Normative values for the KOOS and WOMAC in a young athletic population: history of knee ligament injury is associated with lower scores

Association between clinical laboratory indicators and WOMAC scores in Qatar Biobank participants: The impact of testosterone and fibrinogen on pain, stiffness, and functional limitation

OBJECTIVES

The association between baseline laboratory parameters and experienced well-being in healthy individuals remains uncertain. This study explored the relationship between clinical laboratory profiles and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for pain, stiffness, and physical functional limitation in healthy individuals in Qatar.

METHODS

Clinical laboratory data were collected from 1,764 Qatar Biobank participants who also completed the WOMAC questionnaire: lipid profiles (high-density lipoprotein, low-density lipoprotein, cholesterol, and triglycerides), endocrine markers (TSH, T3, T4, estradiol, and testosterone), and two inflammatory markers (CRP and fibrinogen). Multiple linear regression was used with 11 clinical indicators as independent variables and the subscale and total WOMAC scores as dependent variables. Multivariate effects of each indicator on the outcomes were assessed, and univariate effects were examined when significant.

RESULTS

Testosterone had a significant impact on all WOMAC subscales (pain, stiffness, and functional limitation) and the total WOMAC score. Higher testosterone levels were associated with a reduction in pain (β = -0.03, t = -3.505, p < 0.001, 95% CI = -0.052, -0.015), stiffness (β = -0.01, t = -2.265, p = 0.024, 95% CI = -0.018, -0.001), physical dysfunction (β = -0.08, t = -3.265, p = 0.001, 95% CI = -0.135, -0.034), and total WOMAC scores (β = -0.127, t = -3.444, p < 0.001, 95% CI = -0.199, -0.055). Elevated fibrinogen levels were associated with an increase in stiffness (β = 0.155, t = 2.241, p = 0.025, 95% CI = 0.019, 0.290), physical dysfunction (β = 1.17, t = 2.808, p = 0.005, 95% CI = 0.354, 1.997), and total WOMAC scores (β = 1.610, t = 2.691, p = 0.007, 95% CI = 0.437, 2.784).

CONCLUSION

Testosterone may protect against pain, stiffness, and physical dysfunction, while high fibrinogen levels might be a surrogate of systemic inflammation that enhances stiffness and limits physical function. Measuring multiple clinical and laboratory markers in healthy individuals may enhance our understanding of the molecular mechanisms underlying pain.

Machine learning in knee injury sequelae detection: Unravelling the role of psychological factors and preventing long-term sequelae

Purpose

This study evaluated the performance of three machine learning (ML) algorithms-decision tree (DT), multilayer perceptron (MLP) and extreme gradient boosting (XGB)-in identifying regular athletes who suffered a knee injury several months to years prior. In addition, the contribution of psychological variables in addition to biomechanical ones in the classification performance of the ML algorithms was assessed, to better identify factors to get back to competitive sport with the lowest possible risk of new knee injury.

Methods

A cohort of 96 athletes, 36 with prior knee injuries, practicing an average of 5.7 ± 2.4 h per week, participated in a horizontal force-velocity test on a ballistic ergometer providing data of force, velocity and power from each lower limb. They also completed a psychological questionnaire, which included components from the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Sport Anxiety Scale (SAS). The three ML algorithms were trained on a thousand different train-test sets. Also, Shapley values were calculated for each input variable of a data set to highlight its contribution to the prediction from an ML model.

Results

Over a thousand cross-validations, higher area under the curve (AUC) values were obtained when accounted for the psychological attributes (p < 0.001). Also, higher AUC values were obtained from MLP compared to XGB or DT (p < 0.001). XGB exhibited higher AUC values than DT (p < 0.001).

Conclusions

Our results suggested that psychological factors play a more important role in recognition than biomechanical factors, with KOOS and SAS scores ranking high in the list of influential factors. Additionally, the computing stability of MLP could be recommended for classification tasks in the context of knee injuries.

Level of Evidence

Level III.

People Are More Variable Than Their Hop Test Would Suggest: Hop Performance and Self-Reported Outcomes Over 11 Years Following ACL Reconstruction

We aimed to report the trajectory of self-reported outcomes up to 11 years post-ACLR. We also explored the relationship between hop performance at 1 year and: (i) future self-reported knee outcomes; and (ii) risk of subsequent knee events. 124 participants (43 women, mean age 31 ± 8 years) were recruited at 1 year following hamstring-autograft ACLR. Hop performance was assessed with single-forward and side-hop tests. Follow-up was completed at 3 (n = 114), 5 (n = 89) and 11 years (n = 72) post-ACLR. Self-reported outcomes were assessed at each follow-up with the Knee injury Osteoarthritis Outcome Score (KOOS) pain and quality of life (QOL) subscales. Generalized linear mixed models estimated the relationship between hop performance and self-reported outcomes. Subsequent knee events (new injury/surgery) to either knee were recorded, with the relationship between hop performance and risk of subsequent knee events analyzed with Cox proportional hazards. Self-reported knee outcomes were stable (mean change < 10 points) across all timepoints but with major within-sample variability. There was a modest relationship between greater hop performance at 1 year and better future KOOS-pain (average marginal effect [AME] % improvement with + 1 cm single forward hop = 0.06% [95% CI 0.02-0.10]). A nonlinear spline relationship showed better single-forward hop performance was associated with better KOOS-QOL for scores < 108 cm, not present for higher hop scores > 108 cm. There were 21 index and 11 contralateral subsequent knee events. Hop performance was not related to risk of a subsequent knee event (hazard ratio index knee 0.99 [95% CI 0.98-1.02]). In conclusion, self-reported knee pain and quality of life were generally stable across the 11-year follow-up period. Greater hop performance at 1-year post-ACLR was related to better self-reported knee outcomes up to 11-year follow-up (of questionable clinical importance), but not associated with the risk of subsequent knee injury/surgery.

Responsiveness of Patient-Reported Outcome Measures After Large Knee Articular Cartilage Transplantation: A Systematic Review and Meta-analysis

BACKGROUND

Cartilage transplantation is commonly used to treat large (>4 cm2) articular cartilage defects of the knee. The 2 most common transplants are osteochondral allograft transplantation and autologous chondrocyte implantation. Several patient-reported outcome measures (PROMs) have been used to determine the efficacy of treatment, but it is unknown which measures are the most effective.

PURPOSE

To report the multiple PROMs used after large knee articular cartilage transplantation surgery and to compare the responsiveness between them.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the PubMed/MEDLINE and Web of Science databases was performed. A total of 181 articles met inclusion criteria. Patient and study characteristics were extracted, including pre- and postoperative means for PROMs. From the articles that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up, reported pre- and postoperative means and standard deviations; n = 131), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles.

RESULTS

A total of 10,015 patients (10,093 knees; mean age, 34.8 years; mean body mass index, 26.1) were included in this study. The mean follow-up time was 58.3 months (range, 1.5-247.2 months), imaging findings were reported in 80 articles (44.2%), patient satisfaction was reported in 39 articles (21.5%), and range of motion was reported in 10 articles (5.5%). There were 58 unique PROM instruments identified, with the most used being the International Knee Documentation Committee (IKDC) score (n = 118; 65.2%), followed by Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (n = 58; 32.0%), KOOS Sport and Recreation (n = 58; 32.0%), KOOS Quality of Life (n = 57; 31.5%), KOOS Activities of Daily Living (n = 57; 31.5%), and KOOS Symptoms (n = 57; 31.5%). Overall, IKDC was found to have the greatest effect size (1.68) and the best responsiveness of the other PROMs, which include KOOS Pain (RE, 1.38), KOOS Symptoms (RE, 3.06), KOOS Activities of Daily Living (RE, 1.65), KOOS Sport and Recreation (RE, 1.44), Lysholm (RE, 1.76), and Tegner (RE, 1.56).

CONCLUSION

The IKDC is the most responsive PROM after large knee articular cartilage transplantation surgery. The IKDC score is recommended for assessing outcomes after cartilage transplantation surgery.

Not all patient-reported outcome measures are equivalent at two years compared to one year after anterior cruciate ligament reconstruction based on a retrospective analysis

OBJECTIVE

This article aims to assess for clinically important differences in patient-reported outcome measures (PROMs) at one and two years post anterior cruciate ligament reconstruction (ACLR).

METHODS

A retrospective comparison of prospectively collected PROMs for a single cohort who underwent a primary ACLR with or without associated meniscal surgery from 2016 to 2020 was assessed. Six externally validated PROMs were collected preoperatively and at standardized times postoperatively. Descriptive statistics and paired equivalence testing of PROMs at one and two years after surgery was completed using previously published or calculated minimal clinically important differences as upper and lower equivalence limits. A repeated measures analysis of PROMs that were not clinically equivalent at one and two years after surgery was completed to assess for a clinically significant difference. Subgroup analyses based on sex, age and associated meniscal injury were completed.

RESULTS

One-hundred and forty-five participants with a mean age of 28.7 years (standard deviation: 9.9 years) were included in the final analysis. All PROMs were clinically equivalent at two years compared to one year after ACLR except the quality of life and sport and recreation domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The quality of life (mean difference (MD):12.3, P ​< ​0.01, effect size (η2): 0.65) and sport and recreation (MD: 8.78, P ​< ​0.01, η2: 0.50) domains of the KOOS were clinically different at two years compared to one year postoperatively. No major differences were found in the subgroup analyses compared to the entire included sample.

CONCLUSION

While most PROMs were equivalent at two years compared to one year after ACLR, the quality of life and sport and recreation domains of the KOOS, which reflect knee performance during higher demand activities, exhibited a clinically significant difference.

LEVEL OF EVIDENCE

IV.

Clinical Outcomes of a Novel Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Large Single-Center Case Series With a Minimum 2-Year Follow-up

Background

A novel hybrid transtibial (HTT) approach to femoral tunnel drilling in anterior cruciate ligament reconstruction (ACLR) has been developed that circumvents the need for knee hyperflexion and orients the graft in the most anatomic position without sacrificing the tunnel length or aperture.

Hypothesis

Patients who underwent ACLR utilizing the HTT technique would achieve excellent patient-reported outcome scores and experience low rates of graft failure and reoperations.

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent primary ACLR at a single institution between 2005 and 2020 were retrospectively reviewed. Patients treated with the HTT, anteromedial portal (AMP), and transtibial (TT) approaches were matched based on age, sex, and body mass index ±3 kg/m2. Demographic and surgical data as well as femoral tunnel angle measurements on anteroposterior and lateral radiographs were collected for the 3 groups. However, clinical outcomes were only reported for the HTT group because of concerns of graft heterogeneity.

Results

A total of 170 patients (median age, 26.5 years [interquartile range (IQR), 18.0-35.0 years]) who underwent ACLR using the HTT approach were included. The median coronal- and sagittal-plane femoral tunnel angles were 47° (IQR, 42°-53°) and 40° (IQR, 34°-46°), respectively. The sagittal-plane femoral tunnel angles in the HTT group were significantly more horizontal compared with those in the TT group (P < .0001), whereas the coronal-plane femoral tunnel angles in the HTT group were found to be significantly more vertical compared with those in the AMP group (P = .001) and more horizontal compared with those in the TT group (P < .0001). The graft failure and reoperation rates in the HTT group at a minimum 2-year follow-up were 1.8% (3/170) and 4.7% (8/170), respectively. The complication rate was 6.5% (11/170), with the most common complication being subjective stiffness in 7 patients. The median Lysholm score was 89.5 (IQR, 79.0-98.0); the median International Knee Documentation Committee score was 83.9 (IQR, 65.5-90.8); and the median Veterans RAND 12-Item Health Survey physical and mental component summary scores were 55.0 (IQR, 52.6-55.9) and 56.2 (IQR, 49.1-59.3), respectively.

Conclusion

ACLR using the HTT technique was associated with low graft retear and revision surgery rates and good patient-reported outcome scores at medium-term follow-up and demonstrated femoral tunnel obliquity on postoperative radiographs that correlated with optimal parameters previously reported in cadaveric and biomechanical studies.

The effect of attending rehabilitation after traumatic knee joint injury on femoral articular cartilage morphology in collegiate rugby players with a history of intracapsular knee joint injury during two-year consecutive rugby seasons

Introduction

This present study aimed to compare ultrasonographic measures of femoral articular cartilage during two-year seasons between collegiate rugby players who have attended supervised rehabilitation following intracapsular knee joint injury and those without a history of knee injury.

Methods

Using a prospective observational study design, 12 male collegiate rugby players with a previous history of intracapsular knee joint injury who have received and completed supervised rehabilitation following their injury and 44 players without knee joint injury participated in this study. Ultrasonographic images were used to verify changes in femoral articular cartilage thickness and cross-sectional area (CSA) with or without a previous history of knee joint injury over two consecutive rugby seasons.

Results

Significant time main effects were observed for the lateral condylar thickness (p < 0.001), the intercondylar thickness (p = 0.001), the medial condylar thickness (p < 0.001), and CSA (p < 0.001). No significant interactions nor group main effects were identified for all femoral articular cartilage (p < 0.05).

Conclusions

Collegiate rugby players demonstrated a decrease in femoral articular cartilage thickness and CSA over two-year consecutive rugby seasons. These findings indicate that engaging in collegiate rugby induces alterations in femoral articular cartilage structure. Furthermore, there were no differences in all femoral cartilage outcome measures between rugby players with and without a previous history of traumatic knee joint injury. Therefore, attending supervised rehabilitation at the time of their knee joint injury appeared to reduce the impact of a previous history of intracapsular knee joint injury on the change in femoral articular cartilage thickness and CSA among active rugby players.

A Comprehensive Review on the Diagnosis of Knee Injury by Deep Learning-Based Magnetic Resonance Imaging

The continual improvement in the field of medical diagnosis has led to the monopoly of using deep learning (DL)-based magnetic resonance imaging (MRI) for the diagnosis of knee injury related to meniscal injury, ligament injury including the cruciate ligaments, collateral ligaments and medial patella-femoral ligament, and cartilage injury. The present systematic review was done by PubMed and Directory of Open Access Journals (DOAJ), wherein we finalised 24 studies conducted on the accuracy of DL MRI studies for knee injury identification. The studies showed an accuracy of 72.5% to 100% indicating that DL MRI holds an equivalent performance as humans in decision-making and management of knee injuries. This further opens up future exploration for improving MRI-based diagnosis keeping in mind the limitations of verification bias and data imbalance in ground truth subjectivity.

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Limited evidence exists regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport after a lateral ankle sprain (LAS) injury.

OBJECTIVE

To evaluate self-reports of improvement in health status, pain, function, and disability at return to sport after an LAS.

DESIGN

Descriptive study.

SETTING

Sixty-nine athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 637 patients (males = 53.2%) who were diagnosed with an LAS, restricted from sport after injury, and subsequently medically cleared to return to sport within 60 days were included.

MAIN OUTCOME MEASURE(S)

Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in the time to return to sport.

RESULTS

Most patients sustained an LAS injury while participating in basketball, football, or soccer and were cleared to return to sport 8 days after injury. More than two-thirds of patients reported a meaningful improvement in health status between the time of injury and return to sport. However, many noted deficits related to pain (65.1%), function (86.2%), or disability (35.8%) at return to sport. No differences were seen between males and females for pain (P = .90), function (P = .68), change in health status (P = .45), or disability (P = .21) at return to sport, although males returned to sport slightly sooner than females (P = .025).

CONCLUSIONS

Despite self-perceived improvements in health status since the time of injury, patients typically returned to sport with deficits in pain, function, and disability after an LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury.

Patients Experience Significant and Meaningful Changes in Self-Report of Function During the First 2 Weeks After an Ankle Sprain Injury: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury.

DESIGN

A retrospective analysis of electronic medical records.

METHODS

Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points.

RESULTS

Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P < .001) and FAAM Sport (FAAM-Sport) (P < .001). At the patient level, 86.5% (64/74) and 85.2% (69/81) of patients reported changes that exceeded the minimal clinically important difference value for the FAAM-ADL and FAAM-Sport, respectively, between weeks 1 and 2. At week 2, 31.8% (28/88) and 47.7% (42/88) of patients reported a score below 90% on the FAAM-ADL and below 80% on the FAAM-Sport subscale, respectively. Also, 36.4% (32/88) and 25.0% (22/88) of patients reported a score of 100% on the FAAM-ADL and FAAM-Sport subscales, respectively, at week 2.

CONCLUSIONS

Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient's perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

A comparison of preoperative scores prior to anterior cruciate ligament reconstruction with optimal preinjury scores and final scores at two-year follow up

AIMS

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

METHODS

We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale.

RESULTS

We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001).

CONCLUSION

Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected.Cite this article: Bone Jt Open 2023;4(1):46-52.

Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis

OBJECTIVE

Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.

DESIGN

Living systematic review and meta-analysis.

DATA SOURCES

Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.

ELIGIBILITY CRITERIA

Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.

DATA SYNTHESIS

Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.

RESULTS

Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.

CONCLUSIONS

There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.

PROSPERO REGISTRATION NUMBER

CRD42021256537.

Influence of body mass index and anterior cruciate ligament reconstruction on gait biomechanics

Body mass index (BMI) and history of anterior cruciate ligament reconstruction (ACLR) independently influence gait biomechanics and knee osteoarthritis risk, but the interaction between these factors is unclear. The purpose of this study was to compare gait biomechanics between individuals with and without ACLR, and with and without overweight/obesity. We examined 104 individuals divided into four groups: with and without ACLR, and with low or high BMI (n = 26 per group). Three-dimensional gait biomechanics were evaluated at preferred speed. The peak vertical ground reaction force, knee flexion angle and excursion, external knee flexion moment, and external knee adduction moment were extracted for analysis. Gait features were compared between groups using 2 (with and without overweight/obesity) × 2 (with and without ACLR) analysis of variance. Primary findings indicated that those with ACLR and high BMI had a larger external knee adduction moment compared with those with low BMI and with (p = 0.004) and without ACLR (p = 0.005), and compared with those without ACLR and high BMI (p = 0.001). The main effects of ACLR and BMI group were found for the knee flexion moment, and those with ACLR and with high BMI had lower knee flexion moments compared with those without ACLR (p = 0.031) and with low BMI (p = 0.021), respectively. Data suggest that individuals with ACLR and high BMI may benefit from additional intervention targeting the knee adduction moment. Moreover, lower external knee flexion moments in those with high BMI and ACLR were consistent, but high BMI did not exacerbate deficits in the knee flexion moment in those with ACLR. [Correction added on 9 November 2022, after first online publication: In the preceding sentence, for clarity, the words "reductions in the lower" was removed from the initial sentence to read "Moreover, lower external knee flexion moments".].

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

OBJECTIVE

Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

DESIGN

Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

ELIGIBILITY

Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

RESULTS

Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

CONCLUSION

There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Lower rate of acceptable knee function in adolescents compared with young adults five years after acl reconstruction: results from the swedish national knee ligament register

Background

The number of studies with a large cohort of patients that primarily focus on patient-reported outcomes after ACL reconstruction in children and adolescents is limited. The purpose of the present study was to determine whether patient age affects the proportion of patients that achieve a patient-acceptable symptom state (PASS) on the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales one, two, five and 10 years after an ACL reconstruction.

Methods

The patient data in the present study were extracted from the Swedish National Knee Ligament Register (SNKLR). Patients aged between five and 35 years that underwent a primary ACL reconstruction between 1 January 2005 and 31 December 2017 and had completed the KOOS questionnaire at the one-, two-, five- or 10-year follow-up were included. A total of 2,848 patients met the inclusion criteria and were included in the study; 47 paediatric patients (females 5–13, males 5–15 years), 522 adolescents (females 14–19, males 16–19 years) and 2,279 young adults (females 20–35, males 20–35 years). The results from the KOOS were presented as the mean and 95% confidence interval (CI) for the mean. For comparisons between groups, the chi-square test was used for non-ordered categorical variables. For pairwise comparisons between groups, Fisher’s exact test (2-sided) was used for dichotomous variables. All the statistical analyses was set at 5%.

Results

Adolescents reported a significantly lower score than young adults on the KOOS4 at the two- (68.4 vs. 72.1; P < 0.05), five- (69.8 vs. 76.0; P < 0.05) and 10-year follow-ups (69.8 vs. 78.2; P < 0.05). Moreover, a significantly smaller proportion of adolescents achieved a PASS on each of the KOOS subscales when compared with young adults at the five-year follow-up (Symptoms: 83.3% vs. 91.6%; Pain: 42.9% vs. 55.3%; Function in daily living: 31.4% vs. 41.1%; Function in sports and recreational activities: 42.3% vs. 55.7%; Knee-related quality of life: 50.0% vs. 65.0%; P < 0.05).

Conclusions

A significantly smaller proportion of adolescents achieved a PASS on each of the KOOS subscales when compared with young adults five years after ACL reconstruction. The results of the present study provide important information for physicians and physiotherapists treating young patients after an ACL injury and they can aid in providing realistic expectations in terms of the mid- and long-term outcomes.

Level of evidence

Prospective Observational Register/Cohort Study, Level II.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05727-6.

Fracture-related infection of the patella: Treatment options and outcome

BACKGROUND

Fracture-related infection (FRI) after the operative management of patella fractures is a serious complication that can result in prolonged hospitalization, multiple revision procedures and permanent functional impairment. Till today, treatment modalities and outcome of FRI of the patella are not well described. Therefore, the main objective of this retrospective cohort study was to evaluate treatment options, functional outcome and healthcare costs related to FRI of the patella.

METHODS

This study evaluated 111 consecutive patients that were surgically treated for patella fractures, at the department of trauma surgery of the University Hospitals Leuven (Belgium), between January 2015 and April 2020. Patients were excluded if they (1) were younger than 18 years at the time of injury or (2) died during follow up. The minimal follow-up for all patients was 18 months.

RESULTS

During the 5-year study period, 107 patients with 108 patella fractures were included. A total of 10 patients were diagnosed with an FRI (9.3%). Four of these were treated with a DAIR approach and three patients underwent implant removal or exchange. Finally, three patients were treated with total patellectomy. Out of the 10 patients, two were diagnosed with a recurrence of infection. Overall, we observed substantial lower scores for all Knee Injury and Osteoarthritis Outcome Score subscales in the FRI group, compared to a reference population. Moreover, our study shows that direct hospital-related healthcare costs of FRI of the patella were nine times higher compared to non-FRI cases.

CONCLUSIONS

FRI of the patella is a challenging complication and recurrence of infection not uncommon. Although multiple treatment modalities exist, a multidisciplinary patient-specific approach is crucial. An early or delayed onset infection can be managed with a DAIR approach, but only when the construct is stable and the soft tissue coverage adequate. In patients with an FRI, implant removal is preferred when the fracture has healed. A total patellectomy can be used as a salvage procedure in complex cases with acceptable functional results. Overall, FRI of the patella leads to both a negative impact on the functional status of the patient and a ninefold increase in total healthcare costs.

Knee Injury Detection Using Deep Learning on MRI Studies: A Systematic Review

The improved treatment of knee injuries critically relies on having an accurate and cost-effective detection. In recent years, deep-learning-based approaches have monopolized knee injury detection in MRI studies. The aim of this paper is to present the findings of a systematic literature review of knee (anterior cruciate ligament, meniscus, and cartilage) injury detection papers using deep learning. The systematic review was carried out following the PRISMA guidelines on several databases, including PubMed, Cochrane Library, EMBASE, and Google Scholar. Appropriate metrics were chosen to interpret the results. The prediction accuracy of the deep-learning models for the identification of knee injuries ranged from 72.5-100%. Deep learning has the potential to act at par with human-level performance in decision-making tasks related to the MRI-based diagnosis of knee injuries. The limitations of the present deep-learning approaches include data imbalance, model generalizability across different centers, verification bias, lack of related classification studies with more than two classes, and ground-truth subjectivity. There are several possible avenues of further exploration of deep learning for improving MRI-based knee injury diagnosis. Explainability and lightweightness of the deployed deep-learning systems are expected to become crucial enablers for their widespread use in clinical practice.

Does Gender Influence Outcome in Cartilage Repair Surgery? An Analysis of 4,968 Consecutive Patients from the German Cartilage Registry (Knorpel Register DGOU)

The goal was to examine gender differences of patient characteristics and outcome after cartilage repair based on a collective of nearly 5,000 patients. Patient characteristics, accompanying therapies, and outcome (Knee Injury and Osteoarthritis Outcome Score [KOOS], reoperations, patient satisfaction) of 4,986 patients of the German cartilage register DGOU were assessed by t test for possible gender differences. P values <0.05 were considered statistically significant. Women were older than men (38.07 ± 12.54 vs. 26.94 ± 12.394 years, P = 0.002), more often preoperated (0.30 ± 0.63 vs. 0.24 ± 0.55, P = 0.001), and had a longer symptom duration (25.22 ± 41.20 vs. 20.67 ± 35.32 months, P < 0.001). Men had greater mean leg axis malalignment than women (3.24° ± 3.26° vs. 2.67° ± 3.06°, P < 0.001), less favorable meniscal status (P = 0.001), worse defect stage (P = 0.006), and a more severely damaged corresponding articular surface (P = 0.042). At baseline (59.84 ± 17.49 vs. 52.10 ± 17.77, P < 0.001), after 6 months (72.83 ± 15.56 vs. 66.56 ± 17.66, P < 0.001), after 12 months (77.88 ± 15.95 vs. 73.07 ± 18.12, P < 0.001), and after 24 months (79.311 ± 15.94 vs. 74.39 ± 18.81, P < 0.001), men had better absolute KOOS values, but women had better relative KOOS increases 6 months (14.59 ± 17.31 vs. 12.49 ± 16.3, P = 0.005) as well as 12 months postoperatively (20.27 ± 18.6 vs. 17.34 ± 17.79, P = 0.001) compared with preoperatively, although 12 and 24 months postoperatively they were subjectively less satisfied with the outcome (P < 0.001) and had a higher reintervention rate at 24 months (0.17 ± 0.38 vs. 0.12 ± 0.33, P = 0.008). In summary, the present work shows specific gender differences in terms of patient characteristics, defect etiology, defect localization, concomitant therapy, and the choice of cartilage repair procedure. Unexpectedly, contrary to the established scientific opinion, it could be demonstrated that women show relatively better postoperative KOOS increases, despite a higher revision rate and higher subjective dissatisfaction.

Clinical relevance of MRI knee abnormalities in Australian rules football players: a longitudinal study

Background/Aim

The clinical relevance of MRI knee abnormalities in athletes is unclear. This study aimed to determine the prevalence of MRI knee abnormalities in Australian Rules Football (ARF) players and describe their associations with pain, function, past and incident injury and surgery history.

Methods

75 male players (mean age 21, range 16–30) from the Tasmanian State Football League were examined early in the playing season (baseline). History of knee injury/surgery and knee pain and function were assessed. Players underwent MRI scans of both knees at baseline. Clinical measurements and MRI scans were repeated at the end of the season, and incident knee injuries during the season were recorded.

Results

MRI knee abnormalities were common at baseline (67% bone marrow lesions, 16% meniscal tear/extrusion, 43% cartilage defects, 67% effusion synovitis). Meniscal tears/extrusion and synovial fluid volume were positively associated with knee symptoms, but these associations were small in magnitude and did not persist after further accounting for injury history. Players with a history of injury were at a greater risk of having meniscal tears/extrusion, effusion synovitis and greater synovial fluid volume. In contrast, players with a history of surgery were at a greater risk of having cartilage defects and meniscal tears/extrusion. Incident injuries were significantly associated with worsening symptoms, BML development and incident meniscal damage.

Conclusions

MRI abnormalities are common in ARF players, are linked to a previous knee injury and surgery history, as well as incident injury but do not dictate clinical symptomatology.

Rehabilitation and Return to Play Following Meniscus Repair

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.

Effect of Anterior Cruciate Ligament Rupture on Physical Activity, Sports Participation, Patient-Reported Health Outcomes, and Physical Function in Young Female Athletes

BACKGROUND

Return to sports (RTS) is frequently considered an indicator of successful recovery after anterior cruciate ligament reconstruction (ACLR). However, despite the well-recognized health benefits of physical activity (PA), little is known about objectively measured PA in the 1 to 2 years after ACLR. Given that young female athletes have a high prevalence of ACLR and lower RTS rates as compared with their male counterparts, an in-depth examination of PA in this subgroup is warranted.

HYPOTHESIS

We hypothesized that female youth and young adults who have had ACLR in the previous 1 to 2 years would have less moderate or vigorous PA (MVPA) compared with healthy matched controls. We also hypothesized that the ACLR group would report lower levels of sports participation, patient-reported health outcomes, and physical function.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Participants included 51 female athletes with primary unilateral ACLR for a sports-related injury in the previous 1 to 2 years and 51 age- and sports-matched controls. Outcomes included objectively measured PA (GT3X accelerometers), previous and current sports participation and RTS, body mass index, Knee injury and Osteoarthritis Outcome Score (KOOS), triple single-leg hop, and one-leg rise. Mean within-pair differences with 95% CIs were used to assess differences between groups across all outcomes. Multivariable linear regression (clustered by pair) was used to examine whether the ACLR group had less MVPA than did the age- and sports-matched control group, adjusting for total wear time, age, time since injury, and body mass index.

RESULTS

Median age was 17.8 years (range, 14.6-22.6 years). There was no significant difference between groups in MVPA. However, the injury group had fewer mean minutes per day of vigorous PA (-1.22; 95% CI, -2.40 to -0.04), poorer KOOS values on all subscales, and shorter triple single-leg hop distance. In the injury group, 28 (55%) returned to sports, including 14 (27.5%) who returned at preinjury performance level. Across both groups, over one-third changed their most important sport, shifting toward an individual-based sport.

CONCLUSION

At 1 to 2 years after ACLR, female athletes demonstrated no differences in combined MVPA and only a very small reduction in vigorous PA, yet they had higher levels of self-reported knee pain and symptoms, reduced knee function in sports, lower quality of life, and poorer objective knee function compared with matched controls.

ACL reconstruction for all is not cost-effective after acute ACL rupture

OBJECTIVES

To conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator).

METHODS

Patients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping.

RESULTS

A total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective.

CONCLUSION

Routine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

Self-Reported Knee Pain Does Not Impact Physical Training Negatively in Conscripts

INTRODUCTION

Despite the great number of investigations on the effects of injuries during military service, there is limited information available on the use of self-reported instruments. This study evaluated self-reported knee pain (KP) and its effect on physical performance during military service in the Estonian Defense Forces.

MATERIAL AND METHODS

Ninety-five male conscripts aged 19-25 years were divided into two study groups based on the occurrence of KP or not. Self-reported KP and function according to the Knee Injury and Osteoarthritis Outcome Score (KOOS) were measured. Physical fitness level was scored using the Army Physical Fitness Test (APFT). KOOS and APFT were measured in the beginning and at the end of the 6-month period of military service.

RESULTS

Significant differences in favor of the group without KP (P < 0.001) were found for all subgroups of the KOOS. In spite of KP, the physical condition improved significantly (P < 0.001) in both study groups as measured with both the APFT test (22.2% increase) and running time (10.3% decrease).

CONCLUSION

In conclusion, self-reported KP and limited function according to KOOS did not hinder the improvement of physical condition and running speed as assessed by APFT in Estonian conscripts.

Patient-Reported Outcomes One to Five Years After Anterior Cruciate Ligament Reconstruction: The Effect of Combined Injury and Associations With Osteoarthritis Features Defined on Magnetic Resonance Imaging

OBJECTIVE

Persistent symptoms and poor quality of life (QoL) are common following anterior cruciate ligament reconstruction (ACLR). We aimed to determine the influence of a combined ACL injury (i.e., concomitant meniscectomy and/or arthroscopic chondral defect at the time of ACLR and/or secondary injury/surgery to ACLR knee) and cartilage defects defined on magnetic resonance imaging (MRI), bone marrow lesions (BMLs), and meniscal lesions on patient-reported outcomes 1 to 5 years after ACLR.

METHODS

A total of 80 participants (50 men; mean ± SD age 32 ± 14 years) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) questionnaires as well as a 3T MRI assessment at 1 and 5 years after ACLR. Median patient-reported outcome scores were compared between isolated and combined ACL injuries and with published normative values. Using multivariate regression, we evaluated the association between compartment-specific MRI cartilage, BMLs, and meniscal lesions and patient-reported outcomes at 1 and 5 years.

RESULTS

Individuals with a combined injury had significantly worse scores in the KOOS subscale of function in sport and recreation (KOOS sport/rec) and in the IKDC questionnaire at 1 year, and worse scores in the KOOS subscales of pain (KOOS pain), symptoms (KOOS symptoms), and QoL (KOOS QoL) and in the IKDC questionnaire at 5 years compared to those with an isolated injury. Although no feature on MRI was associated with patient-reported outcomes cross-sectionally at 1 year, patellofemoral cartilage defects at 1 year were significantly associated with worse 5-year KOOS symptoms (β = -9.79, 95% confidence interval [95% CI] -16.67, -2.91), KOOS sport/rec (β = -7.94, 95% CI -15.27, -0.61), KOOS QoL (β = -8.29, 95% CI -15.28, -1.29), and IKDC (β = -4.79, 95% CI -9.34, -0.24) scores. Patellofemoral cartilage defects at 5 years were also significantly associated with worse 5-year KOOS symptoms (β = -6.86, 95% CI -13.49, -0.24) and KOOS QoL (β = -11.71, 95% CI -19.08, -4.33) scores.

CONCLUSION

Combined injury and patellofemoral cartilage defects shown on MRI are associated with poorer long-term outcomes. Clinicians should be vigilant and aware of individuals with these injuries, as such individuals may benefit from targeted interventions to improve QoL and optimize symptoms.

Prevalence of knee injuries among male college students in Riyadh, Kingdom of Saudi Arabia

BACKGROUND

The knee is considered the most common injured joint between young sport participants. However, there is lack of proper prevalence estimation in our population. The purpose of this study was to identify the prevalence of knee injuries among male college students and to observe the demographic data associated with it. Our secondary objective was to evaluate the awareness and knowledge about these injuries.

METHODS

This is a cross-sectional study. A survey was distributed to collect the data among male college students, King Saud University, Riyadh, Saudi Arabia. Out of 688 students who participated and completed the questionnaire, a total of 482 were considered valid and met the inclusion criteria. Data were analyzed using Statistical Package for Social Sciences (SPSS).

RESULTS

The overall prevalence of knee injury was 23.2% (n = 112). Most of them injured during sport activities especially soccer and 68.7% involved in a non-contact mechanism of injury. Among those who went to a hospital mostly were diagnosed as contusion (31.4%) then as meniscus tear, ACL, and collateral ligament injury, respectively. Majority was treated conservatively and only 10.7% needed surgery surprisingly. There was no statistically significant difference between those who are injured and whether they were warmed up and stretched or not (P = 0.619). Low level of knowledge about knee injuries was noticed among the participants 57.7%.

CONCLUSION

Our study has highlighted the high prevalence of knee injuries and the need to raise the level of awareness and knowledge about these injuries in our population. Soccer was the most common sport associated with knee injuries; most of these injuries were treated conservatively.

Early knee osteoarthritis prevalence is highest among middle-aged adult females with obesity based on new set of diagnostic criteria from a large sample cohort study in the Japanese general population

PURPOSE

A few new criteria for early detection and prevention of early knee osteoarthritis (EKOA) have been proposed. However, its prevalence, risk factors, relationship with function and prognosis have not been clarified. The purpose of this study was to investigate the prevalence of EKOA and its risk factors in the Japanese general population.

METHODS

A total of 1104 volunteers (443 males, 661 females) who participated in the Iwaki cohort study in Japan were enrolled in this cross-sectional study. Their bilateral weight-bearing anterior-posterior knee radiographs were classified by Kellgren-Lawrence (KL) grade. EKOA (KL grade 0/1) was defined according to the following criteria: knee injury and osteoarthritis outcome score < 85%, joint line tenderness, and crepitus and its prevalence among age-sex groups was calculated. Logistic regression analyses were performed to determine the risk factors for EKOA.

RESULTS

Eight hundred and twenty-two participants had KL grade 0/1, and the EKOA prevalence was 9.5% in males and 15.0% in females (p = 0.011). The prevalence of EKOA increased with age. The highest prevalence was noted in females aged 50-59 years. Logistic regression analysis showed that the risk factors for EKOA were age (p < 0.001, odds ratio (OR) 1.1), female sex (p = 0.002, OR 2.5), high body mass index (p < 0.001, OR 1.2), and history of knee injury (p < 0.001, OR 21.7).

CONCLUSIONS

The highest EKOA prevalence was observed in middle adult females (50-59 years old). The risk factors for EKOA were female sex, ageing, obesity and knee injury history, which were extremely similar to those of definitive knee osteoarthritis.

LEVEL OF EVIDENCE

Level I in diagnostic studies-investigating a diagnostic test.

Pain Catastrophizing in College Athletes

BACKGROUND

Pain is the most common patient-reported symptom but the perception of pain is complex, differs between individuals and is not directly proportional to the extent of injury. The relationship between aberrant pain coping strategies such as pain catastrophizing and the presence of pain in competitive athletes should be further established to employ the most optimal treatment.

HYPOTHESIS

The hypotheses were that numeric pain rating and pain catastrophizing (Pain Catastrophizing Scale, PCS) scores would have a moderate to strong relationship in college athletes, and athletes with either a current injury or previous injury, or playing with pain, would have significantly higher pain catastrophizing scores compared with noninjured/nonpainful athletes.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

III.

METHODS

College athletes completed a demographic form, injury questionnaire, numeric pain rating, and the PCS. All athletes were medically cleared for sports participation at the time of survey completion. A total PCS score was calculated in addition to a rumination, magnification, and helplessness score. Spearman rank was utilized to measure the strength of relationship between the PCS score and pain rating.

RESULTS

A total of 291 athletes from 15 different sports completed the questionnaires (males: 156, females: 135; age: 19 [2] y). Negligible correlations existed between the PCS score and pain (r = .27). Athletes who were currently injured or previously injured had significantly higher PCS scores compared with uninjured athletes (P < .01).

CONCLUSIONS

Approximately one-third of college athletes reported playing injured and/or with pain, but the relationship between pain rating and PCS score was negligible. The individualistic nature of pain perception and coping strategies would suggest that clinicians may want to consider screening for pain catastrophizing either prior to athletic participation or for athletes not following an expected recovery after injury in an effort to enhance individualized patient care.

The Impact of a Previous Ankle Injury on Current Health-Related Quality of Life in College Athletes

CONTEXT

There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL).

OBJECTIVE

To determine the impact of a previous ankle injury on current HRQOL in college athletes.

DESIGN

Cross-sectional study.

SETTING

Athletic training clinics.

PARTICIPANTS

A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143).

MAIN OUTCOME MEASURES

Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12).

METHODS

A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12.

RESULTS

No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males.

CONCLUSIONS

Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients' region-specific function as well as aspects of their HRQOL.

Physical activity and health-related quality of life in former elite and recreational cricketers from the UK with upper extremity or lower extremity persistent joint pain: a cross-sectional study

OBJECTIVE

To evaluate and compare physical activity (PA) and health-related quality of life (HRQoL) in former elite and recreational cricketers with upper extremity (UE), lower extremity (LE) or no joint pain.

STUDY DESIGN

Cross-sectional cohort.

SETTING

Despite the high prevalence of joint pain in former athletes, the impact of UE pain and LE pain on PA and HRQoL and potential differences between former recreational and elite athletes are poorly understood.

PARTICIPANTS

703 former cricketers aged ≥18 years (mean age 58.7, SD 12.9, played an average of 30 (IQR 20-40) seasons, 72% of whom had played at a recreational level) were recruited through the Cricket Health and Wellbeing Study and met eligibility requirements (UE pain, LE pain or no joint pain (defined as pain on most days of the past month)).

PRIMARY AND SECONDARY OUTCOMES

The International Physical Activity Questionnaire-Short Form collected weekly metabolic equivalents (METS), while the Short-Form 8 collected physical (PCS) and mental (MCS) component scores. Kruskal-Wallis tests with Dunn's post-hoc and multivariable linear regressions were performed.

RESULTS

Weekly METS were similar in former cricketers with UE pain (median (IQR) 2560 (722-4398)), LE pain (2215 (527-3903)) and no pain (2449 (695-4203), p=0.39). MCS were similar between groups (UE pain 56.0 (52.1-60.0); LE pain 55.2 (51.1-59.4); no pain 54.7 (50.7-58.7), p=0.38). PCS were more impaired in former cricketers with UE pain (49.8 (44.9-54.8)) or LE pain (46.7 (41.0-51.9)) compared with no pain (54.2 (51.5-56.9), p<0.0001). Former cricketers with LE pain reported worse PCS than those with UE pain (p=0.04). Similar relationships were observed in former elite and recreational cricketers.

CONCLUSION

Despite impaired physical components of HRQoL in former cricketers with UE pain or LE pain, pain was not related to PA levels or mental components of HRQoL. Physical components of HRQoL were most impaired in those with LE pain, and findings were similar among former elite and recreational cricketers.

Are priorities of younger patients with knee pain addressed by PROMs? A qualitative study

OBJECTIVES

To describe the impact of knee pain and dysfunction in young adults and determine whether current patient reported outcome measures (PROMs) address their recovery priorities.

DESIGN

Qualitative.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Young adults, 23-30 years.

MAIN OUTCOME MEASURES

1:1 semi-structured interviews were held and analyzed with NVivo version 11. The Lower Extremity Functional Scale (LEFS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) were compared to participant identified functional limitations.

RESULTS

9 themes were identified in 7 interviews: Incomplete Recovery as Acceptable, Motivation for Adequate Long Term Function, Guidance Needed to Facilitate Recovery, Sports: To Play or Not to Play, Pain, Therapy Participation and Interventions, Impact on Life, Decreased Knowledge and Condition Management, and A Wide Range of Functional Limitations. The LEFS captured 23/26 identified functional activities, the KOOS 22/26, the IKDC 16/26, and the WOMAC 13/26.

CONCLUSIONS

Incomplete recovery as an acceptable outcome was the most unique theme found in this study. LEFS captured the most relevant functional activities reported by this group. Physical Therapists should consider these findings in PROM selection to better inform meaningful outcome measurement.

Recurrent lateral patella dislocation affects knee function as much as ACL deficiency - however patients wait five times longer for treatment

Background

Surgical treatment of young patients with recurrent lateral patella dislocation (RLDP) is often recommended because of loss of knee function that compromises their level of activity or even their daily life functioning. This situation is comparable to young patients with an anterior cruciate ligament (ACL) rupture. The purpose of this study was therefore to explore the time from injury to surgery and the pre-operative symptoms and knee function of young RLPD patients scheduled for stabilizing surgery and compare this group to age and sex-matched ACL-deficient patients.

Method

Forty-seven patients with unilateral RLPD listed for isolated medial patellofemoral ligament reconstruction were included in the study (RLPD-group). This group was compared to an age, sex and BMI matched ACL patient group obtained from the Norwegian knee ligament registry (ACL-group) for the following outcome measures: the knee injury and osteoarthritis outcome score (KOOS) assessed on the day of surgery and time from injury to surgery.

Results

The RLPD-group scored significantly lower than the ACL-group for the three KOOS subscales “Pain” (73.6 vs. 79.8, p < 0.05), “Symptoms” (71.7 vs. 79.3, p < 0.05) and “ADL” (84.7 vs 89.5, p < 0.05). The lowest KOOS values were found for Sports/Recreation (53.5 vs. 51.3, p = 0.65) and Quality of life (37.6 vs. 36.7, p = 0.81). The average time from primary injury to surgery was 6 months for the ACL group and 31 months for the RLPD group.

Conclusion

RLPD affected knee function as much as ACL deficiency, and was associated with more pain. Still the RLDP patients waited on average 5 times longer for surgery.

Trial registration

The patients with RLPD consisted of patients who were examined for possible recruitment for a concurrent prospective randomized controlled trial comparing conservative treatment and isolated surgical medial patellofemoral ligament (MPFL) reconstruction (Clinical trials no: NCT02263807, October 2014).

Hip Disability and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index Values in Asymptomatic and Arthritic Cohorts

The primary aim of this study was to determine whether an electronic, multicenter data collection system could be used to establish normal population reference values for the Hip Disability and Osteoarthritis Outcome Score (HOOS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The secondary aim was to investigate differences in asymptomatic HOOS and WOMAC values reported in 2 geographically distinct English-speaking countries and compare these with a symptomatic arthritic patient cohort. A total of 552 participants were recruited. Asymptomatic Australian and Canadian cohorts were compared; combined asymptomatic cohorts were compared with an arthritic cohort. There was a statistically significant association between age and asymptomatic HOOS (P<.0001) and WOMAC (P<.0001) values; as age increased, values worsened. Females had worse HOOS and WOMAC values (P<.0001). When compared with age- and sex-matched asymptomatic participants, arthritic participants had worse scores (P<.0001). Asymptomatic Australians had a statistically significant 3.8% better (higher) HOOS (P<.0001) in all age groups (P<.0001). When compared with age- and sex-matched asymptomatic participants, younger arthritic participants reported worse activities of daily living and sports and recreation HOOS values. This observational study established an electronic HOOS and WOMAC patient-reported outcome measures database of asymptomatic individuals in 2 geographically distinct countries. An asymptomatic control group should be sourced from the same country of origin as the proposed study. Factors that should be considered when recording the HOOS and WOMAC include age, sex, geographic location, history of an inactive hip problem, contralateral hip disease, and active knee, ankle, or foot problems. [Orthopedics. 2019; 42(2):e216-e224.].

Determination of normal KOOS and WOMAC values in a healthy population

PURPOSE

The KOOS questionnaire is used to assess the symptoms and function of patients with traumatic or degenerative knee pathology. The WOMAC score has been validated mainly in the context of knee osteoarthritis. The distribution of these scores in a non-diseased population is not known. The hypothesis was that KOOS and WOMAC scores were influenced by patients' age, sex, and BMI. The primary objective of this study was to describe, for the first time, the distribution of KOOS and WOMAC scores in a healthy population based on age, sex, and BMI.

METHODS

This was a pilot (innovative), cross-sectional, international, multicenter, descriptive study. Persons accompanying patients to our clinic were invited to participate in this study by filling out the KOOS questionnaire. These data were also used to calculate the WOMAC score. The study was designed according to guidelines on pilot studies and planned to enroll a minimum of 30 subjects in each age, gender, and BMI group. Expected KOOS and WOMAC scores by age, gender, and BMI were determined using a linear regression model.

RESULTS

Seven hundred and fourteen subjects were included: 305 men (42.7%) and 409 women (57.3%). For the KOOS score, as age increases, there was a decrease in the "ADL" (p = 0.0001) and "sport" (p = 0.0001) items and an increase in the "symptoms" (p = 0.0025) and "QOL" items (p = 0.0001). Women had lower scores (p < 0.05) than men on all the KOOS items, except "QOL". For the WOMAC, the "pain", "stiffness", and "function" items varied significantly based on age (p = 0.0203) and sex (p = 0.0121). The "stiffness" item varied significantly based on age (p = 0.0005) and sex (p = 0.0477). The "function" item varied significantly based on age (p = 0.0001) and sex (p = 0.0256). The expected value for the KOOS and WOMAC scores in a healthy population without any knee ailments were determined.

CONCLUSIONS

The KOOS and WOMAC scores vary significantly based on age, sex, and BMI in a healthy population. This study also provides KOOS and WOMAC values in a population without any knee issue. These scores can be used, in a daily practice, as a reference to assess functional outcomes after a surgical procedure.

LEVEL OF EVIDENCE

IV.

The Impact of Knee Injury History on Health-Related Quality of Life in Adolescent Athletes

CONTEXT

Current evidence suggests that, despite returning to full participation, physically active adults with a previous knee injury experience lower health-related quality of life (HRQOL) than those with no knee injury history. It is unknown if this relationship is present in adolescent athletes.

OBJECTIVE

To determine the impact of knee injury history on HRQOL in adolescent athletes who were medically cleared for full participation.

DESIGN

Cross-sectional.

SETTING

Athletic training clinics.

PARTICIPANTS

A convenience sample of 183 adolescent athletes, who were medically cleared for full participation, were grouped by self-report of a previous knee injury: positive knee injury history (HIS; n = 36, age = 15.7 [1.4] y, height = 168.0 [11.9] cm, and weight = 71.8 [11.9] kg) and no knee injury history (NO-HIS; n = 147, age = 15.5 [1.4] y, height = 166.0 [10.5] cm, and weight = 67.6 [14.6] kg).

INTERVENTIONS

Participants completed the Pediatric International Knee Documentation Committee form and Pediatric Quality of Life Inventory during their preparticipation examination.

MAIN OUTCOME MEASURES

Generalized linear models were used to compare group differences for the total and subscale scores of the Pediatric International Knee Documentation Committee and Pediatric Quality of Life Inventory.

RESULTS

Main effects of injury group indicated that the HIS group reported significantly lower scores than the NO-HIS group for the Pediatric International Knee Documentation Committee total score (P < .001; HIS = 79.2 [21.7], NO-HIS = 95.8 [8.6]) and for the Pediatric Quality of Life Inventory total (P = .001; HIS = 85.7 [10.9], NO-HIS = 90.9 [7.3]), physical functioning (P = .002; HIS = 86.7 [13.6], NO-HIS = 92.1 [8.2]), school functioning (P = .01; HIS = 80.6 [12.4], NO-HIS = 86.8 [12.2]), and social functioning (P = .01; HIS = 89.3 [12.4], NO-HIS = 94.6 [8.9]) scores. No group differences were reported for the emotional functioning subscale (P = .13; HIS = 85.7 [17.7], NO-HIS = 89.7 [13.1]). No interactions or main effects of sex were reported (P > .05).

CONCLUSIONS

Our findings suggest that, despite returning to full sport participation, adolescent athletes with a previous knee injury generally experience lower HRQOL than their peers with no knee injury history, specifically for knee-specific HRQOL, physical functioning, school functioning, and social functioning. Our results are similar to previous findings reported in college athletes and military cadets.

Changes in Patient-Reported Outcome Measures From the Time of Injury to Return to Play in Adolescent Athletes at Secondary Schools With an Athletic Trainer

CONTEXT

Typically, athletic trainers rely on clinician-centered measures to evaluate athletes' return-to-play status. However, clinician-centered measures do not provide information regarding patients' perceptions.

OBJECTIVE

To determine whether clinically important changes in patient-reported outcomes were observed from the time of lower extremity injury to the time of return to play in adolescent athletes.

DESIGN

Cross-sectional study.

SETTING

The National Athletic Treatment, Injury and Outcomes Network (NATION) program has captured injury and treatment data in 31 sports from 147 secondary schools across 26 states. A subsample of 24 schools participated in the outcomes study arm during the 2012-2013 and 2013-2014 academic years.

PATIENTS OR OTHER PARTICIPANTS

To be included in this report, student-athletes must have sustained a knee, lower leg, ankle, or foot injury that restricted participation from sport for at least 3 days. A total of 76 initial assessments were started by athletes; for 69 of those, return-to-play surveys were completed and analyzed.

MAIN OUTCOME MEASURE(S)

All student-athletes completed generic patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System [PROMIS] survey, Global Rating of Change scale, and Numeric Pain Rating Scale) and, depending on body region, completed an additional region-specific measure (Knee Injury and Osteoarthritis Outcome Score or Foot and Ankle Ability Measure). All applicable surveys were completed at both the initial and return-to-play time points. Means and standard deviations for the total scores of each patient-reported outcome measure at each time point were calculated. Change scores that reflected the difference from the initial to the return-to-play time points were calculated for each participant and compared with established benchmarks for change.

RESULTS

The greatest improvement in patient-reported outcomes was in the region-specific forms, with scores ranging from 9.92 to 37.73 on the different region-specific subscales (Knee Injury and Osteoarthritis Outcome Score or Foot and Ankle Ability Measure; scores range from 0-100). The region-specific subscales on average still showed a 21.8- to 37.5-point deficit in reported health at return to play. The PROMIS Lower Extremity score increased on average by 13 points; all other PROMIS scales were within normative values after injury.

CONCLUSIONS

Adolescent athletes who were injured at a high school with an athletic trainer may have shown improvement in patient-reported outcomes over time, but when they returned to play, their outcome scores remained lower than norms from comparable athlete groups.

Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years' Follow-up

BACKGROUND

There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited.

PURPOSE

To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-six children aged <13 years with a total intrasubstance ACL injury were included. None of these patients had additional injuries that warranted early surgery. At final follow-up at a mean 8 years after the time of injury, 44 patients remained in the study. The same test battery was conducted at baseline, 1 and 2 years, and final follow-up at approximately 18 years of age. The test battery included functional tests (hop tests and isokinetic muscle strength tests of quadriceps and hamstrings), patient-reported outcome measures (including the Knee injury and Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form), and clinical examination. Medical records were reviewed to assess surgical history and complications.

RESULTS

At a mean 8 years of follow-up, 24 patients (55%) had undergone ACL reconstruction, and 16 (36%) had undergone meniscal surgery. Quadriceps muscle strength symmetry was >90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports.

CONCLUSION

Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery.

The Long-Term Impact of Osteoarthritis Following Knee Surgery in Former College Athletes

CONTEXT

Individuals who sustain a knee surgery have been shown to have an increased likelihood to develop osteoarthritis (OA).

OBJECTIVE

Identify the consequences of knee surgery in a cohort of former college athletes.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

A group of 100 former Division I college athletes aged 40-65 years (60 males and 40 females) participated in the study.

INTERVENTIONS

All individuals self-reported whether they sustained a knee injury during college requiring surgery and if they have been diagnosed with knee OA by a medical physician post knee injury. Individuals were categorized into 3 groups: no history of knee injury requiring surgery (33 males and 24 females; 54.53 [5.95] y), history of knee surgery in college with no diagnosis of OA later in life (4 males and 6 females; 51.26 [7.29] y), and history of knee surgery in college with physician diagnosed OA later in life (23 males and 10 females; 54.21 [7.64] y). All individuals completed the knee injury and osteoarthritis outcome score (KOOS) and short form-36 version 2.

MAIN OUTCOME MEASURES

Scores on the KOOS and short form-36 version 2.

RESULTS

A majority (76.7%) of individuals who had a knee surgery in college did develop OA. The largest mean differences were between the healthy knee and surgical knee/OA groups on the KOOS-quality of life scale (mean difference: 49.76; χ2(3) = 44.65; P < .001) and KOOS-sports scale (mean difference: 43.69; χ2(3) = 28.69; P < .001), with the surgical knee/OA group scoring worse.

CONCLUSIONS

Later in life functional limitations were observed in individuals who sustained a knee injury requiring surgery and developed OA. These findings support increased efforts toward prevention of knee injuries and consideration of the long-term implication when making treatment and return to activity decisions.

Knee osteoarthritis in professional football is related to severe knee injury and knee surgery

BACKGROUND

As a consequence of severe knee injuries, knee osteoarthritis (OA) seems prevalent in retired professional footballers. However, some epidemiological data remain missing, for instance whether knee OA is also prevalent in current professional footballers, whether knee OA is associated with knee injuries and surgeries, and whether knee OA leads to a lower level of functioning. Therefore, three research questions were answered: (i) what is the prevalence of knee osteoarthritis (OA) among current and retired professional footballers? (ii) is severe knee injury or knee surgery associated with knee OA among current and retired professional footballers? (iii) what are the consequences of knee OA on physical knee function among current and retired professional footballers?

METHODS

An observational study based on a cross-sectional design by means of questionnaires was conducted. Participants were current and retired professional footballers recruited by the World Players' Union (FIFPro). Information about severe knee injury and knee OA was gathered (medical record or team doctor), while physical knee function was assessed through a validated scale.

RESULTS

A total of 1360 participants (964 current and 396 retired professional footballers) were enrolled in the study (response rate of 54%). Prevalence of knee OA was 13% among current players and 28% among retired players (p < 0.01), being higher among older players. Current and retired professional footballers were nearly twice as likely to suffer from knee OA by every additional severe knee injury and by every additional knee surgery (risk ratio: 1.72-1.96; p < 0.01). Current and retired professional footballers with knee OA reported a lower level of physical knee function than current and retired players without OA (p < 0.01), their physical knee function being also lower than reference values (adult population, young athletic population and amateur footballers).

CONCLUSION

The prevalence of knee OA was higher among retired than among current professional footballers and reached up to 40%, leading to negative consequences for their physical knee function. Current and retired professional footballers were nearly twice as likely to suffer from knee OA by every additional severe knee injury and by every additional knee surgery incurred during their career. Management of knee OA should be prioritized among professional footballers, especially to prevent the worsening of the condition during their retirement years.

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.

Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants

OBJECTIVES

The complication rate following operative treatment of patellar fractures remains high and is associated with a poor functional outcome. The primary goal of this study was to evaluate our functional outcome of patellar fracture osteosynthesis and define strategies to improve the outcome. The healthcare costs and utilization were calculated.

METHODS

All demographic, clinical, radiographic variables and hospital-related costs of 111 patients with 113 surgically treated patellar fractures between January 2005 and December 2014 were analyzed. Fractures were grouped as either simple or complex. Functional outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

There were 67 simple fractures (59.3%) and 46 complex fractures (40.7%). The overall complication rate was 48.7%, including 19.5% implant-related complications. In 69 patients (61.1%), implants were removed. The outcome was rather poor, with considerable impairment in all KOOS subscales with the knee-related quality of life rated worst (median 62.5, IQR 37.5-81.25). Poor outcome correlated significantly with complex patellar fractures and extensive tension-band constructs.

CONCLUSIONS

The operative treatment of patellar fractures was associated with a high complication rate, functional impairment and reduced quality of life. Complex patellar fractures and extensive tension-band constructs were identified as the main determinants of poor outcome and increased economic burden due to higher reinterventions rates. Strategies to reduce complications and improve outcome should focus on less onerous implants.

Normal population reference values for the Oxford and Harris Hip Scores - electronic data collection and its implications for clinical practice

BACKGROUND

The aim of this study was to assess whether the Harris Hip Score (HHS) and the Oxford Hip Score (OHS) were comparable in normal, healthy, pathology-free individuals of different age, gender, ethnicity, handedness and nationality. The purpose of this study was to establish normal population values for the HHS and OHS using an electronic data collection system.

METHODS

317 Australian and 310 Canadian citizens with no active hip pain, injury or pathology in the ipsilateral hip corresponding to their dominant arm, were evaluated. Participants completed an electronically-administered questionnaire and were assessed clinically. Chi-square tests, Fisher's exact test and Poisson regression models were used where appropriate, to investigate the association between hip scores, ethnicity, nationality, gender, handedness and age.

RESULTS

There was a statistically significant association between the OHS and age (p<0.0001) and the HHS and age (p = 0.0006); demonstrating that as age increased, normal hip scores decreased. There was no statistically significant association between the HHS and gender (p = 0.1389); or HSS and nationality, adjusting for age (p = 0.5698) and adjusting for gender (p = 0.6997). There was no statistically significant association between the OHS and gender (p = 0.1350). Australians reported a statistically significant 4.2% higher overall OHS value compared to Canadians (p = 0.0490). There was no statistically significant association between the OHS and nationality in age groups 18-79 years. Participants >80 years reported a statistically significant association between the OHS and nationality (p<0.0001).

CONCLUSIONS

Studies using an electronic control group should consider differences in gender, age, ethnicity and nationality when using the HHS and OHS to assess patient outcomes. This study has established an electronic, normal control group for studies using the HHS and OHS. When using the OHS, the control group should be sourced from the same country of origin. When using the HHS, the control group should be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin.

The Role of Athletic Trainers in Preventing and Managing Posttraumatic Osteoarthritis in Physically Active Populations: a Consensus Statement of the Athletic Trainers' Osteoarthritis Consortium

OBJECTIVE

  To provide athletic trainers with a fundamental understanding of the pathogenesis and risk factors associated with the development of posttraumatic osteoarthritis (PTOA) as well as the best current recommendations for preventing and managing this condition.

BACKGROUND

  Posttraumatic osteoarthritis, or osteoarthritis that develops secondary to joint injury, accounts for approximately 5.5 million US cases annually. A young athlete with a joint injury is at high risk for PTOA before the age of 40, which could lead to the patient living more than half of his or her life with a painful and disabling disorder. Given our frequent contact with physically active people who often sustain traumatic joint injuries, athletic trainers are in a unique position to help prevent and manage PTOA. We can, therefore, regularly monitor joint health in at-risk patients and implement early therapies as necessary.

RECOMMENDATIONS

  The recommendations for preventing and managing PTOA are based on the best available evidence. Primary injury prevention, self-management strategies, maintenance of a healthy body weight, and an appropriate level of physical activity should be encouraged among those at risk for PTOA after acute traumatic joint injury. Education of athletic trainers and patients regarding PTOA is also critical for effective prevention and management of this disease.

Preoperative Pain and Function: Profiles of Patients Selected for Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is an effective treatment to relieve pain and restore function in patients with advanced knee osteoarthritis. TKA utilization is growing rapidly, and the appropriateness of current TKA use is of great interest. We examined patient-reported preoperative pain and function profiles to understand symptom severity at the time of TKA decision.

METHODS

Data were from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement. We included patients undergoing primary, unilateral TKAs between 2011 and 2014 for osteoarthritis and had data on the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and Short-Form 36-item Physical Component Summary (PCS) score. We compared patient profiles across groupings by symptoms: (1) little pain and high function (KOOS ≥70, PCS ≥40); (2) little pain but poor function (KOOS ≥70, PCS <40); (3) high pain but high function (KOOS <70, PCS ≥40); and (4) high pain and poor function (KOOS <70, PCS <40).

RESULTS

Of 6936 patients, 77% had high pain and poor function (group 4), 19% had high pain "or" poor function (groups 2-3), and 5% had little pain and high function before TKA (group 1). In group 1, 86% were constantly aware of their knee problem, 48% reported pain daily yet 5% experienced severe or extreme pain on stairs, and 1% pain in bed. Over half had a lot of limitations in vigorous activities. Compared with group 4, group 1 were older, less obese, more educated, and included more men and people reporting being healthy, less disabled, and happy (P < .05 for all).

CONCLUSION

Most patients undergoing TKAs had significant pain and/or poor function. Our results provide critical information given the current debate of potentially inappropriate TKA utilization in the United States.

Defining Thresholds for the Patient Acceptable Symptom State for the IKDC Subjective Knee Form and KOOS for Patients Who Underwent ACL Reconstruction

BACKGROUND

A clinically meaningful change in patient-reported outcome (PRO) may not be associated with an acceptable state that corresponds to "feeling well," also known as the patient acceptable symptom state (PASS). The PASS thresholds for the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS) have not been determined for individuals after anterior cruciate ligament (ACL) reconstruction.

PURPOSE

To determine the PASS thresholds for the IKDC-SKF and KOOS in individuals at 1 to 5 years after ACL reconstruction.

STUDY DESIGN

Cohort study (diagnosis): Level of evidence, 2.

METHODS

Individuals 1 to 5 years after primary ACL reconstruction completed a survey that included the IKDC-SKF and KOOS. All subjects assessed satisfaction with their current state by answering the question, "Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?"

RESULTS

A total of 251 participants (mean age ± SD, 26.1 ± 9.9 years) completed the survey at an average of 3.4 ± 1.3 years after ACL reconstruction. Of these, 223 (89.2%) individuals indicated that they were in an acceptable symptom state (PASS-Y). Analysis of the receiver operating characteristic curve revealed that the IKDC-SKF and each of the KOOS subscales (pain, symptoms, activities of daily living [ADL], sport and recreation [sport/rec], and quality of life [QoL]) were significantly better identifiers of PASS than chance as indicated by the significance of the area under the curves. The PASS threshold (sensitivity, specificity) was 75.9 (0.83, 0.96) for the IKDC-SKF, 88.9 (0.82, 0.81) for the KOOS pain, 57.1 (0.78, 0.67) for the KOOS symptoms, 100.0 (0.70, 0.89) for the KOOS ADL, 75.0 (0.87, 0.88) for the KOOS sport/rec, and 62.5 (0.82, 0.85) for the KOOS QoL. In addition, the difference between PASS-Y and PASS-N was statistically significant (P < .001) for all PROs.

CONCLUSION

To our knowledge, this is the first study to identify the PASS thresholds for the IKDC-SKF and the KOOS subscales for individuals 1 to 5 years after ACL reconstruction. By identifying threshold values for the PASS, this study provides additional information to facilitate interpretation of the IKDC-SKF and KOOS in daily practice and clinical research related to ACL reconstruction.