Critical analysis of knee ligament rating systems

Patient reported outcome measures in anterior cruciate ligament rupture and reconstruction: The significance of outcome score prediction

BACKGROUND

Numerous anterior cruciate ligament (ACL) clinical outcome measures exist. However, the result of one score does not equate to the findings of another even when evaluating the same patient group.

AIM

To investigate if statistically derived formulae can be used to predict the outcome of one knee scoring system when the result of another is known in patients with ACL rupture before and after reconstruction.

METHODS

Fifty patients with ACL rupture were evaluated using nine clinical outcome measures. These included Tegner Activity Score, Lysholm Knee Score, Cincinnati Knee Score, International Knee Documentation Committee (IKDC) Objective Knee Score, Tapper and Hoover Meniscal Grading Score, IKDC Subjective Knee Score, Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), Short Form-12 Item Health Survey and Knee Injury and Osteoarthritis Outcome Score. Thirty-four patients underwent an ACL reconstruction and were reassessed post-operatively.

RESULTS

The mean total of each of the nine outcome scores appreciably differed from each other. Significant correlations and regressions were found between most of the outcome scores and were stronger post-operatively. The strongest correlation was found between Cincinnati and KOS-ADLS (r = 0.91, P < 0.001). The strongest regression formula was also found between Cincinnati and KOS-ADLS (R² = 0.84, P < 0.001).

CONCLUSION

The formulae produced from this study can be used to predict the outcome of one knee score when the results of the other are known. These formulae could facilitate the conduct of systematic reviews and meta-analysis in studies relating to ACL injuries by allowing the pooling of substantially more data.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Effects of Lumbar Core Stability Exercise Programme on Knee Pain, Range of Motion, and Function Post Anterior Cruciate Ligament Reconstruction

Purpose

To study the additional effects of lumbar core stability on knee pain, range of motion and function post ACL reconstruction.

Methods

An experimental comparative study was undertaken at a tertiary orthopaedic and rehabilitation centre with a total of 60 patients with ACL reconstruction, randomly allotted into two groups. Both groups were given institutional rehabilitation protocol; and additional lumbar core stability exercise programme was given to experimental group. Intervention period was 4 weeks. Pain on VAS, range of motion (ROM) and function using Modified Lysholm Scoring Scale (MLSS) and Tegner Activity Level (TAL) were the outcome measures.

Results

Between group analyses of MLSS and TAL by Mann Whitney U test showed a statistically significant difference (p = 0.038) and statistically non-significant difference (p = 1.00), respectively.

Conclusion

Institutional conventional exercise protocol is effective in reducing pain and improving the ROM post and lumbar core stability exercise programme is effective in improving function, post ACL reconstruction.

Extensor mechanism ruptures of the knee: differences in demographic data and long-term outcome after surgical treatment

Extensor mechanism ruptures are rare injuries. Until now, only few reports of medium or long-term outcomes have been published.

PURPOSE

The objective of this study was to quantify differences in demographic data and complications referring to patients with either quadriceps tendon ruptures (QTR) or patellar tendon (PTR) ruptures and to evaluate if complete functional restitution can be achieved after surgical treatment.

METHODS

A search was conducted through the database of our level I trauma center in order to identify all patients surgically treated for QTRs or PTRs within 15 years and with a follow-up period of at least three years. Demographic data were collected by scanning their medical records. Of all patients available for a final check-up, their outcomes were assessed using the Knee Society Clinical Rating System (KSS), the Oxford Knee Score (OKS) and the Reduced WOMAC Function Scale (rWOMAC). Furthermore, patient perception (PP) was evaluated.

RESULTS

130 patients (93 QTRs and 43 PTRs) met the inclusion criteria. 8% of the QTR- and 13% of the PTR-patients suffered wound healing disorders/septic complications. 8% in the QTR-group sustained a rerupture. 62% of all patients were available for clinical evaluation, the mean follow-up period was 10.3 years in the QTR-group and 9.0 years in the PTR-group. In both groups good to excellent outcomes were revealed. Of the KSS-Knee, the mean score value was 93.1 in the QTR-group and 91.4 in the PTR-group; KSS-Function: 89.7/96.4; OKS: 14.6/13.1; rWOMAC: 95.7/98.3; PP: 88.5/93.3. QTR-patients suffering a rerupture had a significantly worse outcome in all scores except for the KSS-Knee (p≤0.026), whereas PTR-patients with healing disorders/septic complications showed a significant inferior outcome solely in the PP-scale (p=0.02).

Meniscal and articular cartilage lesions in the anterior cruciate ligament-deficient knee: correlation between time from injury and knee scores

PURPOSE

Anterior cruciate ligament (ACL) rupture is associated with meniscal tears and/or articular cartilage damage. The aim of this study was twofold: (a) to report and correlate the incidence of meniscal and cartilage lesions in ACL-deficient knees with time from injury and (b) to correlate lesions of menisci and cartilage with widely used knee scores.

METHODS

Data were analysed from 109 consecutive patients with ACL rupture. Meniscal and articular cartilage lesions were documented during the arthroscopic reconstruction of the ACL. Patients were distributed into 3 groups according to time from injury; group A: 0-3 months (35 patients), group B: 3-12 months (39 patients) and group C: more than 12 months (35 patients). Lysholm, KOOS and IKDC rating scales were recorded preoperatively. Logistic regression analyses were applied to correlate the concomitant intra-articular pathologies with the time from injury and knee-rating scales.

RESULTS

Of 109 patients, 32 (29%) had a medial meniscus tear, 20 (19%) had a lateral meniscus tear, 17 (15%) had both menisci torn and 40 (37%) had no meniscal tear. Analysis revealed that time from injury was not a significant factor for the presence of a meniscal lesion. The odds of development of a high-grade cartilage lesion in an ACL-deficient knee reconstructed more than 12 months from time from injury are 5.5 and 12.5 times higher when compared with knees that underwent ACL reconstruction less than 3 months and between 3 and 12 months after knee injury, respectively. No association was found between intra-articular pathology and the KOOS and Lysholm scores. A positive correlation between the IKDC score and patients without any intra-articular pathology was found.

CONCLUSIONS

The presence of high-grade cartilage lesions is significantly increased in an ACL-deficient knee when reconstruction is performed more than 12 months after injury. However, the incidence of meniscal tears is not increased significantly. Correlation of intra-articular pathology in ACL-deficient knees with knee-rating scales is weak.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Patient-specific evaluation of knee disorders in clinical practice

BACKGROUND

Nowadays, an increasing number of patients expect their physician to provide a measureable and, therefore, comparable treatment effect that quantifies success or failure of the applied therapy. Unfortunately, different knee classification schemes applied to the same patient may provide diverging results. Therefore, the objective of this paper was to present recommendations to clinicians for a meaningful outcome assessment of their patients.

METHODS

Out of 39 knee evaluation systems available in the literature, we performed an elimination process based on the criteria (1) widespread use, (2) available reference values and (3) publication of at least one validation study.

RESULTS

Six clinical scores were detected which met the inclusion criteria. Owing to authors' recommendations and personal opinion the International Knee Documentation Committee (IKDC) Score, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) were identified to be the most suitable outcome measures that enable patients a realistic assessment of their treatment effect compared with individuals in similar life situations.

CONCLUSION

To our opinion the IKDC should be applied to athletic patients suffering from post-traumatic knee symptoms who are younger than 50 years. For non-athletes aged 50 years and older the WOMAC is considered suitable whereas the KOOS is recommended to all other patients with knee disorders.

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery

Outcome measures may be simple questions or complex measures that assess multiple interrelated domains affecting treatment outcomes. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. Joint and disease-specific outcome measures have been developed for the hip, knee, and foot and ankle. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability. General health measures and activity level scores should be included in outcome assessments after treatment for orthopaedic conditions.

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES

Objective: To evaluate the modified Lysholm protocol among patients with knees that were considered to be normal (without previous complaints or pathological conditions in this region). Method: Between January 2010 and March 2010, a prospective study was conducted on 300 patients with orthopedic complaints in other regions of the body who came to the emergency service of our hospital. The inclusion criterion among these patients was the absence of complaints or previous surgery in the knee that was considered to be dominant. The age range was from 16 to 40 years, with an average of 28.8 years. Our study group consisted of 153 males and 147 females. In the modified Lysholm system, the maximum score is 100 points and this includes functional and objective criteria. Altogether, 50% of the total score is based on symptoms of pain and instability. Results: The average score using the Lysholm protocol was 95 points in the knees that were considered normal. Males had higher scores than females. Conclusion: These patients with knees that were considered normal did not achieve the maximum score when evaluated using the modified Lysholm protocol. This study suggests that this line of research on functional evaluation systems for the knee is open for further evaluations. Moreover, creation and development of new forms of functional assessment for the knee should be investigated in order to achieve a worldwide consensus.

Clinical outcome after microfracture of the knee: a meta-analysis of before/after-data of controlled studies

PURPOSE

The aims of this study were to systematically review the medical literature, in order to find controlled studies about microfracture in the treatment of patients with full-thickness cartilage lesions of the knee, to statistically combine these studies in order to determine a best estimate of the average treatment effect, and to gather information to detect cartilage-specific and patient-specific factors that might have an influence on the clinical outcome.

METHODS

We searched four electronic databases for controlled clinical trials or controlled prospective observational studies. We pooled before/after-data of study arms using the term microfracture.

RESULTS

We calculated an overall best estimate of 1.106, with [0.566; 1.646] as 95% confidence interval of the mean standardized treatment effect for a representative patient population.

CONCLUSIONS

Our meta-analysis revealed a clinically relevant improvement of the postoperative clinical status as compared to the preoperative status. An increase of 22 overall KOOS points may provide a rough estimate for the mean expected treatment effect achieved by microfracturing.

Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents

PURPOSE

The aim of this meta-analysis was to evaluate the clinical outcomes and risks of anterior cruciate ligament (ACL) surgery in children and adolescents.

METHODS

We electronically searched Medline, the Cochrane Controlled Trial Database, Embase, and Medpilot for studies on surgical treatment for ACL ruptures in skeletally immature patients. We extracted baseline demographics, follow-up intervals, surgical details (i.e., ligament suture or reconstruction, physeal-sparing or transphyseal techniques, type of transplant, and methods of fixation). Endpoints comprised rates of growth disturbances and reruptures, as well as knee function (measured by the International Knee Documentation Committee's documentation system and the Lysholm score). Unweighted overall effect sizes (risks, risk ratios [RRs], and means of functional scores) were estimated by use of crude nominators and denominators, and random-effects meta-regression analysis was used for weighted data synthesis.

RESULTS

A total of 55 articles reporting on 935 patients (median age, 13 years; range, 1.5 to 16 years) were suitable for the study. After a median follow-up of 40 months (range, 14 to 89 months), the weighted rate of leg-length differences or axis deviations was 1.8% (95% confidence interval [CI], 0% to 3.9%] and that of reruptures was 4.8% (95% CI, 2.9% to 6.7%). Excellent or good function (International Knee Documentation Committee grade A or B) was achieved in 84.2% (95% CI, 75.8% to 92.6%) of all knees, and Lysholm scores averaged 96.3 (95% CI, 95.5 to 97.2). Transphyseal reconstruction was associated with a significantly lower risk of leg-length differences or axis deviations compared with physeal-sparing techniques (1.9% v 5.8%; RR, 0.34; 95% CI, 0.14 to 0.81) but had a higher risk of rerupture (4.2% v 1.4%; RR, 2.91; 95% CI, 0.70 to 12.12). Sutures did not result in any growth disturbances, with a weighted rerupture rate of 4.6% (95% CI, 2.6 to 6.7). Fixation far from the joint line fared better than close fixation with regard to this endpoint (1.4% v 3.2%; RR, 0.42; 95% CI, 0.09 to 1.93). Bone-patellar tendon-bone grafts, which are also less likely to fail, were associated with higher risks of leg-length differences or axis deviations than were hamstrings (3.6% v 2.0%; RR, 1.82; 95% CI, 0.66 to 5.03). Meta-regression did not show a significant impact of the publication year on event rates.

CONCLUSIONS

This meta-analysis showed low rates of leg-length differences or axis deviations and graft failures after ACL reconstruction in skeletally immature patients. Hamstring transplants may lower the risk of leg-length differences or axis deviations, and physeal-sparing techniques may increase the risk. Randomized controlled trials are needed to clarify important issues in managing ACL ruptures in children and adolescents.

LEVEL OF EVIDENCE

Level IV, meta-analysis of case series.

Posterolateral corner reconstruction of the knee: evaluation of a technique with clinical outcomes and stress radiography

BACKGROUND

Injuries to the posterolateral corner of the knee remain a challenging problem and have been cited frequently as a reason for failure of anterior and posterior cruciate ligament reconstructions. Although several reconstructive techniques currently exist, there are relatively few clinical outcomes data after reconstruction of the posterolateral corner.

PURPOSE

The study was undertaken to examine the clinical outcomes and provide objective data using arthrometry and stress radiography of a posterolateral corner reconstruction technique.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective cohort study of a consecutive series of patients who underwent posterolateral corner reconstruction of the knee was evaluated. The surgery featured dual femoral tunnels, a transfibular tunnel, and a free graft to reconstruct the posterolateral corner of the knee. All patients had concomitant reconstruction of one or both cruciate ligaments. Outcomes were assessed using the Short Form-12, Lysholm, and Tegner knee scores. A clinical examination, KT-2000 arthrometry measurements, single-legged hop quotient, and varus and posterior Telos stress radiographs were obtained and compared with results for the contralateral, uninjured knees.

RESULTS

Twenty-four (83%) of 29 consecutive patients were evaluated at a mean 39 months postoperatively (range, 24-81 months). The mean Lysholm and Tegner knee scores were 83 and 6, respectively. The mean difference (+/- standard deviation) in total anterior-posterior side-to-side KT arthrometry measurements was 1.4 +/- 1.3 mm. The varus stress radiographic mean side-to-side difference measured at 20 degrees of flexion was 0.2 +/- 1.9 mm. The mean radiographic posterior tibial displacement with a 15-kg stress at 90 degrees of flexion was 3.2 +/- 4.5 mm in patients undergoing posterior cruciate ligament reconstruction.

CONCLUSION

This reconstruction of the posterolateral corner of the knee with concomitant cruciate ligament reconstruction restores varus and rotational stability at a minimum of 2 years postoperatively.

Knee pain and mobility impairments: meniscal and articular cartilage lesions

The Orthopaedic Section of the American Physical Therapy Association presents this fifth set of clinical practice guidelines on knee pain and mobility impairments, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

Deltoid muscular flap transfer for the treatment of irreparable rotator cuff tears

The purpose of this study was to evaluate the outcome of deltoid muscle flap transfer for the treatment of irreparable rotator cuff tears. In a retrospective study 20 consecutive patients were evaluated. The index procedure took place between 2000 and 2003. Fifteen patients were male, mean age was 62 years. Inclusion criterion was a rotator cuff defect Bateman grade IV. Exclusion criteria were smaller defects, shoulder instability and fractures of the injured shoulder. An open reconstruction with acromioplasty and a pedicled delta flap was performed. Follow up period was mean 42 months. Follow-up included clinical examination, Magnetic Resonance Imaging (MRI) and the Constant and Simple (CS) shoulder tests. According to the Constant shoulder test the results were good in 13 patients, fair in 5 and unsatisfactory in 2. The pre-operative Constant Score improved from mean 25.7 points (±5.3) to 72.3 (±7.8) at follow-up. The mean values for the subcategories of CS increased significantly from 3.9 to 14.4 points for pain and from 4.2 to 15.9 points for activities daily routine (p<0.05). The change in range of motion and strength were not significant (p>0.05). Results of the Simple Shoulder Test showed a significant increase of the mean values from pre-operative 4.3 to 14.7 points post-operatively. MRI showed a subacromial covering of the defect in all cases, all flaps where intact on MRI but always the flap showed marked fatty degeneration. In conclusion, the delta flap is a simple method for the repair of large defects of the rotator cuff leading to satisfying medium results.

Knee injury outcomes measures

Outcomes measures have long been used in the assessment of knee injuries and management protocols. In the past decade, there has been a shift from clinician-based outcomes tools to the development and validation of patient-reported outcomes measures. General health as well as disease- and medical condition-specific outcomes measures have been so modified. The Medical Outcomes Study 36-Item Short Form is the most commonly used general health measure in orthopaedics. Joint-specific measures include the Western Ontario and McMaster Universities Osteoarthritis Index, the Knee Injury and Osteoarthritis Outcome Score, and the International Knee Documentation Committee Subjective Form. The Lysholm Knee Scale and the Cincinnati Knee Rating Scale continue to be popular, especially for the assessment of ligamentous injuries. The ACL Quality of Life score is a disease-specific, patient-reported outcomes measure of anterior cruciate ligament deficiency. The historically used Tegner activity level scale and the recently developed Marx activity level scale are used in conjunction with these outcomes measures to make possible a global assessment of recovery from knee injuries and clinician interventions.

Whole-Organ Arthroscopic Knee Score (WOAKS)

Background

To describe a semi-quantitative score for multi-feature, whole-organ evaluation of the knee in osteoarthritis based on the results of arthroscopic evaluation.

Methods

This was a study of 1,199 patients who were suffering from knee pain for over 3 months (range 3 to 48 months) and had undergone arthroscopy. The mean age of patients was 49.8 (range 17 to 85) years old. Cartilage lesions were graded according to the ICRS protocol (grade 0 to 4 and for osteophytes "grade 5"). Meniscus lesions were classified regarding to the extent of resection which was needed (grade 0: intact meniscus, grade 1: partial meniscectomy, grade 2: subtotal meniscectomy, and grade 3: total meniscectomy). The whole grade of cartilage lesions was calculated as the sum of ICRS grades in all joint surfaces (bearing and non-bearing margin). The whole grade of meniscus lesions was calculated as the sum of the points for medial and lateral meniscus surgery. The Whole-Organ Arthroscopic Knee Score (WOAKS) was the sum of the cartilage and meniscus score.

Results

The mean knee osteoarthritis outcome score (KOOS) of all patients was 67.3 ± 26.0 (range 21 to 128) points. The WOAKS was significantly associated (p = 0.001) with patient age (R = 0.399), the subjective complaints (R = 0.630) in KOOS, and the radiological grade of OA (R = 0.731).

Conclusion

The good correlation between the WOAKS and the subjective complaints as well as the radiological grade of OA suggests that the score can be used as an instrument for description of the "whole organ" knee. This score may be useful for clinical or epidemiological studies in the future.

Functional recovery after anterior cruciate ligament reconstruction: a longitudinal perspective

OBJECTIVE

To evaluate functional hop performance in subjects with an anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone graft during 12, 18, 26, 39, and 52 weeks.

DESIGN

A longitudinal comparative study.

SETTING

University research laboratory.

PARTICIPANTS

Patients (N=19) were evaluated at 12, 18, 26, 39, and 52 weeks after ACL reconstruction surgery.

INTERVENTION

Testing on 5 separate occasions.

MAIN OUTCOME MEASURES

The Cincinnati Knee Rating System and analog scales, the 6-meter timed hop, crossover hop, stair hop, and vertical hop, and limb symmetry indices.

RESULTS

The uninjured and injured legs and test order were randomized. There was a significant test occasion main effect for both the Cincinnati and analog scores (P=.001). Subjective rating scores improved over the 5 testing occasions. For all 4 hop tests, test occasion and limb main effects were significant (P=.001). Paired t test comparisons at each testing occasion indicated a significant difference between the reconstructed and uninjured limb (P<.05). Furthermore, significant test occasion main effects were noted for limb symmetry indices for the 4 hop tests (P=.001). Using a score of greater than or equal to 85% as a criterion for normative limb symmetry, normative scores were recorded in the 6-m timed hop at the week 18 test occasion, the stair hop and vertical hop at the week 26 test occasion, and the crossover hop at the week 39 test occasion.

CONCLUSIONS

These hop tests showed different levels of imposed demands on the knee that could be used to assess functional recovery and readiness to resume sport.

Novel drug product to improve joint motion and function and reduce pain after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

OMS103HP, an investigational drug product containing ketoprofen, amitriptyline, and oxymetazoline, is added to arthroscopic irrigation solution. OMS103HP was evaluated in patients undergoing arthroscopic anterior cruciate ligament reconstruction to assess the drug's safety and ability to improve postoperative knee function and motion, reduce postoperative pain, and allow earlier return to work.

METHODS

This was a prospective, double-blind, vehicle-controlled, parallel-group, randomized study. Allograft anterior cruciate ligament reconstruction patients in both treatment and vehicle control groups were monitored for safety and efficacy (e.g., measurements of knee function and motion, pain, and return to work) over a 30-day postoperative period. The efficacy endpoints of primary interest were assessed by use of both responder and time-to-event analyses.

RESULTS

There were statistically significant differences (P < or = .05) between the OMS103HP and vehicle control groups in the endpoints of knee function (knee function composite and straight-leg raise component of knee function composite), range of motion (median number of days to maximum passive flexion of 90 degrees or greater without pain and time to discontinuation of continuous passive motion), quadriceps and hamstring muscle strength, successful pain management, and return to work. The overall incidences of adverse events and abnormal clinical laboratory values for both OMS103HP- and vehicle-treated subjects were similar, and none was attributed to OMS103HP.

CONCLUSIONS

The clinical benefits of OMS103HP in this study were reduced postoperative pain; improved postoperative knee motion, quadriceps and hamstring muscle strength, and knee function; and earlier return to work as measured by surgeons, nurses, and physical therapists across repeated clinic visits and rehabilitation sessions and recorded by patients in daily diaries. The drug was well tolerated.

Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement

The incidence of anterior cruciate ligament (ACL) injury remains high in young athletes. Because female athletes have a much higher incidence of ACL injuries in sports such as basketball and team handball than male athletes, the IOC Medical Commission invited a multidisciplinary group of ACL expert clinicians and scientists to (1) review current evidence including data from the new Scandinavian ACL registries; (2) critically evaluate high-quality studies of injury mechanics; (3) consider the key elements of successful prevention programmes; (4) summarise clinical management including surgery and conservative management; and (5) identify areas for further research. Risk factors for female athletes suffering ACL injury include: (1) being in the preovulatory phase of the menstrual cycle compared with the postovulatory phase; (2) having decreased intercondylar notch width on plain radiography; and (3) developing increased knee abduction moment (a valgus intersegmental torque) during impact on landing. Well-designed injury prevention programmes reduce the risk of ACL for athletes, particularly women. These programmes attempt to alter dynamic loading of the tibiofemoral joint through neuromuscular and proprioceptive training. They emphasise proper landing and cutting techniques. This includes landing softly on the forefoot and rolling back to the rearfoot, engaging knee and hip flexion and, where possible, landing on two feet. Players are trained to avoid excessive dynamic valgus of the knee and to focus on the "knee over toe position" when cutting.

Rasch analysis of the Knee injury and Osteoarthritis Outcome Score (KOOS): a statistical re-evaluation

The knee injury and Osteoarthritis Outcome Score (KOOS), based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), is widely used to evaluate subjective outcome in anterior cruciate ligament (ACL) reconstructed patients. However, the validity of KOOS has not been assessed using Rasch analysis. The objective of this study was to evaluate the viability of KOOS as an outcome measure for ACL reconstruction using the partial credit Rasch model. Rasch analysis was applied to 200 KOOS questionnaires completed by patients consecutively tested 20 weeks after ACL reconstruction and subsequent rehabilitation. Rasch analysis showed that of the five proposed subscales in KOOS, only knee-related quality of life (QoL) and sport and recreational related function (Sport/Rec) fulfilled the criteria of a unidimensional measurement scale when applied to these patients. The three subdomains in KOOS extracted from WOMAC did not fulfill these criteria. While the content of KOOS appears to be relevant for knee patients, the psychometric measurement properties of KOOS are insufficient for use on patients 20 weeks subsequent to ACL reconstruction. A new knee measure targeted for these patients could be developed based on the content of KOOS. This study demonstrates that knee measurement instruments constructed for a specific condition cannot necessarily be used on patients with other similar conditions.

The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis

The objectives of this study are to review the long-term consequences of injuries to the anterior cruciate ligament and menisci, the pathogenic mechanisms, and the causes of the considerable variability in outcome. Injuries of the anterior cruciate ligament and menisci are common in both athletes and the general population. At 10 to 20 years after the diagnosis, on average, 50% of those with a diagnosed anterior cruciate ligament or meniscus tear have osteoarthritis with associated pain and functional impairment: the young patient with an old knee. These individuals make up a substantial proportion of the overall osteoarthritis population. There is a lack of evidence to support a protective role of repair or reconstructive surgery of the anterior cruciate ligament or meniscus against osteoarthritis development. A consistent finding in a review of the literature is the often poor reporting of critical study variables, precluding data pooling or a meta-analysis. Osteoarthritis development in the injured joints is caused by intra-articular pathogenic processes initiated at the time of injury, combined with long-term changes in dynamic joint loading. Variation in outcome is reinforced by additional variables associated with the individual such as age, sex, genetics, obesity, muscle strength, activity, and reinjury. A better understanding of these variables may improve future prevention and treatment strategies. In evaluating medical treatment, we now expect large randomized clinical trials complemented by postmarketing monitoring. We should strive toward a comparable level of quality of evidence in surgical treatment of knee injuries. In instances in which a randomized clinical trial is not feasible, natural history and other observational cohort studies need to be as carefully designed and reported as the classic randomized clinical trial, to yield useful information.

Proprioception in Individuals with ACL-Deficient Knee and Good Muscular and Functional Performance

The objective of this study was to verify whether proprioception is affected in individuals with ACL-deficient knees and good functional and muscular performances. Eleven subjects with ACL injury and 11 controls participated in the study. Functional performance was assessed using the Cincinnati Knee Rating System (CKRS), hop index, and figure-eight ratio. An isokinetic test was done to evaluate muscular performance. Proprioception was evaluated through position, sense and threshold tests. Analyses of variance were used for data analysis. The injured subjects scored significantly lower in the CKRS (p = 0.001). No statistically significant differences were found in the hop index, in the figure-eight ratio, or in peak torque. There were no statistically significant differences in proprioception bettween groups and between legs. These results indicated that the individuals evaluated in this study with ACL injury and good functional and muscular performance did not have proprioceptive deficits, suggesting that the ligament mechanoreceptors, in some cases, might not contribute relevantly to proprioception.

Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation

In athletes, anterior cruciate ligament (ACL) reconstruction is recommended after injury to restore the normal knee function and allow subsequent return to sport. Successful ACL reconstruction with patellar tendon (PT) and hamstring tendon (HT) grafts combined with a well-structured rehabilitation program could bring athletes back to their previous level of sport activities. We prospectively followed-up 100 athletes who underwent ACL reconstruction with either PT (n=50) or HT grafts (n=50). Evaluation was done pre-operatively and post-operatively (3, 6, 12, and 24 months) using International Knee Documentation Committee (IKDC), Lysholm, Noyes, and Tegner scales. Subjective assessment numeric evaluation (SANE), knee activity rating scale (Marx) and a psychological profile questionnaire (psychovitality) were also utilized. Objective evaluations included isokinetic tests and computerized knee motion analysis. Data gathered were statistically analyzed using the Mann-Whitney non-parametric U-test. Among the 100 patients who have undergone ACL reconstruction, 65% returned to the same level of sports, 24% changed sports and 11% ceased sport activities. No significant difference (P>0.05) in outcome between PT and HT grafts were observed. No significant differences (P>0.05) were noted between athletes who "returned" to their previous sport and those who "did not return" to sports at the same level when using the IKDC, Lysholm, Noyes, and Tegner knee evaluation scales. However, significant difference was observed with the knee scores obtained by those who returned and those who completely ceased participation in sport activities. Computerized laxity test revealed that 90% of these patients have less than 3 mm side-to-side difference with no significant difference between HT and PT groups. Patients who "returned to sports" obtained significantly better scores with the Marx scale (P=0.001) and the psychovitality questionnaire (P=0.001) than those who did not. Conventional knee scales including IKDC, Lysholm, Noyes, and Tegner remain as reliable means of evaluating outcome of ACL reconstruction. However, the data obtained from these are not sufficient to determine which among the patients who had knee reconstruction can successfully return to sport. The use of the Marx knee activity rating scale and the evaluation of the athletes' psychological profile are additional scales that can be useful in determining which among the patients treated have a better chance of returning to their pre-injury activity levels.

Three-year clinical outcome after chondrocyte transplantation using a hyaluronan matrix for cartilage repair

Repair of articular cartilage represents a significant clinical problem and although various new techniques - including the use of autologous chondrocytes - have been developed within the last century the clinical efficacy of these procedures is still discussed controversially. Although autologous chondrocyte transplantation (ACT) has been widely used with success, it has several inherent limitations, including its invasive nature and problems related to the use of the periosteal flap. To overcome these problems autologous chondrocytes transplantation combined with the use of biodegradable scaffolds has received wide attention. Among these, a hyaluronan-based scaffold has been found useful for inducing hyaline cartilage regeneration. In the present study, we have investigated the mid-term efficacy and safety of Hyalograft C grafts in a group of 36 patients undergoing surgery for chronic cartilage lesions of the knee. Clinical Outcome was assessed prospectively before and at 12, 24, and 36 months after surgery. No major adverse events have been reported during the 3-year follow-up. Significant improvements of the evaluated scores were observed (P < 0.02) at 1 year and a continued increase of clinical performance was evident at 2 and 3 years follow-up. Patients under 30 years of age with single lesions showed statistically significant improvements at all follow-up visits compared to those over 30 with multiple defects (P < 0.01). Hyalograft C compares favorably with classic ACT and is particularly indicated in younger patients with single lesions. The graft can be implanted through a miniarthrotomy and needs no additional fixation with sutures except optional fibrin gluing at the defect borders. These results suggest that Hyalograft C is a valid alternative to ACT.

The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data

BACKGROUND

The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument.

PURPOSE

To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form.

STUDY DESIGN

Cross-sectional survey.

METHODS

The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18-24 years, 25-34 years, 35-50 years, and 51-65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size.

RESULTS

Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 +/- 18), 25 to 34 years (89 +/- 16), 35 to 50 years (85 +/- 19), and 51 to 55 years (77 +/- 23); mean scores were also determined for women aged 18 to 24 years (86 +/- 19), 25 to 34 years (86 +/- 19), 35 to 50 years (80 +/- 23), and 51 to 65 years (71 +/- 26). Scores were higher for the subset of respondents with no history of current or prior knee problems.

CONCLUSION

Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age- and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.

Autologous chondrocyte implantation versus debridement for treatment of full-thickness chondral defects of the knee: an observational cohort study with 3-year follow-up

BACKGROUND

Studies that compare the effectiveness of different cartilage repair treatments are needed to update treatment algorithms.

HYPOTHESIS

Autologous chondrocyte implantation provides greater improvement in overall condition score than does debridement at a minimum of 3 years' follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Cohorts for debridement and autologous chondrocyte implantation each included 58 Cartilage Repair Registry patients who met study criteria. A retrospective analysis was performed on prospectively collected baseline and follow-up data.

RESULTS

Patients in the autologous chondrocyte implantation and debridement groups had similar demographics and chondral lesions at baseline. However, more autologous chondrocyte implantation patients failed a previous debridement or marrow stimulation procedure than did debridement patients. Follow-up outcome assessments were completed by 54 autologous chondrocyte implantation patients and 42 debridement patients. Eighty-one percent of the autologous chondrocyte implantation patients and 60% of the debridement patients reported median improvements of 5 points and 2 points, respectively, in the overall condition score. Autologous chondrocyte implantation patients also reported greater improvements in the median pain and swelling scores than did debridement patients. The treatment failure rate was the same for both autologous chondrocyte implantation and debridement patients. Eighteen autologous chondrocyte implantation patients and 1 debridement patient had at least 1 subsequent operation.

CONCLUSION

Although patients treated with debridement for symptomatic, large, focal, chondral defects of the distal femur had some functional improvement at follow-up, patients who received autologous chondrocyte implantations obtained higher levels of knee function and had greater relief from pain and swelling at 3 years.

Adherence to Rehabilitation after Anterior Cruciate Ligament Reconstructive Surgery: Implications for Outcome

Objective:

To investigate the relationship between adherence to rehabilitation and outcome after reconstructive surgery of the anterior cruciate ligament (ACL).

Design:

A prospective cohort study with adherence to rehabilitation evaluated over 8 weeks correlated with outcomes at 9 and 12 months postsurgery.

Participants:

68 patients who had undergone ACL-reconstructive surgery.

Main Outcome Measures:

Adherence was measured to and during appointments and by a self-report diary of home exercise. Outcomes were measured by 6 knee-function scales and 2 hop tests.

Results:

There was a significant relationship between home-exercise adherence and many outcomes for participants under 30 years of age (rs= .33-.44). For participants age 30 and over there was a negative relationship between home-exercise adherence and outcome. There were no significant relationships between adherence to and during physical therapy appointments and outcome after ACL-reconstructive surgery.

Conclusion:

Participants under 30 years of age who adhered to their home-exercise regimen had better functional outcome, whereas adherent participants age 30 and over experienced worse outcome with better home-exercise adherence.

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up

BACKGROUND

In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age.

METHODS

The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted.

RESULTS

The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5.

CONCLUSION

The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument.

Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects

Peterson's pioneering experience with the first clinical application of autologous chondrocyte implantation showed improvement in clinical outcomes, durable as much as 11 years, for a difficult patient population. An assessment of the general applicability of this technology in the United States requires long-term, multicenter followup. The purpose of this multicenter cohort study was to assess the clinical outcomes of patients treated with autologous chondrocyte implantation for lesions of the distal femur. Modified 10-point scales of the Cincinnati knee rating system were used to measure outcomes assessments at baseline and at 5 years. Eighty-seven percent (87 of 100) of patients completed 5-year followup assessments. Patients were an average 37 years of age, had a mean total defect size of 4.9 cm2, and had low baseline overall condition scores. At least one prior cartilage repair procedure had failed in 70% of the patients. At followup, 87 patients reported a mean improvement of 2.6 points in the overall condition score, including 62 with improved conditions, six with no change in condition, and 19 with worsened conditions. Of the 62 patients who improved, the mean overall condition score improved 4.1 points at followup. Patients treated with autologous chondrocyte implantation for large cartilage defects in the distal femur reported improvement in outcome scores at 5 years followup.

LEVEL OF EVIDENCE

Therapeutic study, Level II-1 (prospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Subjective functional assessments and the return to competitive sport after anterior cruciate ligament reconstruction

OBJECTIVES

To examine (a) return to competitive sport within 12 months of anterior cruciate ligament (ACL) reconstruction, (b) maintenance of competitive participation at follow up, and (c) the relation of the level of sports activity and competitive participation at follow up to subjective functional assessments. Also to address the incidence of continued competitive participation despite notable functional problems with the operated knee at 12 months and follow up.

METHODS

All patients were competitive athletes before injury and had undergone ACL reconstruction by the transtibial endoscopic technique with either a bone-patellar tendon-bone or a multiple looped hamstring autograft. Evaluation was carried out a mean of 43 months (range 24-73) after surgery by a postal questionnaire in which the Cincinnati sports activity scale (CSAS) and Cincinnati sports function scales were presented in conjunction with closed questions on change in competitive level and the presence of complaints.

RESULTS

Of 109 selected patients, 77 (71%) responded. At follow up, 62 of 77 patients (81%) reported that they had returned to competition within 12 months of surgery. Within the same time frame, 55 of the above 62 patients (89%) also claimed to have returned to the level at which they were competing before injury (or higher). At follow up, 30 of the above 55 patients (54%) reported to still be competing at this high level. Twelve of the above 55 patients (22%) also admitted to major problems with the operated knee at that time. The overall incidence of patients competing despite major functional impairment in the operated knee was 13 of 62 (21%) at 12 months and six of 47 (13%) at follow up. Thirty eight patients (49%) were active in sport at least four times a week at follow up (CSAS level 1), and, using Spearman's rank correlation between CSAS scores and total sports function scores, r was calculated to be 0.44. Competitive and male patients had higher total sports function scores at follow up than non-competitive (p = 0.005) and female (p = 0.02) patients respectively.

CONCLUSIONS

The reported return to competition at the previous level, both within 12 months and at follow up, was high but as expected considering the standard of treatment, patient selection, and study exclusion criteria. Patients with few functional complaints maintained a high level of sporting activity, even after discontinuing competitive participation.

Arthroscopic microfracture of chondral defects of the knee: a comparison of two postoperative treatments

PURPOSE

We hypothesized that the treatment of focal, full-thickness chondral defects by an identical method of arthroscopic microfracture but with different postoperative regimens would produce similar results.

TYPE OF STUDY

Case control study, retrospective cohort.

METHODS

Fifty patients treated over a 6-year period (1993 to 1999) with a focal, less than 2-cm 2 , full-thickness chondral defect of either the medial or lateral femoral condyle of the knee had arthroscopic surgery to debride loose adjacent cartilage flaps and abortive fibrocartilage from the crater in conjunction with microfracture of the subchondral plate using a hand awl. Postoperatively, 1 group was treated with non-weight bearing and continuous passive motion (CPM) for 6 weeks (group I), and the other group was allowed weight bearing as tolerated and did not use CPM (group II). Results of treatment were assessed by the Lysholm knee rating scale augmented by the Tegner method of activity evaluation. Results were analyzed by independent t test or chi-square test with significance assumed for P < .05.

RESULTS

Forty-three of 50 patients were evaluated at a minimum of 2 years after surgery (mean, 4.2 years; range, 2 to 9 years). The mean age was 39.7 years (range, 16 to 66 years) and there were 19 female and 24 male patients. For group I, Lysholm scores were 37 preoperative, 81 postoperative, and Tegner scores were 3 and 6, respectively. Group II Lysholm scores were 33 preoperative, 85 postoperative, and Tegner scores 3 and 6, respectively. No significant differences between groups were noted.

CONCLUSIONS

In relatively small full-thickness chondral defects of the femoral condyles treated by microfracture, this study found no differences in results comparing 2 rehabilitation regimens differing by weight-bearing status and use of CPM.

LEVEL OF EVIDENCE

Level III, Case Control Study.

Les grilles d'évaluations dans la ligamentoplastie du LCA

INTRODUCTION

Recently, results of surgery for anterior cruciate ligament (ACL) have been systematically assessed. Several scales have been developed, but for most rigorous validation is lacking.

METHODOLOGY

We reviewed reports of published scales for ACL surgery and compared their psychometric properties. We searched the MedLine and Cochrane databases with the key words anterior cruciate ligament, surgery, and rating score. A scale was reviewed if its reliability, validity, and responsiveness were reported at least once.

RESULTS

We reviewed four scales (Lysholm and Tegner, Cincinnati, IKDC, and Koos). Test-retest reliability was good, except for the IKDC. For all scales, construct validity could not been ascertained. Responsiveness was acceptable and of the same magnitude for the Lysholm and Tegner, and Cincinnati scales.

CONCLUSION

None of the scales had sufficient psychometric properties and all seemed too complicated for routine use. Validation of a simple scale is needed. Psychometric properties of the last version of the IKDC (IKDC 2000) and the Cincinnati scales should be studied.

Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction

BACKGROUND

The effectiveness of anterior cruciate ligament reconstruction for restoring normal knee kinematics is largely unknown, particularly during sports movements generating large, rapidly applied forces.

HYPOTHESIS

Under dynamic in vivo loading, significant differences in 3-dimensional kinematics exist between anterior cruciate ligament-reconstructed knees and the contralateral, uninjured knees.

STUDY DESIGN

Prospective, in vivo laboratory study.

METHODS

Kinematics of anterior cruciate ligament-reconstructed and contralateral (uninjured) knees were evaluated for 6 subjects during downhill running 4 to 12 months after anterior cruciate ligament reconstruction, using a 250 frame/s stereoradiographic system. Anatomical reference axes were determined from computed tomography scans. Kinematic differences between the uninjured and reconstructed limbs were evaluated with a repeated-measures analysis of variance.

RESULTS

Anterior tibial translation was similar for the reconstructed and uninjured limbs. However, reconstructed knees were more externally rotated on average by 3.8 +/- 2.3 degrees across all subjects and time points (P =.0011). Reconstructed knees were also more adducted, by an average of 2.8 +/- 1.6 degrees (P =.0091). Although differences were small, they were consistent in all subjects.

CONCLUSIONS

Anterior cruciate ligament reconstruction failed to restore normal rotational knee kinematics during dynamic loading.

CLINICAL RELEVANCE

Although further study is required, these abnormal motions may contribute to long-term joint degeneration associated with anterior cruciate ligament injury/reconstruction.

Comparison of outcomes between males and females after anterior cruciate ligament reconstruction

Few studies have specifically addressed the potential differences in outcome from ACL reconstruction between males and females. The present study compared patient-reported outcomes between the sexes after a minimum of 2 years following arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft. Patients were also categorized as acute or chronic based on the time from injury to surgery. Outcome questionnaires were mailed to 638 patients, resulting in 151 eligible respondents included in the analysis. The outcome instruments used were the Cincinnati scale, the ACL-Quality of Life scale, and the Tegner activity rating scale. At an average of 5 years following ACL reconstruction no differences were found between males (n=74) and females (n=77) on the ACL-QOL scale. Females perceived a significantly higher activity level prior to surgery according to the Tegner scale. However, no other differences were identified by gender or stage based on prior, highest, or current Tegner activity levels. Results of the Cincinnati scale for the entire sample showed that females scored an average of 5.7 points lower than males. Analysis of this difference by patient age indicates a trend toward lower scores in females between 12-18 and over 24 years old. Chronicity was not a factor that affected outcome in either males or females. No differences were found in the number of patients who complained of anterior knee pain. We conclude that autogenous bone-patella tendon-bone ACL reconstruction is equally successful in well-matched populations of males and females.

Criterion related validity of self-reported knee symptoms among athletes

The objective of this study was to investigate the validity of self-reported knee symptoms among athletes. During 12 months, 252 athletes answered a weekly questionnaire about concurrent sports activity, knee pain, knee instability, knee swelling and knee locking. Finally, the athletes answered a retrospective questionnaire summing up symptoms during the preceding 12 months. Accordingly, two 12 month period prevalences of the same period were calculated for each knee symptom. The proportion of agreement between the retrospective 12 month questionnaire and the concurrent weekly questionnaires was for knee pain, knee instability, knee swelling and knee locking, 86%, 89%, 89% and 90%, respectively. Using weekly reports as reference, the corresponding sensitivity of the 12 month period prevalence question was 0.86, 0.71, 0.66 and 0.56, respectively. The sensitivities were all significantly associated with the number of weeks since the last episode of the corresponding knee symptom. As concerns estimation of 12 month period prevalences, a retrospective summary questionnaire at the end of the period is a valid substitute for concurrent weekly questionnaire information on knee pain, knee instability and knee swelling, but only a moderate substitute for information on knee locking. A reduction in the length of the period the athlete should recall knee symptoms might improve the questionnaire validity.