82%), while telephone follow-up was obtained on 1112 (92%). Subjects undergoing previous or concurrent bone grafting of ACL tunnels were compared with subjects without tunnel grafting. Group characteristics were compared using chi-squared and ANOVA statistical analyses.Results:At total of 158 subjects (13%) underwent tunnel grafting procedures compared to 1,047 who did not. Of these, 95 underwent prior staged bone grafting and 63 underwent concomitant bone grafting. Femoral bone grafting was performed on 31 subjects, tibial grafting in 39, and combined grafting in 88. Significant differences were noted in baseline patient reported outcomes (KOOS sports/recreation, KOOS QOL, and Marx activity) favoring the control group. Significant differences were noted in the number of prior ACL reconstructions, prior graft type, prior femoral fixation method, prior femoral and tibial tunnel locations between the two groups. Significant differences were also noted in the current choice of ACL revision reconstruction technique including graft selection, method of femoral tunnel drilling, femoral fixation, tibial fixation and aperture assessment. Both femoral and tibial bone quality was deemed to be abnormal in 20% of revision surgeries in the bone graft group, compared with 6 and 7% in control group (both p<0.001). Two-year patient reported outcomes were inferior in the bone graft group (KOOS sports/recreation, KOOS QOL, and Marx activity).Conclusion:Tunnel bone grafting was performed in 13% of ACL revision patients. These patients had inferior baseline and 2-year patient reported outcomes and activity levels compared to patients not undergoing bone grafting.

Release of Tibialis Posterior Muscle Osseofascial Sheath for Chronic Exertional Compartment Syndrome Leads to Improved Outcomes

Category: Sports Introduction/Purpose: Success rates for surgical management of chronic exertional compartment syndrome (CECS) in the lower extremity are influenced by the leg compartment involved. A failure rate of 40-50% has been associated with release of the deep posterior compartment, which has historically been associated with significantly worse outcomes than isolated anterolateral releases. The tibialis posterior muscle often resides in a separate osseofascial sheath, the so-called “fifth compartment.” At our institution, when a deep posterior release is performed, we routinely examine for this fifth compartment and release it if present. Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in those that underwent 2-versus 4-compartment fasciotomy for CECS. Methods: Our study reports on 48 limbs from 31 patients associated with a consecutive series that presented to a single institution for surgical management of lower extremity CECS from 2007-2016. The mean (standard deviation) follow-up was 65 (+/- 28) months. All patients underwent pre-operative intramuscular compartment pressure testing for CECS diagnosis. All surgeries were performed by a single surgeon. In all patients in which 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath. This sheath was released when present. The presence or absence of the sheath was always dictated in the operative note. Patient satisfaction outcomes were assessed with a Likert scale (excellent, good, fair, or poor). Current activity level was assessed via Marx and Tegner activity scores. Results: Of the 48 limbs, 29 limbs received 2-compartment anterolateral releases only and 19 limbs received 4-compartment fasciotomies. Of those that received 4-compartment fasciotomies, 13 (68%) were found to have a separate osseofascial sheath surrounding the tibialis posterior muscle. At a mean 5-year follow-up interval, 77% of the total cohort rated their outcome as good or excellent. Among the 4-comparment fasciotomy sub-cohort, 79% of patients rated their outcome as good or excellent. Among the entire cohort, there were no revision surgeries performed. The overall mean Tegner and Marx activity scores were 6 and 11 respectively. There was no significant difference in mean outcome scores between those that had 2-versus 4-compartment fasciotomies. Conclusion: Our study illustrates that 1) a separate osseofascial sheath exists around the tibialis posterior muscle in the majority of cases and 2) if this fifth compartment is consistently examined for and released, patients can achieve equivalent success rates and return to a similarly high activity level as those that undergo 2-compartment fasciotomy for CECS. Our study demonstrates superior results for 4-compartment release and includes the longest mean follow-up time for CECS patients in the literature.

Preoperative Outcome Scores are Predictive of Achieving the Minimal Clinically Important Difference After Treatment of Focal Cartilage Defects of the Knee with Osteochondral Grafts

Objectives:Osteochondral autograft transfer (OAT) and fresh osteochondral allograft transplantation (OCA) are popular cartilage restoration techniques that involve the single-stage implantation of viable, mature hyaline cartilage into focal chondral defects of the knee. Both techniques have demonstrated good results, as defined by statistically significant post-surgical improvements in patient-reported outcome measures. Recently, there has been greater focus on what represents a clinically relevant change in outcomes reporting, and commonly applied metrics for measuring clinical significance, such as the minimal clinically important difference (MCID) and substantial clinical benefit (SCB), have become the standard. Although a previous study defined a MCID in patients treated for articular cartilage defects in the knee (Greco et al, AJSM 2010), these patients were treated with various cartilage restoration procedures (e.g., debridement, microfracture, autologous chondrocyte implantation), and none were treated with OAT/OCA. Therefore, the purpose of this study was to define the MCID and SCB thresholds after OAT/OCA for the International Knee Documentation Committee subjective knee form (IKDC) and Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADL) and to determine clinical and demographic patient factors predictive for achieving the MCID and SCB after OAT/OCA.Methods:A prospective institutional cartilage registry was reviewed to identify patients who underwent OAT/OCA. The IKDC and KOS-ADL were administered preoperatively and at a minimum of 2 years postoperatively. The MCID and SCB of these outcome scores were calculated using anchor-based methods. Receiver operative characteristic (ROC) analysis was used to determine the SCB using an anchor question, with the area under the curve (AUC) used to evaluate predictive ability. Multivariate analysis was performed to identify patient factors associated with achieving the MCID and SCB.Results:In total, 173 knees in 173 patients (mean age, 33.0 ± 13.2 years; 37.0% female) were identified. Patient demographics and clinical variables are listed in Table 1. Using the anchor-based method, the MCID for the IKDC and KOS-ADL were 17 ± 3.9 and 10 ± 3.7, respectively. Using the ROC method, the SCB for the IKDC and KOS-ADL were 32 (AUC 0.86) and 10 (AUC 0.76), respectively. Univariate analysis demonstrated no association between procedure (OAT or OCA) or lesion location and likelihood of achieving the MCID/SCB. In multivariate analysis, lower preoperative IKDC scores and higher preoperative Marx Activity Scale scores were predictive of achieving an MCID and SCB on the IKDC, and lower preoperative KOS-ADL scores, lower preoperative SF-36 pain subscale scores, and a history of 1 or less previous ipsilateral knee surgeries were predictive of achieving a MCID and SCB on the KOS-ADL (Table 2).Conclusion:In patients treated for focal cartilage defects of the knee with osteochondral grafts, these values can be used to define a clinically important change and substantial clinical benefit for future outcome studies. In this study population, higher preoperative activity levels and a history of 1 or less previous ipsilateral knee surgeries were predictive of achieving a clinically important change and substantial clinical benefit after OAT/OCA. These findings have implications for managing preoperative expectations of OAT/OCA surgery.Table 1.Patient Demographics and Clinical Variables of Included Patients (N = 173)Age, y33 ± 13.2 Mean ± SD56 (32.4) Age <40 y64 (37.0)Female sex25.8 ± 4.5Body mass index, kg/m2 1.3 ± 1.5No. of previous surgeriesChondral lesion characteristics Lesion location Medial femoral condyle79 (45.7) Lateral femoral condyle59 (34.1) Trochlea28 (16.2) Patella30 (17.3) Lesion area, cm2 4.3 ± 2.6Procedure Osteochondral autograft transfer75 (43.4) Osteochondral allograft transplantation98 (56.7)Concomitant procedures ACLR2 (1.2) Meniscus allograft transplantation7 (4.0) Realignment osteotomy17 (9.8)Data are reported as n (%) unless otherwise indicated. ACLR = anterior cruciate ligament reconstructionTable 2.Multivariable Logistic Models for Achieving MCID and SCBOdds Ratio (95% CI)P ValueAchieving MCID on IKDC Age (≥40 y/<40 y)1.01 (0.43-2.40)0.985 Sex (Female/Male)0.96 (0.43-2.18)0.923 Preoperative IKDC0.95 (0.92-0.98)0.001 Preoperative Marx Activity Scale1.11 (1.03-1.19)0.005Achieving SCB ON IKDC Age (≥40 y/<40 y)0.60 (0.24-1.40)0.244 Sex (Female/Male)0.69 (0.31-1.50)0.360 Preoperative IKDC0.95 (0.92-0.98)0.001 Preoperative Marx Activity Scale1.14 (1.07-1.23)<0.001Achieving MCID and SCB on KOS-ADL Age (≥40 y/<40 y)0.92 (0.40-2.12)0.845 Sex (Female/Male)1.46 (0.67-3.24)0.343 Previous Knee Surgeries (>1/≤1)0.32 (0.14-0.69)0.005 Preoperative KOS-ADL0.96 (0.93-0.99)0.009 Preoperative SF-36 Pain Subscale0.98 (0.96-1.00)0.043IKDC = International Knee Documentation Committee Subject Form; KOS-ADL = Knee Outcome Survey - Activities of Daily Living Scale; MCID = minimal clinically significant difference; SCB = substantial clinical benefit

Does Time from Injury to Surgery Affect Outcomes Following Surgical Repair of Partial and Complete Proximal Hamstring Ruptures?

Objectives:The purpose of this study was to determine if time from injury to surgery affected postoperative outcomes after primary repair of partial and complete proximal hamstring ruptures. The secondary aim of the study was to assess patients’ experiences from initial evaluation to finding a treating surgeon to help increase awareness of the injury.Methods:Office records from 2008 to 2016 were reviewed from one orthopedic surgeon’s practice. A total of 124 partial and complete proximal hamstring repairs in 121 patients were identified. Ninety-two patients completed questionnaires including a custom survey in addition to validated outcome measures: Lower Extremity Outcome Score (LEFS), custom LEFS, Marx Activity Scale, custom Marx scale, and University of California at Los Angeles (UCLA) Activity Score. A chart review was performed to collect demographic, encounter, and operative information. Results were analyzed and compared for both partial and complete proximal hamstring repairs performed ≤ 3 weeks, ≤ 6 weeks, and > 6 weeks following injury.Results:Mean follow-up of study respondents was 43 months (range, 6-116 months). Of the 93 proximal hamstring repairs reviewed, 50.5% (9/28 partial, 38/65 complete), 78.5% (16/28 partial, 57/65 complete) and 21.5% (12/28 partial, 8/65 complete) were performed ≤ 3 weeks, ≤ 6 weeks, and > 6 weeks, respectively. At various injury-to-surgery time intervals, no statistical difference was found in the LEFS, custom LEFS, Marx Activity Scale, custom Marx Scale, and UCLA Activity Scores. Overall, partial proximal hamstring repairs had better outcome scores compared to complete tears although this was not statistically significant with the exception of leg pain at rest, which was higher after repair of complete tears (P = 0.021). Additionally, female gender and age were negative predictors of outcome scores. Increasing time from injury-to-surgery was associated with lower perceived strength of operative side compared to contralateral leg, most notable with surgery > 6 weeks after injury (% patients with perceived near or full strength of the contralateral limb: partial tears ≤ 6 weeks 93.8% versus > 6 weeks 75%; complete tears ≤ 6 weeks 75.4% versus > 6 weeks 50%). Patients who underwent repair > 6 weeks following injury for both partial and complete tears exhibited a greater sitting intolerance after one hour compared to those repaired ≤ 6 weeks (0% partial, 7.1% complete ≤ 6 weeks; 12.5% partial, 25% complete > 6 weeks). The majority of patients with complete ruptures (42%) were initially evaluated at a local emergency room while most partial tears were evaluated by their primary care physician (35.7%). Patients with repairs performed > 6 weeks following injury visited, on average, 2.6 practitioners prior to evaluation by the treating surgeon compared to 1.6 for those surgically treated ≤ 6 weeks following injury.Conclusion:Proximal hamstring ruptures performed in both the acute and chronic setting can expect overall successful outcomes but may experience lower perceived strength and difficulty with prolonged sitting with repair > 6 weeks following injury. Patients also faced challenges in correct diagnosis of the injury and referral to an appropriate treating surgeon. These findings emphasize the need for increased awareness of the injury not only within the orthopedic community, but also the emergency room and primary care settings.

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as “younger” and those above as “older” (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 (ClinicalTrials.gov identifier).

Chondral Delamination of Fresh Osteochondral Allografts after Implantation in the Knee: A Matched Cohort Analysis.

Delamination of the chondral surface of an osteochondral allograft (OCA) from the underlying cancellous bone has been described as a mode of failure after implantation in the knee. Our hypothesis was that increased storage time of the OCA is associated with increased risk of graft delamination after implantation. Prospective data on 13 patients with evidence of OCA delamination identified on magnetic resonance imaging or during subsequent surgery from 2000 to 2015 were reviewed. A cohort of 33 patients without evidence of graft delamination were then matched to the delamination group based on recipient age, sex, body mass index (BMI), and chondral defect location. The matched cohort size was established based on a power calculation for determining differences in OCA storage times. All patients had a minimum 2-year follow-up. There was no difference in donor age, donor sex, and graft storage time between groups (30 vs. 31 days, P = 0.78). There were no differences between number of previous ipsilateral knee surgeries (1.8 vs. 0.84, P = 0.26), BMI (26.8 vs. 25.0 kg/m2, P = 0.31), total chondral defect size (6.5 vs. 5.8 cm2, P = 0.41) or preoperative Marx activity scores between groups. There is no association between OCA storage time, activity level scores, or number of previous ipsilateral knee surgeries and graft delamination in our patient population. Further work is needed to identify the etiology for this mode of failure of OCAs.

Change in KOOS and WOMAC Scores in a Young Athletic Population With and Without Anterior Cruciate Ligament Injury

Background: Several studies have examined changes in patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) injury, but no studies to date have prospectively evaluated changes from preinjury baseline through injury and follow-up among ACL-injured patients compared to the baseline and follow-up changes of uninjured patients. Purpose: To examine changes in PROMs over time from preinjury baseline to at least 2 years after ACL reconstruction and to compare these changes with those of an uninjured control group having similar physical activity requirements. Study Design: Cohort study; Level of evidence, 2. Methods: The authors conducted a prospective cohort study with a nested case-control analysis at a US service academy. All incoming first year students were recruited to participate in this study. Consenting participants completed a baseline questionnaire that included the KOOS (Knee injury and Osteoarthritis Outcome Score), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and MARS (Marx Activity Rating Scale). Participants who sustained a subsequent ACL injury completed assessments at the time of surgery and at 6, 12, and 24 months after surgery. Healthy participants were recruited to repeat the baseline assessments within 1 year of graduation. Inter- and intragroup differences at these time points were evaluated with dependent and independent t tests, respectively. We also compared these results with established minimum clinically important difference (MCID) values. Results: Of 1268 first year students entering the academy, 1005 with no previous injuries consented to participate in this study (82% male, mean ± SD age 19 ± 1 years). Of those enrolled, 30 suffered an ACL injury and met the inclusion criteria for this study. Ninety uninjured control students who met the inclusion criteria completed follow-up assessments. There were statistically significant differences across all KOOS and WOMAC subscales between ACL-injured group and uninjured group at the time of the final follow-up assessment. Four KOOS subscales (Pain, Symptoms, Sports and Recreation Function, and Knee-Related Quality of Life) and the WOMAC Stiffness subscale demonstrated >8-point differences between groups, which exceeded the established MCID for these instruments. There were no significant differences between the ACL-injured group and uninjured groups noted for the MARS (P = .635). At the time of final follow-up, the ACL-injured group also reported significant deficits on the WOMAC Stiffness subscale (P = .032), the MARS (P = .030), and all KOOS subscales, with the exception of Functional Activities of Daily Living, as compared with their preinjury baseline scores. These deficits exceeded the established MCID values for 3 KOOS subscales and the MARS. Conclusion: Patients with ACL injuries reported significant deficits on PROMs at least 2 years after surgical reconstruction in relation to preinjury baseline scores and an uninjured control group. Many of these deficits exceeded established MCID values.

Accelerated rehabilitation results in good outcomes following acute repair of proximal hamstring ruptures.

To assess outcomes of patients who underwent proximal hamstring repair utilizing an accelerated rehabilitation protocol with immediate weight bearing as tolerated and no bracing. Retrospective chart review identified 47 proximal hamstring tendon repairs with suture anchors in 43 patients performed during 2008-2015. Rehabilitation included no immobilization or limited weightbearing. Patients were contacted by phone to assess outcomes utilizing the lower extremity functional score (LEFS), single-assessment numeric evaluation (SANE), and Marx activity scale. Overall patient-reported scores were calculated and results of acute and chronic repairs compared. Thirty-four patients (38 repairs, 80.8%) were available for follow-up at mean of 4.1 ± 2.0years following repair. There were two re-tears: one complete rupture 5 weeks postoperative and one partial rupture 10 weeks postoperative in the chronic group. Patients in general reported low pain and good function with a mean LEFS score of 87 ± 21%, a mean SANE score of 88.1 ± 11.6, and a mean numeric pain score of 8.5 ± 15.3 in the last week and 12.2 ± 21.1 with activity. The acute repair group was noted to have a higher mean LEFS score (93.7 versus 79.8%, p = 0.004) and SANE score (91.3 versus 83.8, p = 0.047), and lower pain with activity (21.7 versus 4.8, p < 0.001) as compared to the chronic group. Repair of acute proximal hamstring ruptures results in good function and pain relief with the use of a rehabilitation protocol that does not require weight-bearing restrictions or bracing. III, therapeutic.

Decision to Return to Sport Participation After Anterior Cruciate Ligament Reconstruction, Part II: Self-Reported and Functional Performance Outcomes.

Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments. To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR. Case-control study. University research laboratory. Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years). The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged-hop tests, isokinetic quadriceps and hamstrings strength at 60°/s and 180°/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session. The Limb Symmetry Index was calculated for all functional performance measures. Mann-Whitney U tests were used to compare measures between groups ( P < .10). Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67-97.70; NRTS median = 82.76, range = 63.22-96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54-100; NRTS median = 71, range = 54-100; P = .08). No differences were observed for any functional performance measures. The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices.

Performance of the PROMIS in Patients After Anterior Cruciate Ligament Reconstruction.

Background:The Patient-Reported Outcomes Measurement Information System (PROMIS) is designed to advance patient-reported outcome (PRO) instruments by utilizing question banks for major health domains.Purpose:To compare the responsiveness and construct validity of the PROMIS physical function computer adaptive test (PF CAT) with current PRO instruments for patients before and up to 2 years after anterior cruciate ligament (ACL) reconstruction.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Initially, 157 patients completed the PROMIS PF CAT, Short Form–36 Health Survey (SF-36 physical function [PF] and general health [GH]), Marx Activity Rating Scale (MARS), Knee injury and Osteoarthritis Outcome Score (KOOS activities of daily living [ADL], sport, and quality of life [QOL]), and EuroQol–5 dimensions questionnaire (EQ-5D) at 6 weeks, 6 months, and 2 years after ACL reconstruction. Correlations between instruments, ceiling and floor effects, effect sizes (Cohen d), and standardized response means to describe responsiveness were evaluated. Subgroup analyses compared participants with and without additional arthroscopic procedures using linear mixed models.Results:At baseline, 6 weeks, and 6 months, the PROMIS PF CAT showed excellent or excellent-good correlations with the SF-36 PF (r = 0.75-0.80, P < .01), KOOS-ADL (r = 0.63-0.70, P < .01), and KOOS-sport (r = 0.32-0.69, P < .01); excellent-good correlation with the EQ-5D (r = 0.60-0.71, P < .01); and good correlation with the KOOS-QOL (r = 0.52-0.58, P < .01). As expected, there were poor correlations with the MARS (r = 0.00-0.24, P < .01) and SF-36 GH (r = 0.16-0.34, P < .01 ). At 2 years, the PROMIS PF CAT showed good to excellent correlations with all PRO instruments (r = 0.42-0.72, P < .01), including the MARS (r = 0.42, P < .01), indicating frequent return to preinjury function. The PROMIS PF CAT had the fewest ceiling or floor effects of all instruments tested, and patients answered, on average, 4 questions. There was no significant difference in baseline physical function scores between subgroups; at follow-up, all groups showed improvements in scores that were not statistically different.Conclusion:The PROMIS PF CAT is a valid tool to assess outcomes after ACL reconstruction up to 2 years after surgery, demonstrating the highest responsiveness to change with the fewest ceiling and floor effects and a low time burden among all instruments tested. The PROMIS PF CAT is a beneficial alternative for assessing physical function in adults before and after ACL reconstruction.

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.

Performance of PROMIS Physical Function Compared with KOOS, SF-36, Eq5d And Marx Activity Scale in Patients Who Undergo ACL Reconstruction

Objectives:Anterior cruciate ligament reconstruction is a commonly performed orthopaedic procedure. PROMIS (Patient-Reported Outcome Measurement Information System) was developed by the National Institutes of Health in an effort to advance patient-reported outcome (PRO) instruments by developing question banks for major health domains. Our goal was to compare the responsiveness and construct validity of the PROMIS physical function (PF) computer adaptive test (CAT) with current PRO instruments utilized in patients who undergo anterior cruciate ligament reconstruction.Methods:A total of 174 patients ages 14-53 scheduled to undergo anterior cruciate ligament reconstruction were asked to complete PROMIS PF-CAT, Short Form-36 Health Survey (SF36-PF and -GH), Marx activity rating scale (Marx), Knee Injury and Osteoarthritis Score (KOOS-ADL, -Sport, -QOL), and the EuroQol five dimensions questionnaire (EQ5D) at their preoperative visit. These surveys were repeated at six weeks and six months after surgery. Correlations between PRO instruments was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3) using Spearman Correlation Coefficients. The effect size (Cohen d) and standardized response mean (SRM) were used to describe the responsiveness of each PRO at the 6 week and 6 month follow-up visits and were defined as small (0.2), medium (0.5) and large (0.8). Ceiling and floor effects were defined as present if ≥15% of participants scored the highest or lowest score on a PRO, respectively. Subgroup analyses were performed comparing change in PRO scores at follow-up between participants with and without additional arthroscopic procedures (meniscal debridement and/or repair, microfracture, or OATS vs ACL reconstruction only) using linear mixed models.Results:There were excellent and excellent-good correlations between the PROMIS PF-CAT and physical function PROs including the SF36-PF (r=0.75-0.80, p<.01), KOOS-ADL (r=0.62-0.70, p<.01) and KOOS-Sport (r=0.32-0.69, p<0.01) at most time points, respectively. There was also excellent-good correlation with the EQ5D (r=0.60-0.71, p<.01) and good correlation with the KOOS-QOL (r=0.52-0.58, p<0.01). As expected, there was no (p>0.05) to poor correlation with Marx activity (r=0.24, p<0.01) and the SF36-GH (r=0.32-0.34, p<0.01). No ceiling or floor effects were noted for the PROMIS PF-CAT; there was a ceiling effect noted for KOOS-ADL at the 6 month visit (38.1%). Effect size estimates for physical function PROs increased from small to large changes from the 6 week to 6 month visits and were largest in the PROMIS PF-CAT (1.34) followed by KOOS-ADL (1.19) and SF36-PF (1.06). Patients answered on average 4 questions utilizing the PROMIS. Baseline subgroup analyses showed no significant differences in physical function PRO scores, and at follow-up, both groups showed significant improvement in physical function PRO scores that was not statistically different.Conclusion:Our results support the construct validity of the PROMIS PF-CAT in patients who undergo ACL reconstruction. Responsiveness to change was highest by 6 months postop and greater for the PROMIS PF-CAT than for other measures of physical function with no ceiling or floor effects and a low time-burden. Taken together, these findings suggest that the PROMIS PF-CAT is a beneficial alternative to measuring and tracking changes in physical function in adults undergoing ACL reconstruction.

Anterior versus Posterior Tibial Tunnel Placement in ACL Reconstruction

Objectives:Previously, we reported that the use of the posterior border of the anterior horn of the lateral meniscus as a landmark for tibial tunnel placement during anatomic ACL reconstruction resulted in a wide variation of tunnel location in the sagittal plane. The effects of such tibial tunnel variations on functional outcomes have not been previously reported.Hypothesis:Anteriorly placed tibial tunnels lead to better anterior knee stability than posteriorly placed tunnels.Study Design:Cohort study, Level of evidence 3.Methods:71 patients (aged 18-55) underwent isolated unilateral anatomic single bundle primary ACL reconstruction with quadrupled hamstring tendons or bone patellar tendon bone autografts between March 2013 and June 2014 by the same surgeon using an accessory medial portal technique. All guide pins for the tibial tunnel were placed using a 55-degree guide using the posterior border of the anterior horn of the lateral meniscus as a landmark. Following pin placement, a true lateral fluoroscopic image was obtained and these were digitally analyzed to measure the location of the pin along the length of the tibial plateau using the method described by Amis and Jakob. The patients were divided into two groups—one anterior and the other posterior to 40% of the tibial plateau length. Side-to-side difference in anterior knee translation (KT-1000), thigh circumference, range of motion, IKDC and Marx activity scale were evaluated and compared between the groups at a minimum of 2 years following ACL reconstructive surgery.Results:50 patients (26 in the anterior group and 24 in the posterior group) were avaliable for follow-up at a mean of 2.5 years. There was no difference in the terms of age, sex, BMI, loss of extension, graft type (Hams-BPTB) and size (mm) between the groups (p>.05). In terms of stability, the mean side-to-side difference was 0.19±1.3 mm for anterior group and 1.27 ±1.3 mm for posterior group based on KT-1000 measurements (P<.005). The IKDC (75.1±4.1 vs 79.2±2.8) and Marx activity (6.6±1.05 vs 8.3±1.04) scores were similar in both groups. No difference in thigh circumference was found between the involved and uninvolved extremities of the both groups (-1.48±1.41 vs -1.52±1.17).Conclusion:Using the posterior border of the anterior horn of the lateral meniscus as a landmark yields a wide range of tibial tunnel locations along the tibial plateau. Anterior placement of the tibial tunnel leads to better anterior knee stability than posterior placement does.

Ten-Year Outcomes and Risk Factors After Anterior Cruciate Ligament Reconstruction: A MOON Longitudinal Prospective Cohort Study

Background: The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown. Hypothesis/Purpose: Our objective was to identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years. Study Design: Therapeutic study; Level of evidence, 2. Methods: Unilateral ACL reconstruction procedures were identified and prospectively enrolled between 2002 and 2004 from 7 sites in the Multicenter Orthopaedic Outcomes Network (MOON). Patients preoperatively completed a series of validated outcome instruments, including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale. At the time of surgery, physicians documented all intra-articular abnormalities, treatment, and surgical techniques utilized. Patients were followed at 2, 6, and 10 years postoperatively and asked to complete the same outcome instruments that they completed at baseline. The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of the outcome. Results: A total of 1592 patients were enrolled (57% male; median age, 24 years). Ten-year follow-up was obtained on 83% (n = 1320) of the cohort. Both IKDC and KOOS scores significantly improved at 2 years and were maintained at 6 and 10 years. Conversely, Marx scores dropped markedly over time, from a median score of 12 points at baseline to 9 points at 2 years, 7 points at 6 years, and 6 points at 10 years. The patient-specific risk factors for inferior 10-year outcomes were lower baseline scores; higher body mass index; being a smoker at baseline; having a medial or lateral meniscus procedure performed before index ACL reconstruction; undergoing revision ACL reconstruction; undergoing lateral meniscectomy; grade 3 to 4 articular cartilage lesions in the medial, lateral, or patellofemoral compartments; and undergoing any subsequent ipsilateral knee surgery after index ACL reconstruction. Conclusion: Patients were able to perform sports-related functions and maintain a relatively high knee-related quality of life 10 years after ACL reconstruction, although activity levels significantly declined over time. Multivariable analysis identified several key modifiable risk factors that significantly influence the outcome.

Differences in the Lateral Compartment Joint Space Width After Anterior Cruciate Ligament Reconstruction: Data From the MOON Onsite Cohort

Background: Anterior cruciate ligament (ACL) reconstruction can effectively return athletes to the playing field, but they are still at risk of developing posttraumatic osteoarthritis (PTOA). No studies have used multivariable analysis to evaluate the predictors of radiographic PTOA in the lateral compartment of the knee at short-term follow-up after ACL reconstruction. Purpose: To determine the predictors of radiographic joint space narrowing in the lateral compartment 2 to 3 years after ACL reconstruction in a young, active cohort. Study Design: Cohort study; Level of evidence, 2. Methods: A nested cohort of 358 patients from the Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort who were aged ≤33 years, were injured playing a sport, and had never undergone surgery on the contralateral knee were followed up 2 years after ACL reconstruction with questionnaires and with weightbearing knee radiographs using the metatarsophalangeal (MTP) joint technique. The joint space width in the lateral compartment was measured using a semiautomatic computerized method, and multivariable predictive modeling was used to evaluate the relationship between meniscus treatment, cartilage injury, graft type, and joint space while adjusting for age, sex, body mass index, and Marx activity score. Results: The mean lateral joint space width was 0.11 mm narrower on the ACL-reconstructed knee compared with the contralateral healthy knee (7.69 mm vs 7.80 mm, respectively; P < .01). Statistically significant predictors of a narrower joint space width on the ACL-reconstructed knee included lateral meniscectomy (P < .001) and a Marx activity score less than 16 points (P < .001). Conclusion: This study identifies lateral meniscectomy and a lower baseline Marx activity score to be predictors of radiographic joint space narrowing in the lateral compartment 2 to 3 years after ACL reconstruction in young, active patients without a prior knee injury.

Patellofemoral Cartilage Lesions Treated With Particulated Juvenile Allograft Cartilage: A Prospective Study With Minimum 2-Year Clinical and Magnetic Resonance Imaging Outcomes

To analyze the functional outcomes of patients treated with particulated juvenile articular cartilage (PJAC) for symptomatic articular cartilage lesions in the patellofemoral joint, correlates clinical outcomes with magnetic resonance imaging (MRI) appearance of the repair tissue using cartilage-sensitive quantitative T2-mapping. All patients treated with PJAC for patellofemoral lesions were identified and prospectively followed with clinical outcome scores (International Knee Documentation Committee [IKDC], Knee Outcome Survey-Activities of Daily Living [KOS-ADL], and Marx Activity Scale [MAS]). Postoperative MRI scans using quantitative T2 mapping were obtained and interpreted by an independent musculoskeletal radiologist. Twenty-seven patients treated with PJAC for 30 full-thickness patellofemoral cartilage lesions were identified; mean postoperative follow-up was 3.84years. Improvements from pre- to postoperative mean IKDC (45.9 vs 71.2, P < .001) and KOS-ADL (60.7 vs 78.8, P < .001) scores were observed; no significant change in MAS was seen (7.04 vs 7.17, P= .97). Advanced age, history of previous surgery, lesion location (patella vs trochlea), or concomitant tibial tubercle osteotomy did not affect outcome scores. Greater body mass index was associated with less improvement in KOS-ADL score. No patients required reoperation for graft-related issues. Lesion fill exceeding 67% by MRI assessment was noted in 69.2% of lesions; depth of lesion fill did not correlate with clinical outcomes. Quantitative T2-mapping revealed prolonged relaxation time at the graft site compared with adjacent normal cartilage at both deep and superficial zones. This study found significantly improved pain and function in patients treated with PJAC for symptomatic patellofemoral articular cartilage defects. No patients required reoperation for graft-related issues. Postoperative MRI revealed majority lesion fill in more than 69% of patients, but persistent morphologic differences between graft site and normal adjacent cartilage remain. Though we support PJAC use in this setting to improve patient subjective outcomes, improved appearance on postoperative imaging was not found to provide additional clinical benefit. Level IV, case series.