The Forgotten Joint Score-12 in Anterior Cruciate Ligament injuries

Longitudinal Evaluation Using the Forgotten Joint Score-12 for Double-Bundle Primary Anterior Cruciate Ligament Reconstruction: A Retrospective Observational Study

Introduction There are several postoperative evaluation methods for anterior cruciate ligament reconstruction (ACLR), and patient-reported outcome measurement (PROM) is one of the most important for evaluating postoperative clinical results. However, conventional PROMs have a high risk of a ceiling effect at one and two years postoperatively and do not accurately reflect functional improvement over time. Therefore, a longitudinal evaluation using PROM with a low risk of ceiling effect is necessary. The forgotten joint score-12 (FJS) was developed for clinical evaluation after arthroplasty. It is considered an evaluation method after arthroplasty with a low risk of demonstrating a ceiling effect. However, few studies have used the FJS as an evaluation method after ACLR, particularly those tracking changes over time. This study aimed to longitudinally evaluate FJS at one and two years after ACLR. Methods This is a retrospective observational study of postoperative patients using existing data and a questionnaire-based survey. This study included patients who underwent primary double-bundle ACLR between August 2017 and August 2021. We compared the FJS, knee injury and osteoarthritis outcome score (KOOS), and Lysholm knee scale (LKS) scores at one and two years post-surgery using the Wilcoxon signed-rank test. The ceiling effect for each PROM was calculated at one and two years post-surgery. A ceiling was defined as obtaining a perfect score in PROMs, and the risk of demonstrating a ceiling effect was the percentage of perfect scores among all cases. The risk of demonstrating a ceiling effect for each PROM was compared using the McNemar test. To identify factors influencing FJS one-year post-ACLR across all cases, multivariate linear regression analysis was conducted for the FJS.  Results Finally, 87 patients were included in this study. Fifty-six participants were women, and 31 were men, with an average age of 28.5 ± 11.8 years at the time of surgery and a BMI of 23.2 ± 3.7 kg/m2. Fifty-eight patients with meniscus injuries requiring treatment were observed. A total of 54 patients were used to compare the results at one and two years, while 87 patients were included in the multivariate analysis for FJS at one year. The median of FJS at one and two years post-surgery were 90.6 and 95.8, respectively. The FJS showed a statistically significant improvement from one to two years (p = 0.033). Question #12 in FJS showed a significant improvement from the first to the second year postoperatively (1.74 ± 1.46 vs 1.15 ± 1.25 at one year vs two years, respectively; p = 0.0016). FJS had a lower risk of demonstrating a ceiling effect than KOOS ADL at one and two years (FJS vs KOOS ADL; at first year: 20.4% and 48.1%, p < 0.001; at second year: 33.3% and 63.0%, p = 0.0013). There was no difference compared to the other PROMs. According to the multivariate linear regression analysis, predictive factors for higher FJS scores at one year post-surgery were younger age and limb symmetry index of single-leg hop test(SLH-LSI) on the affected side that was close to that of the healthy side (SLH-LSI > 0.9). Conclusions The FJS continued to improve over two years after ACLR. The FJS post-ACLR was higher in younger individuals and those with SLH-LSI of 0.9 or higher.

Forgotten joint score associated with prosthesis weight in cementless total hip arthroplasty: a prospective clinical study

Background

This prospective study aimed to investigate the influence of weight difference between implanted prosthesis and removed bone in cementless total hip arthroplasty (THA) on hip awareness and patient-reported outcomes.

Methods

A total of 48 patients (56 hips) who underwent primary THA were prospectively enrolled. Implanted prosthesis and removed bone were weighed intraoperatively. Forgotten Joint Score (FJS) and Western Ontario and McMaster Universities (WOMAC) scores were obtained before and at 1 and 3 months after surgery. Patients were divided into groups A, B, and C according to the percentile of the weight difference.

Results

The mean weight difference of the implanted prosthesis and removed bone was 117.97 ± 47.35 g. A negative correlation was found among the weight differences of the three groups and 1- and 3-month postoperative FJS (correlation coefficients, -0.331 and -0.734, respectively). A positive correlation was found among the weight difference of the three groups and 3-month postoperative WOMAC (correlation coefficient, 0.403). A significant difference in 3-month postoperative FJS and WOMAC scores was found among the three groups. The mean 3-month postoperative FJS (79.00) of group C was significantly lower than that of group A (93.32) (P < 0.05). The mean WOMAC score (15.83) of group A was significantly lower than that of group C (23.67) (P < 0.05).

Conclusion

The implanted prosthesis is larger than the removed bone in cementless THA. The weight difference is negatively correlated with hip function. The weight difference should be minimized to achieve optimal hip joint awareness.

Translation and Cross-Cultural Adaptation of the Anterior Cruciate Ligament Donor Site Morbidity Questionnaire Into Turkish

This study aimed to translate the ACL Donor Site Morbidity (ACL-DSM) questionnaire into Turkish and assess the reliability and validity of the Turkish version of the ACL-DSM questionnaire (ACL-DSM-Tr) among individuals following anterior cruciate ligament (ACL) reconstruction. The process involved forward and back-translation, cultural adaptation, and validation of the ACL-DSM-Tr questionnaire on ninety-nine patients (mean age 30.73 ± 8.55 years). Participants completed ACL-DSM-Tr, International Knee Documentary Committee (IKDC) subjective form, ACL Return to Sport (ACL-RSI), and Forgotten Joint Scale (FJS) questionnaires. The internal consistency, reliability, and validity of the ACL-DSM-Tr were analyzed. The ACL-DSM-Tr demonstrated a high internal consistency (Cronbach's alpha .755) and excellent test-retest reliability (Spearman correlation r = .811, p < .001; Cronbach's alpha .890). The ACL-DSM-Tr score exhibited a strong positive correlation with the IKDC score (r = .690, p < .001) and a moderate positive correlation with the FJS score (r = .535, p < .001). Despite a fair correlation between ACL-DSM-Tr and ACL- RSI subgroup scores, no significant correlation was observed with the ACL-RSI total score (p = .297). In conclusion, the ACL-DSM-Tr demonstrated internal consistency, reliability, and validity in patients with ACL reconstruction. This questionnaire has the potential to yield significant benefits in monitoring patient satisfaction and evaluating the level of comfort experienced at the donor site following ACL reconstruction.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review

PURPOSE

To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures.

METHODS

Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.).

RESULTS

Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS.

CONCLUSIONS

The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Use of the forgotten joint score (FJS)-12 to evaluate knee awareness after quadriceps tendon reconstruction

BACKGROUND

Quadriceps tendon rupture (QTR) is a severe injury of the knee extensor apparatus. The study aims to validate the use of forgotten joint score (FJS-12) for functional outcome assessing after surgical treatment of QTR.

METHODS

Fifty-seven patients who underwent surgery for QTR with transosseous suture reconstruction in a single orthopaedic surgery and traumatology center between 2015 and 2020 were eligible for enrolment in this retrospective case series. The demographic data and other pre-operative details such as age, gender, comorbidities and medication use also were extracted from the medical records. Patient reported outcome measures (PROMs) were gathered in the form of Western Ontario and McMaster Universities Arthritis Index Score (WOMAC), Tegner Activity Score (TAS), Lysholm Score and FJS-12 at a mean follow-up time of 49.84 months ± 20.64 months. The FJS-12 was validated by correlation with WOMAC, TAS and Lysholm Score.

RESULTS

The mean age of all patients were 69.2 ± 13.6 years with 51 (89.5%) males and 6 (10.5%) females. The mean time from injury to surgery was 3.39 ± 5.46 days. All patients reported satisfactory functional outcomes after surgery on FJS-12, WOMAC and Lysholm scores, except the TAS, which decreased slightly from pre-operative level. There was a high negative correlation between WOMAC and FJS-12, but moderate positive correlations between FJS-12 and TAS and Lysholm scores. The Cronbach's alpha value was 0.96 for 12 items in FJS-12.

CONCLUSION

This study has found that FJS-12 is a reliable and easy to assess tool for functional outcomes after QTR reconstruction. It has shown moderate to strong correlation with other commonly used outcome measures (WOMAC, TAS and Lysholm).

Joint awareness and return to pre-injury level of activities after ACL reconstruction in athletes vs non-athletes

PURPOSE

The outcome of arthroscopic anterior cruciate ligament reconstruction (ACLR) in the non-athlete population is under-reported. The study aimed to compare the functional outcomes of ACLR in the non-athlete and athlete population by patient reported outcome measures (PROMs)- International Knee Documentation Committee score (IKDC), Lysholm knee scoring scale, Forgotten joint score (FJS-12) and return to pre-injury activity level. The study also correlated the FJS-12 score with other commonly used PROM's (IKDC and Lysholm).

METHODS

This was a prospective comparative study including patients undergoing ACLR. Patients were divided into two groups. Group-1 (non-athletes) and Group-2 (athletes, defined as those with pre-injury Tegner activity level > 5). Demographic profile, management of associated meniscal injury, perioperative and midterm complications were noted. All patients had 24 months follow-up. Knee laxity assessment by pivot shift test, functional outcome scores (Lysholm and IKDC) and FJS-12 were assessed preoperatively and postoperatively at 12 and 24 months.

RESULTS

Group 1 and 2 included 69 and 47 participants, respectively, (total 116 patients). The mean age of group 1 was significantly higher than group 2 (33.1 ± 8.0 vs 25.0 ± 4.9 years; p < 0.005). There was no statistically significant difference in PROMs and FJS-12 scores between the groups at any follow-up. Return to pre-injury Tegner activity level post-ACLR was 88.4% (n = 61) and 46.8% (n = 22) in group 1 and 2, respectively (p). The ceiling effect in FJS-12, IKDC, and Lysholm scores were achieved by 9.3%, 19.5%, and 34.7% of patients (n = 116), respectively, at 2-year follow-up. The ceiling effect of FJS-12, Lysholm, and IKDC scores between the groups at final follow-up was not statistically significant (p = 1, p = .524, p = .09, respectively).

CONCLUSION

The functional outcome of ACLR was comparable between athletes and non-athletes. FJS-12 has a lower ceiling effect and better discriminatory power than Lysholm and IKDC scores. FJS-12 score can be satisfactorily used in ACLR to observe and monitor changes in patient satisfaction and outcome.

LEVEL OF STUDY

II, Prospective comparative study.

Normative FJS-12 scores for the knee in an Asian population: a cross-sectional study

Background

The Forgotten Joint Score is a patient-reported outcome measure validated in assessing patients post knee arthroplasty, anterior cruciate ligament (ACL) reconstruction surgery and patellar dislocation. A previous study had established the normative scores of a population in the USA but included knees with pathology. The aim of our study is to obtain normative Forgotten Joint Scores in young Asian adults without any pre-existing knee pathologies to increase the interpretability of the Forgotten Joint Score-12 (FJS-12) score.

Methods

We conducted a cross-sectional study across young healthy Asian adults via electronic platforms. Participants who had sought either Western medical consultation, physiotherapy or traditional medical therapies were excluded. Demographic data, occupation, type of sport played, and FJS-12 scores were collected. Scores were stratified into subgroups and analysed.

Results

There were 172 participants who met our inclusion criteria for this study. The average age of participants in our study was 28.1 ± 10.5 years (range 14–70 years), with 83 (47.7%) participants falling into the ages 21–25 years. Average body mass index (BMI) was 21.9 ± 3.3 kg/m² (range 14.7–36.3 kg/m²). The average FJS-12 score was 62.8 ± 25.6. The median FJS-12 was 63.5 with a range of 4.2–100. Nine participants (5.2%) scored the maximum score possible, and 56 (32.6%) participants scored below the midpoint score of 50. The percentiles for each subgroup of participants were tabulated and reported. Notably, males aged 46–70 years old scored the highest average FJS-12 score of 73.4 ± 5.5, and females aged 31–45 years old scored the lowest FJS-12 score of 57.1 ± 25.1. Females scored lower than males, although the difference was not statistically significant (p = 0.157). There were no significant correlations between BMI, age, or type of sport played with FJS-12; however, interestingly, we observed that women reported similar FJS-12 scores across all age groups, while men reported better scores with increasing age.Interestingly, we observed that women reported similar FJS-12 scores across all age groups, while men reported better scores with increasing age. 

Conclusion

Having normative values provides opportunities for benchmarking and comparing individuals against age- and gender-matched peers in the general population. Knowledge of normative values for FJS-12 scores would aid evaluating and tracking progress in patients recovering from injuries or undergoing post-surgery rehabilitation. This would help clinicians  determine if they return to ‘normal’ post intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43019-021-00122-2.

Reliable Internal Consistency and Adequate Validity of the Forgotten Joint Score-12 after Primary Anterior Cruciate Ligament Repair

Purpose

To validate the Forgotten Joint Score-12 (FJS-12) as a subjective outcome metric for patients undergoing arthroscopic primary anterior cruciate ligament (ACL) repair.

Methods

In this retrospective study, all patients undergoing primary ACL repair for complete isolated proximal tears between 2008 and 2018 were eligible for inclusion. Patients were contacted and asked to complete the FJS-12, Lysholm Knee Score, modified Cincinnati score, Single Assessment Numeric Evaluation (SANE), Subjective International Knee Documentation Committee (IKDC), and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale at a minimum of 1 year of follow-up. Internal consistency, convergent validity, and ceiling effects were analyzed.

Results

Ninety-six patients could be included (62%), with a mean FJS-12 score of 86.9 ± 14.0 (range, 31.3-100). The FJS-12 showed reliable internal consistency (Cronbach’s alpha = 0.89). Construct validity was moderate to strong (r = 0. 621-0.702). Ceiling effect for the FJS-12 was 21.9%, which was lower than for the Lysholm (44.6%), modified Cincinnati (45.1%), equal to the IKDC subjective (21.9%), and SANE score (22.0%) but higher compared to the ACL-RSI (12.8%). Furthermore, internal consistency for the other scores was also good to excellent (range Cronbach’s alpha = 0.627-0.953).

Conclusion

The FJS-12 shows high internal consistency and construct validity after primary ACL repair. Furthermore, this metric showed equal or less ceiling effect than most other scores, although still notable. This study suggests that the FJS-12 is an easy and validated outcome metric to evaluate subjective primary repair outcomes.

Level of Evidence

Level III, diagnostic study.