Marx Activity Research Articles

Predictors of postoperative pain using PROMIS pain interference two-years following knee surgery

IntroductionThe purpose of this study was to identify preoperative factors associated with worse PROMIS Pain Interference (PI) two years following knee surgery. MethodsParticipants completed surveys preoperatively and two years postoperatively. Data collected included demographics, medical history, and multiple patient-reported outcomes measures, including PROMIS PI. ResultsAfter controlling for confounders, lower income, smoking, worse PROMIS Anxiety, worse Numeric Pain Score body pain, and worse Marx Activity Rating Scale were independent predictors for worse PROMIS PI two years after surgery. ConclusionWorse PROMIS PI two years after elective knee surgery is associated with multiple socio-demographic patient identifiers.

Return to preinjury sports after anterior cruciate ligament reconstruction is predicted by five independent factors

To determine factors that predict return to the same frequency and type of sports participation with similar activity demands as before injury. Individuals 1 to 5years after primary ACL reconstruction completed a comprehensive survey related to sports participation and activity before injury and after surgery. Patient characteristics, injury variables, and surgical variables were extracted from the medical record. Return to preinjury sports (RTPS) was defined as: "Returning to the same or more demanding type of sports participation, at the same or greater frequency with the same or better Marx Activity Score as before injury." Variables were compared between individuals that achieved comprehensive RTPS and those that did not with univariate and multivariate logistic regression models. Two-hundred and fifty-one patients (mean age 26.1years, SD 9.9) completed the survey at an average of 3.4years (SD 1.3) after ACL reconstruction. The overall rate of RTPS was 48.6%. Patients were more likely to RTPS if they were younger than 19years old (OR = 4.07; 95%CI 2.21-7.50; p < 0.01) or if they were competitive athletes (OR = 2.07; 95%CI 1.24-3.46; p = 0.01). Patients were less likely to RTPS if surgery occurred more than 3months after injury (OR = 0.31, 95%CI 0.17-0.58; p < 0.01), if there was a concomitant cartilage lesion (OR = 0.38; 95%CI 0.21-0.70; p < 0.01), and if cartilage surgery was performed (OR = 0.17; 95%CI 0.04-0.80; p = 0.02). Five variables best predicted RTPS including age at time of surgery. Only time from injury to surgery is a potentially modifiable factor to improve RTPS; however, the reasons for which patients delayed surgery may also contribute to them not returning to sports. Regardless, younger patients, those that partake in sports on a competitive level, those that undergo surgery sooner, or do not have a cartilage injury or require cartilage surgery are more likely to return to pre-injury sports participation. III.

All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus: Comparable 2-Year Outcomes in Male and Female Patients

To determine 2-year functional outcomes using an all-inside quadrupled semitendinosus anterior cruciate ligament (ACL) reconstruction technique in male and female patients. A total of 100 patients who underwent quadrupled semitendinosus all-inside hamstring ACL reconstruction by a single surgeon were enrolled. Patient-reported outcome scores collected preoperatively and postoperatively included visual analog scale, Veterans Rand 12-Item Health Survey (VR-12; Physical and Mental), Marx Activity Scale, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A total of 100 ACL reconstructions comprising 62 female, and 38 male patients were included in this study. Mean graft diameter was 9.4 mm in female and 9.8 mm in male patients (range, 9-11). Outcome scores demonstrated improvement from preoperative to 2-year postoperative respectively: visual analog scale pain 3.18, 1.07, VR-12 physical 36.35, 52.64, VR-12 mental 53.96, 54.65, KOOS pain 59.17, 89.03, KOOS symptoms 52.64, 80.79, KOOS Activities of Daily Living 69.38, 95.4, KOOS Sport 28.97, 81.25, KOOS Quality of Life 27.54, 71.56, WOMAC Pain 71.56, 92.65, WOMAC Stiffness 60.55, 84.13, and WOMAC Function 69.38, 95.4. Marx activity score decreased from baseline (10.98) to 2 years' postoperatively (8.75). At 2 years, patient expectations were met or exceeded with regards to pain (94%), motion and strength (91%), normal function of daily living (95%), and return to sport (79%). Anatomic all-inside quadrupled semitendinosus ACL reconstruction improves functional outcomes similarly to previous studies between baseline and clinical follow-up at 1-year and 2-years postoperatively and is comparable in both male and female patients. Level III, retrospective comparative study.

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts.

To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. Thirty-five QT patients (age 20; range 15-34years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32years) patients. The following assessments were performed at 6 and 12months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12months) and between-subject (Graft; QT and HT) factors. Patient reported outcome measures and hop performance improved between 6 and 12months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60deg/s (p < 0.001) and 180deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60deg/s (p < 0.01) and 180deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group. Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12months. This may have implications for decisions regarding return to sport. III.

Posterior cruciate ligament repair with suture tape augmentation: a case series with minimum 2-year follow-up

PurposeThe posterior cruciate ligament (PCL) is an important stabilizer of the knee and can be damaged in up to 20% of ligamentous injuries. Numerous techniques for surgical treatment have been described in the literature with none shown to be clearly superior. The aim of this study was to assess the 2-year outcomes of PCL repair with suture tape augmentation.MethodsSeventeen patients undergoing PCL repair with suture tape augmentation were prospectively followed up for a minimum of two years. One patient was lost to follow-up leaving sixteen patients in the final analysis (94.1%). Indications for this procedure were acute Grade III PCL ruptures, symptomatic chronic tears and PCL tears as part of a multi-ligament injury. Exclusion criteria were patients with retracted PCL remnants or poor tissue quality. Patient-reported outcomes were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and Marx Activity Scale. Patients with any postoperative complications were identified. Mean differences between the outcomes pre-operatively and at two years postoperatively were evaluated using paired t-tests with significance set at p < 0.05.ResultsThe mean KOOS at 2 years was 87.0, 75.5, 93.0, 69.6 and 54.2 for pain, symptoms, ADL, sport/recreation and QOL respectively. These improved significantly from 60.2, 49.8, 65.0, 33.0 and 34.2 preoperatively (p < 0.05). The mean WOMAC scores at 2 years were 91.0, 78.3 and 93.0 for pain, stiffness and function respectively. These improved significantly from 63.0, 51.7 and 65.0 preoperatively (p < 0.01). The VAS score improved from 3.0 to 0.8 (p < 0.01) and the VR-12 score improved from 34.9 to 50.9 at 2 years (p < 0.001). However, the Marx activity scale decreased from 8.7 pre-injury to 6.3 at 2 years (N.S.). One patient (6.3%) suffered a re-rupture.ConclusionPCL repair with suture tape augmentation demonstrates satisfactory patient reported outcome measures at minimum 2-year follow-up. These figures compare favorably with success rates described in the literature for PCL reconstruction techniques. Therefore, PCL repair with suture tape augmentation is an effective treatment option in selected patients.Level of evidenceIV

Effect of Tibial Tunnel Placement Using the Lateral Meniscus as a Landmark on Clinical Outcomes of Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: It remains unclear if use of the lateral meniscus anterior horn (LMAH) as a landmark will produce consistent tunnel positions in the anteroposterior (AP) distance across the tibial plateau. Purpose: To evaluate the AP location of anterior cruciate ligament (ACL) reconstruction tibial tunnels utilizing the LMAH as an intra-articular landmark and to examine how tunnel placement affects knee stability and clinical outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was conducted of 98 patients who underwent primary ACL reconstruction with quadrupled hamstring tendon autografts between March 2013 and June 2017. Patients with unilateral ACL injuries and a minimum follow-up of 2 years were included in the study. All guide pins for the tibial tunnel were placed using the posterior border of the LMAH as an intra-articular landmark. Guide pins were evaluated with the Bernard-Hertel grid in the femur and the Stäubli-Rauschning method in the tibia. Patients were divided by the radiographic location of the articular entry point of the guide pin with relation to the anterior 40% of the tibial plateau. Outcomes were evaluated by the Marx Activity Scale and International Knee Documentation Committee (IKDC) form. Anterior knee laxity was evaluated using a KT-1000 arthrometer and graded with the objective portion of the IKDC form. Rotational stability was evaluated using the pivot-shift test. Results: A total of 60 patients were available for follow-up at a mean 28.6 months. The overall percentage of AP placement of the tibial tunnel was 39.3% ± 3.8% (mean ± SD; range, 31%-47%). Side-to-side difference of anterior knee laxity was significantly lower in the anterior group than the posterior group (1.2 ± 1.1 mm vs 2.5 ± 1.3 mm; P < .001; r = 0.51). The percentage of AP placement of the tibial tunnel demonstrated a positive medium correlation with side-to-side difference of anterior knee laxity as measured by a KT-1000 arthrometer (r = 0.430; P < .001). The anterior group reported significantly better distribution of IKDC grading as compared with the posterior group (26 grade A and 6 grade B vs 15 grade A and 13 grade B; P = .043; V = 0.297). The pivot-shift test results and outcome scores showed no significant differences between the groups. Conclusion: Using the posterior border of the LMAH as an intraoperative landmark yields a wide range of tibial tunnel locations along the tibial plateau, with anterior placement of the tibial tunnel leading toward improved anterior knee stability.

Strength deficits and flexion range of motion following primary anterior cruciate ligament reconstruction differ between quadriceps and hamstring autografts

ObjectiveTo determine if anterior cruciate ligament (ACL) reconstruction with a quadriceps tendon (QT) could achieve faster postoperative recovery compared with hamstring tendon (HT) ACL reconstruction.MethodsThirty-seven QT patients were matched for gender, age and preinjury activity level with 74 HT patients. A 6-month postoperative assessment included standardised reported outcome measures: patient-reported outcome measures (PROMs) (International Knee Documentation Committee-subjective knee evaluation form, Knee injury and Osteoarthritis Outcome Score-knee related quality of life subscale, ACL-Return to Sport after Injury scale, Marx activity scale, anterior knee pain), range of motion (active, standing and passive), anterior knee laxity testing, hop tests (single and triple crossover hop for distance) and isokinetic strength testing of the knee extensors and flexors. T-tests or Mann Whitney U tests were used to compare data between groups.ResultsThere were no significant differences between the two groups for any of the PROMs. The HT group had reduced active and standing knee flexion range compared with the QT group (p<0.001). Isokinetic strength testing showed significant deficits in limb symmetry indices for both concentric hamstring peak torque at 60°/s (p<0.001) and 180°/s (p=0.01) in the HT group. There were significantly greater deficits in limb symmetry indices for concentric quadriceps peak torque at 60°/s (p<0.001) and 180°/s (p=0.001) in the QT group.ConclusionThe QT graft does not appear to offer a more rapid recovery in terms of knee symptoms or function which could have allowed for faster progression to the dynamic phases of rehabilitation.Level of evidenceLevel III.

Impact of Postoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients.

The purposes of this study were to identify the patient characteristics associated with refilling a postoperative opioid prescription after knee surgery and to determine whether refilling opioids is associated with 2-year patient-reported outcomes. We hypothesized that postoperative refill of opioids would be associated with worse 2-year patient-reported outcomes. We studied 192 patients undergoing knee surgery at a single urban academic institution. Patients completed multiple patient-reported outcome measures preoperatively and 2 years postoperatively, including six Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale scores for the operative knee and the rest of the body, Marx Activity Rating Scale, as well as measures of met expectations, improvement, and satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Patients who refilled a postoperative opioid prescription were compared with those who did not, and TMEs were calculated for those who refilled (Refill TMEs). One hundred twenty-nine patients (67%) refilled at least one postoperative opioid prescription. Black race, older age, higher average body mass index (BMI), smoking, greater medical comorbidities, preoperative opioid use, lower income, government insurance, and knee arthroplasty were associated with refilling opioids. Greater Refill TMEs was associated with black or white race, older age, higher average BMI, smoking, greater medical comorbidities, preoperative opioid use, government insurance, and unemployment. Refilling opioids and greater Refill TMEs were associated with worse postoperative scores on most patient-reported outcome measures 2 years after knee surgery. However, refilling opioids and greater Refill TMEs did not have a significant association with improvement after surgery. Multivariable analysis controlling for potential confounding variables confirmed that greater postoperative Refill TMEs independently predicted worse 2-year PROMIS Physical Function, 2-year PROMIS Pain Interference, and 2-year IKDC knee function scores. Postoperative refill of opioids was associated with worse 2-year patient-reported outcomes in a dose-dependent fashion. These findings reinforce the importance of counseling patients regarding opioid use and optimizing opioid-sparing pain management postoperatively.

Satisfactory patient-reported outcomes at 5 years following primary repair with suture tape augmentation for proximal anterior cruciate ligament tears

PurposeAn enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears.MethodsThirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified.ResultsThree patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05).ConclusionPrimary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores.Level of evidenceLevel IV.

Clinically Significant Outcomes Following the Treatment of Focal Cartilage Defects of the Knee With Microfracture Augmentation Using Cartilage Allograft Extracellular Matrix: A Multicenter Prospective Study

To determine the short-term outcomes following microfracture augmented with cartilage allograft extracellular matrix for the treatment of symptomatic focal cartilage defects of the adult knee. Forty-eight patients enrolled by 8 surgeons from 8 separate institutions were included in this study. Patients underwent microfracture augmented by cartilage allograft extracellular matrix (BioCartilage; Arthrex, Naples, FL) and were followed at designated time points (3, 6, 12, and 24 months) to assess patient-reported outcomes (PROs), clinically significant outcomes (CSOs), and failure and complication rates. Magnetic resonance imaging (MRI) was offered at 2 years postoperatively regardless of symptomatology, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was documented. PRO compliance was 81.3% at 6 months, 72.9% at 12 months, and 47.9% at 2 years. All joint-specific and function-related PROs significantly improved compared to baseline at 3, 6, 12, 18, and 24 months of follow-up (P < .01), apart from Marx activity scale, which demonstrated a significant decline in postoperative scores at 2 years (P= .034). The percentage of patients achieving CSOs (as defined for microfracture) at 2 years was 90% for minimal clinically important difference and 85% for patient acceptable symptomatic state. Patient factors including age, sex, body mass index, symptoms duration, smoking, presence of a meniscal tear, lesion size, and location were not associated with CSO achievement at 2 years. One patient (2.1%) failed treatment 9.5 months postoperatively due to graft delamination and required a reoperation consisting of arthroscopic debridement. One complication (2.1%) consisting of complaints of clicking, grinding, and crepitus 15 months following the index procedure was reported. Two-year postoperative MRI demonstrated a mean 40.5 ± 22.9 MOCART 2.0 score. In this preliminary study, we found cartilage allograft extracellular matrix to be associated with improvement in functional outcomes, high rates of CSO achievement, and low failure and complication rates at 2-year follow-up. Level III, prospective multicenter cohort study.

Patient-Reported Activity Levels Correlate With Early Cartilage Degeneration After Anterior Cruciate Ligament Reconstruction

Background: The association between activity level after anterior cruciate ligament (ACL) reconstruction (ACLR) and development of posttraumatic osteoarthritis (PTOA) remains unclear. This study investigated the relationship of patient-reported outcomes and progressive cartilage degenerative changes at 3 years after ACLR. Hypothesis: Higher activity levels, as measured by Marx scores, are significantly correlated with early cartilage degeneration after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 35 patients (16 women; mean age, 31.0 ± 7.6 years) with isolated ACLR and without pre-existing arthritis were prospectively enrolled. Patients reported Marx activity scores and Knee injury and Osteoarthritis Outcome Score (KOOS) scores and underwent T1ρ magnetic resonance imaging (MRI) preoperatively, 6 months, 1 year, 2 years, and 3 years after ACLR with soft tissue graft (22 autograft). The change in cartilage relaxation times between preoperative and 3-year imaging was used to identify cartilage degeneration, defined as an increase in T1ρ values by 14.3%. Correlation between Marx activity levels, KOOS scores, and T1ρ degeneration was performed with the Spearman rank test. The Fisher exact test was used to test for association between Marx activity score cutoffs and degeneration. The Student t test was used to compare Whole-Organ Magnetic Resonance Imaging Score (WORMS) and T1ρ relaxation times. Significance was defined as P < .05. Results: Sixteen patients (45.7%) showed evidence of cartilage degeneration at 3 years, most frequently in the medial compartment (n = 12; 34%). Higher Marx activity scores at 3 years correlated with cartilage degeneration in the medial femur (rho = 0.34; P = .045), and medial tibia (rho = 0.43; P = .01). A Marx score of 11 or greater at 3 years was significantly associated with medial compartment degeneration (P = .03), with a positive predictive value of 52.6%. No Marx score cutoff at years 1 or 2 predicted future cartilage degeneration. The KOOS Quality of Life score was inversely correlated with cartilage degeneration (rho = 0.38; P = .02). WORMS did not correlate with degeneration of the medial compartment. Conclusion: Increased activity at 3 years after ACLR was significantly associated with increased risk of medial compartment PTOA. While further research is needed to fully define these relationships, patients may be counseled that return to Marx activity levels of greater than 11 may be associated with a higher risk of medial compartment cartilage degeneration.

Clinical and Functional Effects of Surgical Technique After Repair of Bucket Handle Meniscus Tears

All-inside meniscus repair has recently been explored as an alternative to inside-out meniscus repair of bucket handle meniscus tears. Current evidence suggests there are comparable outcomes between inside-out and all-inside repairs for bucket handle meniscus tears. However, there are limited data that directly compares all-inside with inside-out repairs, particularly with relatively long term follow up of functional outcomes. The aim of the current study was to determine if there are clinical and functional differences between all-inside and inside-out repairs of bucket-handle meniscus tears. All patients who underwent repair for bucket handle meniscus tears at a single institution from 2007 to 2017 were eligible for inclusion in the study (n = 77). Failure rates for this cohort were evaluated through chart review and confirmed via phone. Of this cohort, 9 patients who underwent all-inside meniscus repair were able to be contacted for functional assessment. These patients were then double matched by concomitant procedure (ACLR, chondroplasty, and/or microfracture) with patients who underwent inside-out repairs (n = 18). The patients were called and assessed for repeat surgery, as well as administered the KOOS, IKDC, and Marx activity scale to assess patients functionally. The mean age for the cohort was 27.42 (SD = 9.49) years with a mean follow-up of 6.19 (SD = 2.96) years. Of the patients who underwent All-inside (AI) repair (n=19), 15.78% had repeat surgery (n = 3), and 20.69% (n = 12) of patients who underwent inside-out (IO) repair (n = 58) underwent repeat surgery. Of the matched patients (n = 27), those who underwent all-inside meniscal repair had lower mean KOOS scores than patients with inside-out repairs in each sub-category (means and standard deviations are listed all-inside; inside-out): KOOS – Pain: mean = 78.08 (SD = 22.37); 87.74 (9.67), KOOS – Sports: 64.44 (25.67); 75.29 (22.8), KOOS – Symptoms: 78.97 (11.90); 81.09 (12.54), KOOS – QOL: 43.06 (33.7), 65.44 (22.32), KOOS – ADL: 81.37 (24.2); 94.55 (8.13). All-inside patients had a lower mean IKDC score (AI: mean = 66.4, SD = 27.64; IO: mean = 77.96, SD = 16.77) as well as lower Marx activity scores (AI: mean = 5, SD = 5.83; IO: mean = 7.05, SD = 5.03). The current study suggests that patients who undergo all-inside meniscus repair have worse functional outcomes but a slightly lower failure rate than those who undergo inside-out repair.

Arthroscopic Repair of Rotator Cuff Tears by Human Dermal Allograft Reconstruction vs. Maximal Repair

To determine healing rate of rotator cuff reconstruction with an acellular human dermal allograft compared with the gold standard arthroscopic maximal rotator cuff repair of large, chronic tears of the rotator cuff. Thirty patients with a two-tendon chronic retracted rotator cuff tear were enrolled in the study and were randomly allocated (15) to each group. All the patients were evaluated for structural integrity of repair using a 1.5T MRI at an average of 15 months after surgery. Rotator cuff arthropathy (RCA) and acromio-humeral distance (AHD) were graded using X-rays. Western Ontario Rotator Cuff (WORC), Disabilities of the Arm, Shoulder, and Hand (DASH), Marx Activity Rating Scale (MARX) scores, range of motion (ROM) of shoulder were analyzed. The re-tear rate in the reconstruction group was 13% (2 of 15 patients) compared to 73% (11/15) in the repair group (p=0.008). Progression of RCA was seen in 7% (1/15) and 35.71% (5/15) of patients in the reconstruction and repair group, respectively (p=0.006). The change in AHD (preop-postop) was significantly higher in the repair (reduced by 2.27 mm) than the reconstruction group (increased by 0.1 mm) (P=0.006). Both groups had significant improvements in patient reported outcome scores. The reconstruction group had statistically significant better forward flexion (p= 0.01) and scapular plane abduction (p=0.03) compared to the repair group. Rotator cuff reconstruction with a dermal allograft demonstrated favorable structural healing rates and improved range of motion compared to maximal repair in the short term. Moreover, the maximal repair group were more likely to develop RCA than reconstruction.

All-Inside Quadrupled Semitendinosus vs. BTB ACL Reconstruction in Young Athletes: RCT

Anterior cruciate ligament (ACL) reconstruction is challenging in young athletes. An important clinical question is optimal graft choice in this high-risk group. The purpose of this investigation was to compare clinical outcomes of ACL autograft reconstruction using all-inside GraftLink quadrupled semitendinosis (GraftLink) versus the “gold standard” bone-patellar tendon-bone (BTB) in a high-risk athletic population 24 years or younger. Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the GraftLink (n=32) or BTB (n=32) groups and were followed for two years. MRIs were obtained at one-year follow-up, and radiographs were obtained at two-year follow-up. The primary outcome measure was KT- 1000 stability testing. Secondary outcome measures included: IKDC Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Scale, and SF-12. At 2-year follow-up, no statistical difference existed with KT-1000 measured side to side laxity between GraftLink (0.3 ± 0.7 mm) and BTB (0.0 ± 0.8 mm) (p = 0.197). Additionally, no statistical differences between the groups were found for any secondary outcome measure or with regards to imaging findings. BTB patients reported significantly higher postoperative pain scores at days 3 (p=0.05) and 7 (p=0.018) and had significantly greater kneeling pain at 2 years (p < 0.019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% GraftLink, 74% BTB; p=0.415). Two graft retears (7%; p=0.222) occurred in the GraftLink group. Three patients in the BTB group experienced ACL tears in the contralateral knee (9%; p=0.239). ACL reconstruction with all-inside quadrupled semitendinosis autograft GraftLink construct was equivalent to patellar BTB autograft based on KT-1000 stability testing and validated outcome measures, including IKDC, in athletes 24 years or younger (average age 17.7). There was no significant difference in graft retear rate or return to sport at the same preoperative level between the groups. However, there was significantly less kneeling pain in the GraftLink cohort.

Low knee-related quality of life and persistent physical asymmetries in participants up to 10 years post-ACL reconstruction – A cross-sectional study

ObjectiveTo compare self-report and functional outcomes between participants with anterior cruciate ligament reconstruction (ACLR) with age and activity matched controls. DesignCross-sectional study. SettingUniversity laboratory-based study. ParticipantsTwenty-five participants (30.8 ± 9.7 years; 13 women), two to ten years post anterior cruciate ligament reconstruction; 24 controls (31.0 ± 10 years, 13 women). Main outcome measuresKnee Osteoarthritis and Injury Outcome Score (KOOS), Tegner, Marx Activity and Fear of Re-injury scales, and SF-12; isokinetic quadriceps and hamstring peak torque and single-leg hop distance. ResultsThere were no between-groups differences for the Tegner and the Marx Activity Scales. The ACLR group had lower KOOS dimensions (p < 0.001), SF-12 Physical Component Scores (p = 0.008), and higher Fear of Reinjury Scores (<0.001) than the controls. No significant differences were found for physical performance measures between the ACLR and the control groups. Significant between-side differences for the ACLR group were evident for concentric quadriceps (p < 0.001) and concentric hamstring peak torque (p = 0.002), and hop distance (p < 0.001). ConclusionKnee-specific symptoms and function, activity and quality of life were lower, and fear of re-injury was higher for participants with ACLR than controls. Side-to-side thigh muscle strength and hop distance deficits were evident for the ACLR group.

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Internal Brace Augmentation: Minimum 2-Year Patient-Reported Outcome Measures.

Background:The anterolateral ligament (ALL) contributes to anterolateral rotational stability of the knee. Internal bracing of the anterior cruciate ligament (ACL) and ALL reinforces the ligaments and encourages natural healing by protecting both during the healing phase and supporting early mobilization.Purpose/Hypothesis:To assess the 2-year patient-reported outcomes of combined ACL repair and ALL internal brace augmentation. We hypothesized that significant improvements in outcomes would be seen.Study Design:Case series; Level of evidence, 4.Methods:A total of 43 consecutive patients with acute proximal ACL ruptures were prospectively evaluated for a minimum of 2 years. The mean age at the time of surgery was 25.7 years (range, 13-56 years). Indications for the combined ACL/ALL procedure were associated Segond fractures, grade 3 pivot shift, or high levels of sporting activity. Patients with chronic ruptures or with multiligament injuries were excluded. The Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12), and Marx activity scale were collected preoperatively and at 12 and 24 months postoperatively. Patients with any postoperative complications were identified at the time of this analysis.Results:The mean follow-up period was 44.8 months. Five patients were lost to follow-up, leaving 38 patients (88.4%) in the final analysis. The mean KOOS for Pain, Symptoms, Activities of Daily Living, Sport/Recreation, and Quality of Life improved from a respective 64.9, 58.6, 75.0, 33.7, and 28.9 preoperatively to 91.1, 81.8, 96.1, 82.8, and 74.3 at the 2-year follow-up (P < .0001). The mean WOMAC scores for pain, stiffness, and function improved from 77.5, 65.3, and 75.0 preoperatively to 94.6, 88.6, and 96.0 at the 2-year follow-up (P < .0001). The VAS pain score improved from 3.4 preoperatively to 0.7 at the 2-year follow-up, and the VR-12 physical score improved from 34.4 preoperatively to 52.7 at the 2-year follow-up (P < .0001 for both ). However, the Marx activity score decreased from 13.3 preinjury to 10.6 at the 2-year follow-up (P = .01). Two patients (5.3%) sustained a rerupture.Conclusion:Combined ACL repair and ALL internal brace augmentation demonstrated excellent outcomes in 94.7% of the study patients. Based on our experience with this cohort as well as our isolated ACL repair data, we suggest that high-risk patients with ACL ruptures have an additional ALL procedure to provide rotational stability.

A New Rating Scale for the Rapid Evaluation of High-Level Sports Ability.

Background:Nearly half of patients with an anterior cruciate ligament (ACL) injury who have returned to sport after ACL reconstruction can return to sports activity at a competitive level, so emphasis should be focused not only on the timing of return to the sport but also on measuring the ability to participate in high-level sports activity.Purpose:To develop and evaluate a new, self-administered rating scale for rapid evaluation of high-level sports ability among community-level athletes who return to sports after ACL reconstruction surgery.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:We developed the new rating scale—the Knee Stability in Sports/Cutting-Pivoting Ability (KSS/CPA) scale—in 2 stages. Initially, we used a survey and roundtable discussion to achieve an expert consensus for the KSS/CPA scale from a group of independent orthopaedic experts. Next, 77 amateur athletes who underwent ACL reconstruction by a single surgeon were recruited for a background analysis of data to compare the new scale with results from the Marx activity rating scale, Tegner activity scale, International Knee Documentation Committee Subjective Knee Form, and self-assessment of overall knee function.Results:The KSS/CPA scale was applicable and effective for evaluating the high-level sports ability of community-level athletes who had returned to their sport after ACL reconstruction. Statistical analysis confirmed the test-retest reliability of the new rating scale (intraclass correlation coefficient, 0.85/0.84 postoperatively) as well as its internal consistency (Cronbach alpha coefficient, 0.73 preoperatively and 0.89 postoperatively), construct validity (Spearman correlation coefficient, >0.35 postoperatively), excellent discriminant validity, acceptable responsiveness, and reasonable minimal detectable change (<25).Conclusion:The KSS/CPA scale can act as a supplement to other clinical outcome measures for a more comprehensive evaluation of community-level athletes’ cutting-pivoting ability and knee stability.

Do Self-Reported Drug Allergies Influence Clinically Significant Outcome Improvement Following Osteochondral Allograft Transplantation? A Nested Cohort Study.

To compare clinical outcomes for patients who underwent osteochondral allograft transplantation (OCA) based on the presence or absence of one or more self-reported drug allergies. Prospective data were collected from 245 consecutive patients after OCA of the knee from one large academic institution. Patient-reported allergies were obtained via chart review. Patient-reported outcome measures, including activities of daily living of the Knee Outcome Survey (KOS-ADL), Marx Activity Scale, International Knee Documentation Committee (IKDC), and visual analogue scale (VAS) pain were all collected. The minimal clinically important difference (MCID) for each outcome was quantified using a distribution-based method. Independent t tests were used to compare patient-reported outcome measures between those with and without self-reported allergies, while chi-square analysis of association was used to compare rates of MCID achievement. Of 245 patients included, 83 (33.9%) reported having at least one drug allergy at the time of OCA. There were no statistically significant differences with regard to patient demographics, including age, body mass index, gender, or sports participation between those with and without a reported allergy. Similarly, there were no significant differences found between baseline preoperative patient-reported outcomes. Overall, both cohorts demonstrated a significant improvement from baseline scores at 2 years postoperatively. There were no differences found between any patient-reported outcome at 2 years postoperatively. The presence of at least one self-reported drug allergy was not a significant risk factor for failing to achieve the MCID in any specific outcome measure. The presence of one or more drug allergy was not associated with worse patient-reported outcomes or lower rates of clinically significant outcome improvement after OCA.

Patient-reported outcomes of meniscal repair and meniscectomy in patients 40 years of age and older show similar good results.

The purpose of this study is to evaluate patient-reported outcome measures (PROMs) in patients aged 40years and older who underwent meniscal repair or meniscectomy. All patients aged 40 and older who underwent a meniscal repair at a single institution from 2006 to 2017 were included. Meniscal repair cases were matched with a meniscectomy control group in a 1:3 ratio, selected for an equal proportion of concomitant ACL reconstruction in each group. PROMs, collected at a minimum follow-up of 24months, included International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Marx activity scale, and a patient satisfaction scale. The primary outcome was IKDC score, which was compared between groups using a Mann-Whitney U test. Rate of failure, defined as repeat ipsilateral knee surgery or surgeon report of failure, was reported. Thirty-five meniscal repair patients and 131 meniscectomy patients were identified; 28 (80.0%) and 67 (51.1%) completed all PROMs with mean follow-up of 4.9 and 5.2years, respectively. The mean age was 48.5 ± 7.0years in the meniscal repair cohort and 52.8 ± 7.1years in the meniscectomy cohort (p = 0.009). Concomitant ACL reconstruction was present in 46.4% and 49.3% of the meniscal repair and meniscectomy cohorts, respectively (n.s.). The median IKDC score was 78 (IQR 66, 87) in the repair cohort and 77 (IQR 56, 86) in the meniscectomy cohort (n.s.). The median Marx activity scale was 3.5 (IQR 0, 8) in the repair cohort and 3.0 (IQR 0, 9) in the meniscectomy cohort (n.s.). Over 85% of both groups were satisfied or very satisfied with no between-group differences (n.s.). In patients aged 40years and older, patient-reported outcomes at an average of 5years postoperatively were satisfactory and similar in patients undergoing meniscal repair and meniscectomy, indicating that age alone should not be a contraindication to meniscal repair.Level of evidence: Level III.

Performance of PROMIS Physical Function, Pain Interference, and Depression Computer Adaptive Tests Instruments in Patients Undergoing Meniscal Surgery

PurposeTo compare the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PIF), and depression computer adaptive tests (CAT) relative to legacy instruments in patients undergoing meniscal surgery.MethodsPatients scheduled to undergo meniscal surgery completed legacy knee function PROMs (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] subscores), Marx Activity Rating Scale (MARS), Veterans-Rand 12 (VR12), Short Form 12 (SF12), and the Brief Resilience Scale (BRS) alongside PROMIS PF, PIF, and Depression preoperatively. Spearman rank correlations were calculated, and score distributions were examined for floor and ceiling effects.Results152 patients (46.6 ± 14.9 years, 67.1% male) completed PROMs for appropriate inclusion. PROMIS PF yielded high-moderate to high correlations with the IKDC and KOOS subscales (r = 0.61 to 0.73), demonstrating similar performance to the IKDC. PROMIS PIF demonstrated moderately high-moderate to high correlations with the IKDC, KOOS subscales, VR-12 Physical Component Score (PCS), and SF12 PCS (r = 0.62 to 0.71), performing comparably to KOOS Pain (r = 0.55 to 0.92). PROMIS Depression demonstrated moderate to high-moderate correlations with the mental health legacies (r = 0.46 to 0.66). Significant ceiling effects were observed for MARS (n = 29, 18.8%), and significant floor effects were exhibited by PROMIS Depression (n = 38, 25%) and MARS (n = 27, 17.6%).ConclusionThe PROMIS PF, PIF CAT, and Depression instruments exhibit comparable performance profiles relative to legacy knee PROMs. PROMIS PF and PIF demonstrated no floor and ceiling effects, whereas PROMIS Depression exhibited a significant relative floor effect. PROMIS PF and PIF may be appropriately used to establish functional baselines preoperatively.Level of EvidenceIV, diagnostic case series.