Psychometric properties of the Knee injury and Osteoarthritis Outcome Score for Children (KOOS-Child) in children with knee disorders

Anterior cruciate ligament reconstruction: effect of graft type and gender on early to mid-term clinical outcomes

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is a debilitating condition and often requires surgery to restore joint stability. Common autografts used for reconstruction include patella tendon and hamstring tendons. The primary aim of this study was to evaluate the early to mid-term clinical outcomes of ACL reconstruction using validated patient-reported outcome measures (PROMs). The secondary aim was to compare clinical outcomes between patella tendon and hamstring tendon autografts. The tertiary aim was to compare clinical outcomes between males and females.

METHODS

Patients with an ACL rupture were evaluated before and after surgery using PROM scores which included Lysholm, Tegner, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Short Form-12 Item (SF-12) and EQ-5D-5L.

RESULTS

A total of 87 patients were included in the study. All PROM scores significantly improved following surgery (p < 0.001) at a mean follow-up time of 28 months (range 12 to 88 months). The patella tendon subgroup (n = 27) had superior post-operative results as compared to the hamstring tendon subgroup (n = 60) for KOOS sport and recreation (p = 0.005), KOOS quality of life (p = 0.025), KOOS overall (p = 0.026), Tegner (p = 0.046) and IKDC (p = 0.021) scores. There was no significant difference of PROM scores between males (n = 60) and females (n = 27) (p > 0.05).

CONCLUSIONS

ACL reconstruction significantly improves clinical outcomes for patients with symptomatic instability consequent to ACL rupture. Overall, patella tendon autograft resulted in better clinical outcomes as compared to hamstring tendon autograft following surgery. Gender did not influence clinical outcome following ACL reconstruction.

Good physical function but reduced quality of life in children 3 years after ACL reconstruction

PURPOSE

To assess children's physical function and subjective knee status 1 and 3 years after anterior cruciate ligament (ACL) reconstruction. It was hypothesised that there was no difference between the operated and normal legs in relation to physical strength and function, that there was <-2 mm side-to-side difference in knee laxity, and that the subjective knee function was better 3 years after ACL reconstruction compared to 1 year after.

METHODS

Children (<16 years of age) who had an ACL reconstruction had follow-up with physical function tests (four hop tests and strength measurement in a power rig [PR]), anterior knee laxity (measured using a Rolimeter) and patient-reported outcome measures (Pedi-International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]-Child) 1 and 3 years postoperatively. Changes from 1- to 3-year follow-up were evaluated with a paired t test.

RESULTS

Out of 148 ACL reconstructed children, 60 had all measures. The four hop tests and the PR all yielded a Limb Symmetry Index >90% at both follow-ups. There was a significant improvement from 1- to 3-year follow-up in two-hop tests (6 m on time and crossover hop). Side-to-side knee laxity was >2 mm in four children at 1- and 3-year tests. Pedi-IKDC scores increased, and KOOS-Child improved significantly from 1 to 3 years in two of the five domains: 'Sport' and 'Quality of life', but scores were lower than in a cohort of normal children.

CONCLUSION

The children had good objective physical function 1 and 3 years after ACL reconstruction. However, scores from the KOOS-Child sport-specific function and quality of life domains were lower than in normal children.

LEVEL OF EVIDENCE

Level II.

Self-management including exercise, education and activity modification compared to usual care for adolescents with Osgood-Schlatter (the SOGOOD trial): protocol of a randomized controlled superiority trial

BACKGROUND

Osgood-Schlatter is the most frequent growth-related injury affecting about 10% of physically active adolescents. It can cause long-term pain and limitations in sports and physical activity, with potential sequela well into adulthood. The management of Osgood-Schlatter is very heterogeneous. Recent systematic reviews have found low level evidence for surgical intervention and injection therapies, and an absence of studies on conservative management. Recently, a novel self-management approach with exercise, education, and activity modification, demonstrated favorable outcomes for adolescents with patellofemoral pain and Osgood-Schlatter in prospective cohort studies.

AIM

The aim of this trial is to assess the effectiveness of the novel self-management approach compared to usual care in improving self-reported knee-related function in sport (measured using the KOOS-child 'Sport/play' subscale) after a 5-month period.

METHODS

This trial is a pragmatic, assessor-blinded, randomized controlled trial with a two-group parallel arm design, including participants aged 10-16 years diagnosed with Osgood-Schlatter. Participants will receive 3 months of treatment, consisting of either usual care or the self-management approach including exercise, education, and activity modification, followed by 2 months of self-management. Primary endpoint is the KOOS-child 'Sport/play' score at 5 months. This protocol details the planned methods and procedures.

DISCUSSION

The novel approach has already shown promise in previous cohort studies. This trial will potentially provide much-needed level 1 evidence for the effectiveness of the self-management approach, representing a crucial step towards addressing the long-term pain and limitations associated with Osgood-Schlatter.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05174182. Prospectively registered December 30th 2021. Date of first recruitment: January 3rd 2022. Target sample size: 130 participants.

30 years with the Knee injury and Osteoarthritis Outcome Score (KOOS)

This narrative review describes the development and use of patient-reported outcomes over 30 years, focusing on the Knee injury and Osteoarthritis Outcome Score (KOOS). KOOS is a five-subscale patient-reported instrument intended for use from the time of knee injury to the development of osteoarthritis. Numerous studies have confirmed that the psychometric properties of the KOOS and its short-form KOOS-12 are acceptable. More recent research has focused on the use and interpretation of KOOS scores in clinical trials using thresholds, such as minimal important differences, patient-acceptable symptom states, and treatment failure. As an indication of KOOS's popularity, the total 3854 PubMed results for KOOS have increased exponentially since the first KOOS paper was published 25 years ago and now seem to have plateaued at around 650 annually. The selected articles are not based on a systematic search, but on the author's own publications, reading, and literature search that grew organically from that.

Quality of patient- and proxy-reported outcomes for children with impairment of the lower extremity: A systematic review using the COnsensus-based Standards for selection of health Measurement INstruments methodology

Background

Patient-reported outcome measures have become crucial in the clinical evaluation of patients. Appropriate selection, in a young population, of the instrument is vital to providing evidence-based patient-centered healthcare. This systematic review applies the COnsensus-based Standards for selection of health Measurement INstruments methodology to provide a critically appraised overview of patient-reported outcome measures targeted at pediatric orthopedic patients with lower limb impairment.

Method

A systematic search of electronic databases was performed to identify original studies reporting the development and/or validation of patient-reported outcome measures evaluating children with impairment of the lower extremity. Data extraction, quality assessment, and risk of bias evaluation were performed following the COnsensus-based Standards for selection of health Measurement INstruments guidelines and Preferred Reporting Items for Systematic reviews and Meta-Analyses statement.

Results

A total of 6919 articles were screened. Thirty-three studies were included, reporting evidence on the measurement properties of 13 different patient-reported outcome measures and 20 translations. Four studies reported on content validity and patient-reported outcome measure development. The methodological quality of studies on structural validity, content validity, or patient-reported outcome measure development was mostly rated as "doubtful" or "very good." The quality of evidence on measurement properties varied noticeably, with most studies needing to perform improve their methodological quality to justify their results.

Conclusion

This review provides an extensive overview of all available patient-reported outcome measures for patients with lower extremity impairment within pediatric orthopedics. We cautiously advise the use of four patient-reported outcome measures. However, the scarce availability of research on content validity and patient-reported outcome measure development highlights an area for future research endeavors to improve our knowledge on the currently available patient-reported outcome measures.

Level of evidence

Diagnostic level 1.

The Moroccan Knee Osteoarthritis Outcome Score (KOOS)-Child Scale: Translation, Cultural Adaptation, and Validation

Objective The objective of this study was to perform a cross-cultural validation and adaptation of the Moroccan Dialectal Arabic version of the Knee Osteoarthritis Outcome Score (KOOS)-Child scale. Methodology Two groups of participants were recruited: a group of children affected by knee problems and another group serving as a control, free of any knee pathology. Participants were asked to complete the KOOS-Child scale twice with a minimum interval of 15 days. Results This study included 130 patients aged 9.82 ± 3.16 years, comprising 88 (67.7%) patients with knee problems and 42 (32.3%) controls. The baseline comparison showed no statistically significant difference between the two groups. The KOOS-Child scale was translated into Moroccan Dialectal Arabic without encountering difficulties in the translation and cross-cultural adaptation process. It proved practical, reliable, and suitable for assessing problems that children and adolescents with knee disorders may encounter. The scale exhibited good content validity and test-retest reliability. The Moroccan scale also demonstrated excellent internal consistency, except for the symptoms subscale. Confirmatory factor analysis indicated that the structure of the Moroccan version of the KOOS-Child scale was acceptable. Conclusions The Moroccan KOOS-Child scale exhibited good acceptability, reliability, discriminative capacity, and overall good internal consistency, with the exception of the symptoms subscale.

The mid-term effect of Osgood-Schlatter disease on knee function in young players from elite soccer academies

BACKGROUND

The aim of the study was to evaluate the effect of Osgood-Schlatter disease (OSD) on knee joint function in elite young soccer players. Our hypothesis was that knee joint function in elite young soccer players was impaired following OSD compared with soccer players with no history of OSD.

METHOD

In young male soccer players (n = 36) from elite academies (mean ±SD, age: age: 15,3 ± 1,7 years; height: 1,7 ± 0,06 m; weight: 63,5 ± 8 kg; BMI: 20,7 ± 2). The duration between the completion of treatment or the last complaint to the study commencement was 31 ± 19 months.

RESULTS

The average treatment duration of OSD among study participants was 18,5 ± 12 days (95%, 14-23), and the disease most often manifested in winter and spring, 33% and 31% of cases, respectively. Soccer players with a history of OSD were statistically different in IKDC and KOOS scores when compared with soccer players with no previously reported OSD (Mann-Whitney, p < 0,0001). The soccer players with a history of OSD also use NSAIDs more frequently compared with soccer players with no history of OSD (36% vs 3% respectively).

CONCLUSIONS

OSD among young soccer players, when symptoms resolve, continue about one month and they can return to regular training and participation in games. Wherein, the negative effects in knee joint function were significantly more likely in soccer players with previous OSD history when compared with their peers with no history of OSD. While oral non-steroidal anti-inflammatory drugs was also more widely employed in soccer players with previous OSD history. Potentially this may lead to performance deficits and disadvantages for their future careers and coaches and physicians should be informed.

Adaptation of the Banff Patellofemoral Instability Instrument (BPII) 2.0 into Swedish

BACKGROUND AND PURPOSE

The Banff Patellofemoral Instability Instrument (BPII) 2.0 is a patient-reported outcome measure (PROM) designed specifically for patellofemoral instability. We translated and adapted the BPII 2.0 into Swedish and assessed its psychometric properties.

PATIENTS AND METHODS

The BPII 2.0 was forward- and back-translated. Children aged 10-16 years with patellar dislocation and instability or recurrent dislocation were recruited. Children completed the Swedish BPII 2.0 and KOOS-Child during their initial visit (t0) and 1 week later (t1). Internal consistency and test-retest reliability were evaluated using intraclass correlation coefficients (ICCs) for the BPII 2.0 and KOOS-Child scores comparison. Pearson correlation coefficients examined concurrent validity of the Swedish BPII 2.0 subscales with KOOS-Child subscales.

RESULTS

64 children (46 females), mean age 13.8 (10.0-16.3) years, participated. Time after patellar dislocation or surgery was 3-24 months. 55 patients (86%) returned the second BPII 2.0 and KOOS-Child after an average of 9 (5-22) days. There were no ceiling or floor effects for the total score of the new Swedish BPII 2.0 or for its subscales. BPII 2.0 demonstrated excellent internal consistency at t0 (ICC 0.96, 95% confidence interval [CI] 0.95-0.97) and at t1 (ICC 0.97, CI 0.95-0.98), as well as excellent test-retest reliability (ICC 0.97, CI 0.96-0.98). Concurrent validity of the BPII 2.0 subscales with KOOS-Child subscales was moderate to strong (rho 0.40-0.88).

CONCLUSION

The Swedish BPII 2.0 showed excellent internal consistency as well as excellent test-retest reliability and is a reliable and valid questionnaire.

Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength

OBJECTIVE: To describe age-, sex-, and graft source-specific reference values for patient-reported, physical function, and strength outcome measures in adolescents at 5 to 7 months after anterior cruciate ligament reconstruction. DESIGN: Cross-sectional study. METHODS: Data were collected at 3 universities and 2 children's hospitals. The participants completed at least one of the International Knee Documentation Committee (IKDC) Subjective Evaluation Form, Pediatric IKDC (Pedi-IKDC), Knee Injury and Osteoarthritis Outcomes Score (KOOS), and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Participants also completed single-leg hop tests and/or isokinetic quadriceps and hamstrings strength assessments (at 60°/s). Reference values were summarized using descriptive statistics and stratified for age, sex, and graft source. RESULTS: Reference values were reported for common patient-reported outcomes and measures of physical function and strength from 783 participants (56% females, age = 16. 4 ± 2.0 years) who were in early adolescence (12-14 years, N = 183, 52% females), middle adolescence (15-17 years, N = 456, 58% females), or late adolescence (18-20 years, N = 144, 55% females). Three hundred seventy-nine participants (48.4%) received a bone-patellar tendon-bone autograft, 292 participants (37.3%) received hamstring tendon autograft, and 112 participants (14.3%) received autograft or allograft from an alternative source. CONCLUSION: Reference values for common patient-reported outcomes and measures of physical function and strength differed depending on a patient's age, sex, and graft source. Using patient-specific reference values, in addition to previously described age-appropriate cutoff values, may help clinicians monitor and progress patients through rehabilitation and return to physical activity after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2023;53(4):1-8. Epub: 23 January 2023. doi:10.2519/jospt.2023.11389.

No correlation between performance tests, clinical measurements and data from patient-reported outcome measures (PROM) in children reconstructed for anterior cruciate ligament injury

PURPOSE

To investigate if patient-reported outcome measures (PROMs), functional tests and clinical measures correlate well in children after reconstruction of the anterior cruciate ligament (ACL). It was hypothesized that these outcomes correlate, so it is sufficient to report only one of them.

METHODS

A consecutive group of children (< 16 years old) who had an ACL reconstruction, were prospectively followed and assessed after 1-year with Pedi-IKDC and KOOS-Child, instrumented laxity measurement, range of motion, extension strength and four performance tests. Relations between the different outcomes were calculated by partial correlation coefficient analysis, controlling for gender, age, height, and weight.

RESULTS

Outcomes were available for 141 of 163 children. There were only few positive and weak correlations between performance tests and PROM scores and between clinical measurements and PROM scores. There were weak to strong correlations between the scores from Pedi-IKDC and the scores from each of the five domains of KOOS-Child and a weak to moderate correlation between the different domains of KOOS-Child. Similar correlations were found between the different performance tests.

CONCLUSION

For children who had their ACL reconstructed there was no clinically important correlation between scores obtained by PROMs, a battery of functional performance tests and instrumented laxity of the knee at 1-year follow-up. This is an argument for always to include and report all three types of outcomes.

LEVEL OF EVIDENCE

Level II.

KOOS-Child exhibits inadequate structural validity in a cohort of paediatric patients with ACL deficiency

OBJECTIVES

Knee injury and Osteoarthritis Outcome Score (KOOS)-Child is a modification of the adult KOOS aiming to evaluate knee injury, including ACL deficiency. However, the measurement properties of KOOS-Child have not been assessed in a cohort of children with ACL deficiency. We aimed to study the structure of KOOS-Child using modern test theory models (Rasch analysis and confirmatory factor analysis (CFA)).

METHODS

Data were collected prospectively in a cohort of children with ACL deficiency at three time points: before-and-after ACL surgery, and at 1-year follow-up. For each subscale, structural validity through the fit of a CFA model was evaluated for 153 respondents. Modification indices were examined to find the model of best fit, confirmed using Rasch analysis. Responsiveness was reported for each subscale. Reliability was calculated for each item. Floor and ceiling effects, and Person-item distribution were reported.

RESULTS

All subscales showed inadequate fit to a unidimensional CFA model. Rasch analysis confirmed these results. Adjusting the subscales improved model fit, although this was still quite poor, except for the quality of life subscale. With one exception, all items demonstrated ceiling effects. Person-item distribution confirmed this. Due to lack of fit, reliability was not reported. All subscales were able to detect change from baseline to 1-year follow-up.

CONCLUSIONS

KOOS-Child exhibits inadequate measurement properties in its current form for children with ACL deficiency. Suggestions to make the subscales fit the models better and improve accuracy of KOOS-Child are presented. However, the large ceiling effects observed may reduce sensitivity and induce type 2 errors.

The German version of the KOOS-Child questionnaire (Knee injury and Osteoarthritis Outcome Score for children) shows a good to excellent internal consistency and a high test-retest reliability in children with knee problems

PURPOSE

The Knee Injury Osteoarthritis Outcome Score for children (KOOS-Child) is a self-administered, valid and reliable questionnaire for children and adolescents with knee disorders such as Osgood Schlatter disease, anterior knee pain, and patella dislocation. This study aimed to cross-culturally adapt the German version of the KOOS-Child questionnaire and test the reliability in two groups of children, one treated conservatively and the other surgically.

METHODS

A forward-backward translation of the original questionnaire into the German language was conducted. Children and adolescents between 10 and 18 years of age with knee disorders were included. Two groups were compared: sample one consisted of 24 participants with knee pain [20.8% boys; mean age = 13.4 (1.8) years treated conservatively. These participants completed the KOOS-Child questionnaire twice within two weeks to assess test-retest reliability. The second sample included 23 subjects (21.7% boys; mean age = 15.3 (1.9) years] treated surgically due to a knee disorder. They completed the questionnaire before surgery and six months postoperatively. Test-retest reliability and internal consistency were assessed using Spearman's rank correlation and Cronbach's alpha.

RESULTS

All subscales showed a good to excellent internal consistency at both measurement points in both groups (conservatively treated group: a = 0.88-0.95; surgery group a = 0.80-0.91), with the exception of the subscale knee problems (conservatively treated: a = 0.60 and 0.52; surgery: α = 0.77 and 0.66). Test-retest reliability was between r = 0.85 and 0.94.

CONCLUSION

The predominantly good to excellent internal consistency and the high test-retest reliability justifies the use of the German adaptation of the KOOS-Child questionnaire as a reliable multidimensional instrument for measuring health status and therapeutic effects in adolescents' knee disorders.

Protocol for a randomised, assessor-blinded, parallel group feasibility trial of flat flexible school shoes for adolescents with patellofemoral pain

Background

There are limited evidence-based treatment options for adolescents with patellofemoral pain (PFP). Flat, flexible footwear have been shown to reduce patellofemoral joint loading and pain in adults with PFP. The efficacy of this intervention in adolescents with PFP is not established. The primary aim of this study is to determine the feasibility of conducting a large-scale randomised controlled trial (RCT) of the effect of flat, flexible school footwear, when compared to traditional school footwear, in adolescents with PFP. The secondary aim is to describe changes in self-reported outcome measures for adolescents with PFP while wearing flat, flexible footwear when compared to traditional school shoes.

Methods

Twenty-four adolescents with PFP will be recruited from the community. Following baseline assessment, participants will be randomly allocated to receive either (i) flat, flexible school footwear or, (ii) traditional school footwear. Participants will wear the shoe as per school requirements throughout a 12-week intervention period. Feasibility will be assessed with (i) ≥ 75% adherence to allocated shoe wear of their total weekly school wear time, (ii) a recruitment rate of one participant per fortnight, and (iii) a dropout rate of ≤ 20%. Patient reported outcome measures will describe changes in knee pain, function, quality of life and global rating of change at 6 and 12 weeks. Descriptive statistics will be used for the primary outcomes of feasibility.

Discussion

This study will determine the feasibility of conducting a large scale RCT evaluating the effect of flat, flexible school shoes for adolescents with PFP. A full-scale study will guide evidence-based management of adolescent PFP.

Trial registration

Australian New Zealand Clinical Trials Registry reference: ACTRN12621001525875, Date registered: 9th November 2021.

Measurement Properties of the EQ-5D-Y: A Systematic Review

OBJECTIVES

This study aimed to perform a systematic review of published evidence on the psychometric properties of 3-level version of EQ-5D-Y and 5-level version of EQ-5D-Y (EQ-5D-Y-5L).

METHODS

A literature search on the MEDLINE, Embase, and EuroQol website (until June 2021) was conducted. Original studies on EQ-5D-Y psychometric properties such as feasibility, distribution properties (ceiling and floor effects), reliability (test-retest, interrater, intermodal), validity (known-groups, convergent), and responsiveness, published as full-text articles in English, were included. Studies on experimental EQ-5D-Y versions were excluded. The following data were pooled using random effects models: missing values, the ceiling effect, and correlations coefficients with other measures.

RESULTS

A total of 47 studies (inclusive of 7 on EQ-5D-Y-5L) containing data from 45 310 children and 2690 proxy respondents representing 15 countries were included. These studies were characterized as being high quality according to the quality index. The most represented areas were school populations and musculoskeletal diseases and orthopedics. The EQ-5D-Y dimensions, EQ visual analog scale, and EQ index were reported in 89%, 77%, and 26% of studies, respectively. Most articles addressed validity (known-groups, n = 27; convergent, n = 21) and reliability (test-retest and interrater, n = 10 each). Convergent validity studies showed that, where the assessment of the child's functioning at school is required, EQ-5D-Y should be supplemented with other school-specific measures.

CONCLUSIONS

This systematic review provides a summary of measurement properties and the psychometric performance of 3-level version of EQ-5D-Y and EQ-5D-Y-5L. The existing evidence supports using the EQ-5D-Y descriptive system and EQ visual analog scale in children and adolescent populations. Further research on test-retest reliability and the responsiveness of the EQ-5D-Y index obtained with child-specific value sets is needed.

Patient-Reported Outcome Measures for Pediatric Patients With Sport-Related Injuries: A Systematic Review

Despite a call to incorporate patient-reported outcome measures (PROMs) into all aspects of health care, little is known about which instruments are best suited for a pediatric patient population with sport-related injury. The objective of this article was to perform a systematic review of the currently available evidence to determine which PROMs were used for pediatric patients with sport-related injuries and identify the associated psychometric properties and considerations for clinical utility. We conducted a literature search for articles on PROMs used in the pediatric population through electronic databases and a manual search of reference lists and authors between from inception to 2020. Articles were grouped based on the PROM(s) included, and considerations for clinical utility and psychometric properties were extracted from each article. Thirty-nine articles were included in this review, from which 22 PROMs were identified: 12 PROMs were developed specifically for the pediatric population, 4 were modified versions of an adult scale, and 6 were adult measures used in a pediatric population. Of the PROMs included in this review, the Oxford Ankle Foot Questionnaire for Children and the Pediatric Quality of Life Inventory were the most comprehensive in their development and assessment. Several outcome measures used for pediatric patients had missing or inadequate measurement properties and considerations for clinical utility, particularly in regard to readability, responsiveness, and interpretability. Clinicians and researchers should consider a measure's feasibility, acceptability, appropriateness, and psychometric properties when selecting a PROM for use with the pediatric population.

Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) injuries and surgical intervention in the pediatric population have increased in the recent years. Although surgical techniques have advanced, evidence-based rehabilitation guidelines that consider all aspects of the youth athlete are currently lacking. The purpose of this commentary is to review the current evidence on unique considerations for the pediatric and adolescent population during rehabilitation and return to sport after ACL reconstruction (ACLR), with a focus on children under 18 years of age. This review revealed that returning a youth athlete to sport after ACLR requires knowledge and appreciation of various aspects of the growing athlete different from adults. In addition to postoperative precautions that contribute to a slow rehabilitation process, young athletes need additional time for strength gains. Address risk of reinjury and for contralateral injury by using neuromuscular training and rigorous return-to-sport training programs. Consider return to sport after 9 months because the reinjury rate is high in this population. A combination of time and objective measures, both quantitative and qualitative criteria, and psychological readiness should be used to assess readiness to return to sport and decrease risk of future injury. Healthcare providers should be aware of the psychosocial impact of injury on the youth athletes and refer to sport psychology when necessary.

LEVEL OF EVIDENCE

Level V.

Assessing knee functionality: systematic review of validated outcome measures

BACKGROUND

Functional rating scales allow clinicians to document and quantify alterations and progression of recovery processes. There is neither awareness of numerous knee scales nor are they easy to find or compare to select the most suitable.

OBJECTIVES

We aimed to compile validated knee functional rating tools and analyse the methodological quality of their validation studies. Also, we aimed to provide an operational document of the outcome measures addressing descriptions of parameters, implementations, instructions, interpretations and languages, to identify the most appropriate for future interventions.

METHODS

A systematic review involved a search of PubMed, Web of Science, CINAHL, Scopus, and Dialnet databases from inception through September 2020. The main inclusion criteria were available functional rating scales/questionnaires/indexes for knees and validation studies. Methodological quality was analyzed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement Instruments Risk of Bias (COSMIN-RB).

RESULTS

We selected 73 studies. The studies investigated 41 knee rating tools (general, 46%, and specific, 54%) and 71 validations, including 29,742 individuals with knee disorders. QUADAS-2 obtained the best results in patient selection and index test (applicability section). COSMIN-RB showed the highest quality in construct validity (most analyzed metric property). The specific tools were mainly designed for prosthesis and patellofemoral and anterior cruciate ligament injuries. More considered issues were specific function (93%), especially gait, pain/sensitivity (81%), and physical activity/sports (56%).

CONCLUSIONS AND IMPLICATIONS

We conducted a necessary, useful, unlimited-by-time and feasible compilation of validated tools for assessing knee functional recovery. The methodological quality of the validations was limited. The best validations were for the Copenhagen Knee Range of Motion Scale in osteoarthritis and arthroplasties, Knee Outcome Survey Activities of Daily Living and Lysholm Knee Score for general knee disorders and the Tegner Activity Score for anterior cruciate ligament injuries. The operational document for the scales provides necessary data to identify the most appropriate.

Validity, Responsiveness, and Reliability of the ACL-QOL in an Adolescent Population

BACKGROUND

The anterior cruciate ligament quality of life (ACL-QOL) score is a disease-specific patient-reported outcome measure that assesses patients with ACL deficient and reconstructed knees. The ACL-QOL has demonstrated validity, responsiveness, and reliability in adult populations but has yet to be specifically evaluated in adolescent patients. The purpose of this study was to assess the validity, responsiveness, and reliability of the ACL-QOL in an adolescent population.

METHODS

Between 2010 and 2015, questionnaires from 294 consecutive adolescent patients consented for an ACL reconstruction were collected from an orthopaedic sport medicine clinic. The ACL-QOL was administered preoperatively, and at 6, 12, and 24 months following primary ACL reconstruction. To assess content validity, the Cronbach α and floor and ceiling effects were measured. Question reading level was measured with an online tool (https://readable.com/). Responsiveness was assessed with a 1-way analysis of variance to compare the preoperative and postoperative time periods. A test-retest strategy with completion of the ACL-QOL twice within 3 weeks was used to assess reliability using an intraclass correlation coefficient (ICC 2,k) and the SEM.

RESULTS

The ACL-QOL demonstrated high content validity with a Cronbach αbetween 0.93 and 0.97, with no evidence of floor or ceiling effects at any study time point. The mean readability grade level was calculated to be 6.9, along with a readability score of 68. The ACL-QOL scores revealed a statistically significant improvement over time (P<0.001) with a Cohen d of 0.56, indicating a large effect size. Test-retest reliability revealed an ICC (2,k) of 0.997 (95% confidence interval=0.992-0.999).

CONCLUSIONS

The ACL-QOL demonstrated content validity, responsiveness to change, and reliability in an adolescent ACL reconstruction population. The readability of the ACL-QOL is acceptable for adolescents with an ACL injury. The ACL-QOL is a valid, responsive, and reliable patient-reported outcome measure that can be used in an adolescent population with ACL deficiency or following ACL reconstruction.

LEVEL OF EVIDENCE

Level III.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.

Patient-Reported Outcome Measures (PROMs) Relevant to Musculoskeletal Conditions Translated and Validated in the Greek Language: A COSMIN-Based Systematic Review of Measurement Properties

BACKGROUND

The use of patient-reported outcome measures (PROMs) constitutes a valuable tool in evaluating the quality of care offered in orthopaedic surgery. The aim of this review is to identify the PROMs that have been translated into and validated in the Greek language, summarise their measurement properties, and evaluate their methodological quality according to the COSMIN Risk of Bias Checklist.

METHODS

A structured literature search was conducted using the databases PubMED/MEDLINE, Embase, Scopus, and the Cochrane Library in order to identify PROMs relevant to musculoskeletal conditions translated and validated in the Greek language. The methodological quality of the studies was assessed according to the COSMIN Risk of Bias Checklist, and the quality of measurement properties according to the COMSIN criteria.

RESULTS

Literature search yielded 6743 articles. After removal of duplicates and screening of the articles, 32 studies including PROMs related to musculoskeletal conditions were identified. The studies included 31 PROMs and reported 171 measurement properties. Methodological quality was adequate for 81 of them (47.3%). The most commonly reported measurement properties were internal consistency, reliability, construct validity and responsiveness.

CONCLUSION

The majority of PROMs translated into Greek involves the lower extremity and especially knee pathologies. The search revealed that there are areas of Musculoskeletal Medicine such as skeletal trauma, musculoskeletal oncology, and paediatric orthopaedics in which patient reported-outcome measures have not been translated into Greek. Translation and validation of new outcome measures is encouraged, using studies designed in compliance with the COSMIN guidelines, and further validation of the translated instruments.

Development and validation of the Sorting non-trauMatIc adoLescent knEe pain (SMILE) tool - a development and initial validation study

BACKGROUND

Despite the commonality of adolescent knee pain, there are no tools to support medical doctors to correctly diagnose knee pain. This study aimed to develop and evaluate a support tool for diagnosing the most common types of non-traumatic adolescent knee pain.

METHOD

A systematic search on Medline identified the literature on clinical tests and diagnoses of adolescent knee pain. The search was supplemented by textbooks and transformed into a diagnostic flowchart based on onset, symptoms, and pain localisation. This tool was revised based on feedback from general practitioners and experts in sports medicine. The tool was evaluated on two separate days with blinded assessors. Overall, 27 participants (aged 10-17 years) with non-traumatic knee pain were included. All participants were diagnosed by medical doctors or medical students, without and with the use of the tool. Diagnoses were compared to a gold standard (expert clinician). An interview to inform optimisations of the tool was performed with the assessors. Percentage agreement with the gold standard, and Kappa statistic for interrater reliability were calculated.

RESULTS

The final tool improved diagnostic agreement with the gold standard from 22.7% (95% CI 10.3-35.1) to 77.3% (95% CI 64.9-89.7). Inter-rater reliability increased from poor agreement k = - 0.04 (95% CI, - 0.12-0.04) to moderate agreement k = 0.56 (95% CI, 0.40-0.72).

CONCLUSION

This simple diagnostic tool is quick to use and may assist doctors in diagnosing non-traumatic knee pain in adolescents.

"Greek KOOS-Child: a valid, disease specific, diagnostically accurate and responsive PROM in children with knee-related pathology"

PURPOSE

The Knee Injury Osteoarthritis Outcome Score (KOOS)-Child questionnaire is one of the frequently child-friendly measures used in pediatric studies. The aim of this study was to transculturally adapt the Greek version of KOOS-Child and evaluate its clinimetric properties in children with knee disorders.

METHODS

Children visiting the Outpatients Orthopaedic Clinic of a Greek Paediatric General Hospital were considered eligible if they were aged 8-14 years, had a knee soft tissue injury and associated physical limitations. The transcultural adaptation was based on a multistage backward translation approach. Participants completed the KOOS-Child at their first visit to the orthopedic specialist (baseline), 2 weeks and 3 months after baseline. Content validity of the KOOS-Child was evaluated using general QoL measures (KIDSCREEN and Kid-KINDL) and construct validity was explored by correlating relevant items. Responsiveness was evaluated according to the children's response on the given orthopeadic treatment.

RESULTS

Sample consisted of 59 children (30 males), aged: 11 ± 1.8 years. The KOOS-Child showed high internal consistency (Cronbach's a: 0.80-0.96). Adequate convergent validity with > 75% relevant a priori hypotheses was confirmed. Construct validity was moderate to strong (Pearson's r correlations between related KOOS and Kid-KINDL subdimensions: 0.54-0.62). KOOS and KIDSCREEN subdimensions correlations were fair (Pearson's r correlations: 0.32-0.65). KOOS-Child's diagnostic accuracy was high. Factor analysis extracted height factors accounting for 76.15% of the total variance, confirmed by the scree plot. Responsiveness was moderate to high with Cohen's d from 0.6 to 1.4.

CONCLUSION

The Greek version of the KOOS-Child demonstrated excellent internal consistency, good construct validity, diagnostic accuracy and interpretability as well as good responsiveness. The measure could be used across Greek children with orthopaedic knee problems. Generalisability of findings is limited due to the relatively limited cohort.

LEVEL OF EVIDENCE

II.

Pediatric Simple Knee Value: a simple patient-reported outcome measure for the knee

PURPOSE

The pediatric Simple Knee Value (pedi-SKV) is an outcome score in which paediatric patients are asked 'How would you rate your knee today as a percentage of normal (0% to 100% scale with 100% being normal)?'. The primary aim of this study was to validate the pedi-SKV by measuring its correlation with validated knee function scores used most often in paediatric orthopaedics.

METHODS

This prospective study was conducted at a teaching hospital to evaluate the pedi-SKV's validity. A total of 44 paediatric patients (ten to 15 years old), were enrolled prior to anterior cruciate ligament reconstruction as well as 17 healthy controls. A survey form consisting of the Lysholm, International Knee Documentation Committee Pediatric Form (Pedi-IKDC) and pedi-SKV was given to subjects twice (enrolment and six months postoperatively). The criterion validity of the pedi-SKV was determined by correlating it to existing knee functional scores. Responsiveness to change was evaluated by comparing the pedi-SKV scores before and after surgery (enrolment visit and six-month postoperative visit). Discriminative ability was evaluated by comparing the pedi-SKV distribution in patients versus controls.

RESULTS

There was a strong and significant correlation between the pedi-SKV and the Lysholm and Pedi-IKDC (p < 0.0001). The pedi-SKV had a good responsiveness to change (p < 0.0001 for the pedi-SKV before versus six months postoperatively). Like the other knee-specific functional sores (p < 0.0001), the pedi-SKV was able to distinguish between patients and controls (p < 0.0001).

CONCLUSION

The pedi-SKV is a valid outcome measure that is strongly correlated with the Lysholm and Pedi-IKDC. This is a novel simple score that can be used by physicians in their daily practice.

LEVEL OF EVIDENCE

II.

HAPPi Kneecaps! Protocol for a participant- and assessor-blinded, randomised, parallel group feasibility trial of foot orthoses for adolescents with patellofemoral pain

Background

Patellofemoral pain (PFP) is a common cause of knee pain in adolescents, but there are limited evidence-based treatment options for this population. Foot orthoses can improve pain and function in adults with PFP, and may be effective for adolescents. The primary aim of this study is to determine the feasibility of conducting a full-scale randomised controlled trial (RCT) evaluating the effects of contoured foot orthoses on knee pain severity and patient-perceived global change, compared to flat shoe insoles, in adolescents with PFP. The secondary aim is to provide an estimate of treatment effects for foot orthoses, compared to flat insoles, in adolescents with PFP.

Methods

This randomised, controlled, participant- and assessor-blinded, feasibility trial has two parallel groups. Forty adolescents (aged 12–18 years) with clinical symptoms of PFP will be recruited from Queensland, Australia. Participants will be randomised to receive either prefabricated contoured foot orthoses or flat shoe insoles. Both interventions will be fit by a physiotherapist, and worn for 3 months. Feasibility will be evaluated through assessing willingness of volunteers to enrol, number of eligible participants, recruitment rate, adherence with the study protocol, adverse effects, success of blinding, and drop-out rate. Secondary outcomes will evaluate knee-related pain, symptoms, function, quality of life, global rating of change, patient acceptable symptom state, and use of co-interventions, at 6 weeks and 3 months. Primary outcomes will be reported descriptively, while estimates of standard deviation and between-group differences (with 95% confidence intervals) will be reported for secondary outcomes.

Discussion

Findings of this study will inform the feasibility of a full-scale RCT investigating the efficacy of contoured foot orthoses in adolescents with PFP. This full-scale study is necessary to improve the evidence base for management of adolescent PFP, and enhance outcomes for this population.

Trial registration

ACTRN12619000957190.

The Adolescent Knee Pain (AK-Pain) prognostic tool: protocol for a prospective cohort study

Background: One in three children and adolescents experience knee pain. Approximately one in two adolescents with knee pain will continue to experience pain even five years later and have low quality of life. The general practitioner (GP) is the first point of contact for children and adolescents with knee pain in Denmark. There is a variety of treatments being delivered in general practice, despite similar symptoms and patients' characteristics. This suggests a need to support the GPs in identifying those at high risk of a poor outcome early on, in order to better allocate resources. The aim of this study is to develop a user-friendly prognostic tool to support GPs' management of children and adolescents' knee pain. Methods: A preliminary set of items in the prognostic tool were identified using systematic reviews and meta-analysis of individual participant data. Following feedback from GPs and children and adolescents on the content and understanding, the tool was piloted and implemented in general practice. A cohort of approximately 300 children and adolescents (age 8-19 years old) is being recruited from general practices (recruitment period, July 2019 - June 2020). Clinically meaningful risk groups (e.g. low/medium/high) for the recurrence/persistence of knee pain (at 3 and 6 months) will be identified. Discussion: If successful, this prognostic tool will allow GPs to gain insights into the likely prognosis of adolescents with knee pain and subsequently provide the first building blocks towards stratified care, where treatments will be matched to the patients' prognostic profile. This has the potential to improve the recovery of children and adolescents from knee pain, to improve the allocation of resources in primary care, and to avoid the decline in physical activity and potential associated health and social consequences due to adolescent knee pain. Registration: Registered with ClinicalTrials.gov on 24 June 2019 (ID NCT03995771).

Long-term Prognosis and Impact of Osgood-Schlatter Disease 4 Years After Diagnosis: A Retrospective Study

Background:

Knee pain is common during adolescence, with Osgood-Schlatter disease (OSD) being the most frequent condition. Despite this, research regarding the long-term prognosis of OSD is limited.

Purpose:

To evaluate the prognosis 2 to 6 years after the diagnosis of OSD.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective cohort study included patients diagnosed with OSD at a single orthopaedic department between 2010 and 2016. Patients were contacted in 2018 and asked to complete a self-reported questionnaire regarding knee pain, knee function (Knee injury and Osteoarthritis Outcome Score [KOOS] Sports/Recreation subscale), Health-related quality of life (HRQoL) (youth version of EuroQol 5 dimensions 3 levels [EQ-5D-3L-Y]), and physical activity.

Results:

Out of 84 patients, 43 responded. Of these, 60.5% (n = 26) reported OSD-related knee pain at follow-up (median follow-up, 3.75 years). The median symptom duration was 90 months (interquartile range, 24-150 months) for those still experiencing knee pain, and 42.9% of these reported daily knee pain. Fifty-four percent with knee pain had reduced their sports participation compared with 35.3% of those without knee pain. KOOS Sports/Recreation subscale scores were significantly lower in those with knee pain compared with those without knee pain (53 [95% CI, 42-63] vs 85 [95% CI, 76-94], respectively). Participants with knee pain reported lower HRQoL (0.71 [95% CI, 0.57-0.84]) compared with those without knee pain (0.99 [95% CI, 0.97-1.00]).

Conclusion:

This study indicates that OSD may not always be self-limiting. The lower self-reported function and HRQoL in those with continued pain may be a consequence of impaired physical activity due to knee pain.

Outcome Measures After ACL Injury in Pediatric Patients: A Scoping Review

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries in children is increasing. However, no standardized core set of outcome measures exists for evaluating pediatric ACL injuries.

PURPOSE

To perform a scoping review of the literature to identify patient-reported outcome measures (PROMs) and objective outcome measures used to evaluate pediatric patients after ACL injury and to classify these in accordance with the International Classification of Functioning, Disability, and Health (ICF) domains.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The literature was systematically searched with the PubMed, EMBASE, CINAHL, and PEDro databases. The inclusion criteria were Danish, Norwegian, Swedish, German, or English language; publication between 2010 and 2018; pediatric ACL injury (patients ≤15 years old); and outcome measures. The selected papers were screened for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria.

RESULTS

A total of 68 papers (4286 patients; mean ± SD age, 12.2 ± 2.3 years) were included. Nineteen PROMs and 11 objective outcome measures were identified. The most frequently reported PROMs were the International Knee Documentation Committee (IKDC) Subjective Knee Form (51% of studies), Lysholm scoring scale (46% of studies) and Tegner activity rating scale (37% of studies). Additionally, return to sport was reported in 41% of studies. The most frequent objective measures were knee laxity (76% of studies), growth disturbances (69% of studies), range of motion (41% of studies), and muscle strength (21% of studies). With respect to the ICF domains, the IKDC covered all 3 ICF health domains, the Lysholm score covered the Body Structure and Function and the Activity Limitation domains, while the Tegner score covered the Participation Restriction domain. Objectively measured knee joint laxity, range of motion, and muscle strength covered 1 domain (Body Structure and Function).

CONCLUSION

Pediatric patients with ACL injury were mainly evaluated subjectively with the IKDC and objectively by knee joint laxity. No consensus exists in the evaluation of children after ACL injury. The majority of applied outcome measures are developed for adults. To cover the ICF health domains, future research needs to consider reliable and valid outcome measures relevant for pediatric patients with ACL injury.

Validation of the French version of the KOOS-child questionnaire

PURPOSE

The Knee Injury Osteoarthritis Outcome Score (KOOS) questionnaire is one of the frequently used outcome scores in pediatric studies. However, a recent study demonstrated that the pediatric population had a limited understanding of some of its questions. Therefore, the KOOS-Child questionnaire was developed specifically for this population. Our team produced a French adaptation based on the English version. The objective of the current study was to validate the French adaptation of the KOOS-Child questionnaire.

METHODS

After ethic board approval, the questionnaire was translated from English to French by two French speaking orthopedic surgeons. Following consensus, the translated version was retranslated to English by a professional translator. A group of experts compared the original and back translated version and decided on a final adapted questionnaire version. Ninety-nine 8-16 year-old patients were prospectively recruited from our pediatric orthopedic surgery clinic. Twenty-one control participants and 78 patients suffering from knee pain were recruited. The participants were asked to answer the translated French version of the KOOS-Child questionnaire and two validated French pediatric quality of life surveys.

RESULTS

Statistical analysis demonstrated no statistically significant demographic difference between the control population and the patients suffering from a knee pathology. The mean for the five different domains of the KOOS-Child questionnaire showed statistical differences (p < 0.001) between the two groups. Construct validity was demonstrated through testing of previously validated hypothesis of correlation. Internal consistency was also confirmed in injured patients.

CONCLUSIONS

In conclusion, the current study results demonstrate good to excellent internal consistency, good construct validity and inconclusive discriminant capacity of the French adaptation of the KOOS-Child questionnaire.

LEVEL OF EVIDENCE

II.

PROMs in paediatric knee ligament injury: use the Pedi-IKDC and avoid using adult PROMs

PURPOSE

The aim of this systematic review was to present an evidence-based overview of psychometric properties of patient-reported outcome measures (PROMs) for children with knee ligament injury.

METHODS

A systematic search of literature was performed in PubMed, EMBASE and Cochrane databases. The inclusion criteria were diagnostic studies evaluating psychometric properties (validity, reliability, responsiveness) and comprehensibility of PROMs as well as studies including children (age < 18 years) with knee ligament injury. The systematic review was performed following the PRISMA statement.

RESULTS

Ten studies were included. Eight studies evaluated psychometric properties of PROMs, and two studies analysed comprehensibility of PROMs. The Pedi-IKDC has been evaluated in four studies and has acceptable psychometric properties. The KOOS-Child is evaluated in one study and has acceptable psychometric properties. The use of adult PROMs in children causes problems in comprehensibility.

CONCLUSION

The Pedi-IKDC is an adequate PROM for children with knee ligament injuries. It is valid, reliable and responsive. The KOOS-Child might be an alternative PROM for the Pedi-IKDC, but has only been evaluated in one study. The clinical relevance of the present systematic review is that adult versions of PROMs are not recommended in children and adolescents.

LEVEL OF EVIDENCE

III.

Patient-Reported Outcome Measures for Patellofemoral Instability: a Critical Review

PURPOSE OF REVIEW

The purpose of this paper was to review the current psychometric properties of patient-reported outcome measures that are commonly used for patients with patellofemoral instability. This review provides evidence to guide the selection of subjective outcome measures for assessing outcomes in clinical care and research studies.

RECENT FINDINGS

At the present time, there are two patient-reported outcome measures that have been designed for, and tested on, large cohorts of patellofemoral instability patients, the Banff Patella Instability Instrument (BPII) and the Norwich Patellar Instability Score (NPI). The BPII is a wholistic quality of life outcome measure and the NPI is a symptom score. The use of disease-specific outcome measures such as the BPII and NPI, in combination with generic knee, functional activity, and/or psychological outcome measures that have been proven to be valid and reliable for the patellofemoral instability population, is most likely to provide a well-rounded evaluation of treatment outcomes.

Pedi-IKDC or KOOS-child: which questionnaire should be used in children with knee disorders?

Background

The Pedi International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) child are validated questionnaires for children with knee disorders. The aim of this study was to translate these questionnaires in Dutch and to recommend which questionnaires should – based on their psychometric properties – be used in clinical practice.

Methods

The English Pedi-IKDC and KOOS-Child were translated by the forward-backward procedure. Subsequently, content validity of the Pedi-IKDC and KOOS-Child was evaluated by both patients (n = 18) and experts (n = 18). To evaluate construct validity and interpretability participants with knee disorders (n = 100) completed the Numeric Rating Scale Pain, Lysholm Knee Scoring Scale, EuroQol-5 Dimension, Pedi-IKDC and KOOS-Child at baseline. Participants completed the anchor question, Pedi-IKDC and KOOS-child two weeks (n = 54) and one year (n = 71) after baseline, for evaluating the test-retest reliability and responsiveness. Psychometric properties were interpreted following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria.

Results

The Pedi-IKDC showed adequate test-retest reliability (intraclass correlation coefficient (ICC) 0.9; standard error of measurement (SEM) 8.6; smallest detectable change (SDC) 23.8), adequate content validity (> 75% relevant), adequate construct validity (75% confirmed hypotheses), low floor or ceiling effects (scores between 5 and 95) and adequate responsiveness (> 75% confirmed hypotheses). The KOOS-Child showed an adequate test-retest reliability (ICC 0.8–0.9; SEM 8.9–16.9; SDC 24.7–46.9), adequate content validity (> 75% relevant, except KOOS-Child subscale ADL), adequate construct validity (75% confirmed hypotheses), low floor and ceiling effects (scores between 5 and 95, except KOOS-Child subscale activities of daily living and Sport/play) and moderate responsiveness (40% confirmed hypotheses).

Conclusions

The Pedi IKDC showed better psychometric properties than the KOOS-Child and should therefore be used in children with knee disorders.

A qualitative study examining the validity and comprehensibility of physical activity items: developed and tested in children with juvenile idiopathic arthritis

BACKGROUND

Not all physical activity (PA) questionnaires (PAQ) gather information regarding PA intensity, duration, and modes and only a few were developed specifically for children. We assessed children's comprehensibility of items derived from two published PAQs used in children along with three items designed to ascertain PA intensity in order to assess comprehensibility of items and identify response errors. We modified items to create a new PAQ for children (ASCeND). We hypothesized that children would have comprehension difficulties with some original PAQ items and that ASCeND would be easier to comprehend, and would improve recall and reporting of PA.

METHODS

For this qualitative study, we recruited 30 Swedish children [ages 10-16 years; mean age = 13.0 (SD = 1.8)]; median disease activity score = 4.5 (IQR 2.2-9.0); median disease duration = 5.0 (IQR 2.6-10.8) with juvenile idiopathic arthritis (JIA) from a children's hospital-based rheumatology clinic. We conducted cognitive interviews to identify children's comprehension of PAQ items. Interviews were audiotaped, transcribed, and independently analyzed. In phase one, 10 children were interviewed and items modified based on feedback. In phase two, an additional 20 children were interviewed to gather more feedback and further refine the modified items, to create the ASCeND.

RESULTS

The median interview time was 41 min (IQR 36-56). In phase one, 219 comments were generated regarding directions for recording PA duration, and transportation use, walking, dancing, weight-bearing exercise and cardio fitness. Based on feedback we modified the survey layout, clarified directions and collapsed or defined items to reduce redundancy. In phase two, 95 comments were generated. Most comments related to aerobic fitness and strenuous PA. Children had difficulty recalling total walking and other activities per day. Children used the weather on a particular day, sports practice, or gym schedules to recall time performing activities. The most comments regarding comprehension were generated about the 3-item PA intensity survey, suggesting children had problems responding to intensity items.

CONCLUSIONS

The newer layout facilitated recall of directions or efficiency in answering items. The 3-item intensity survey was difficult to answer. Sports-specific items helped children more accurately recall the amount of daily PA. The ASCeND appeared to be easy to answer and to comprehend.

Longitudinal Fibular Deficiency: A Cross-Sectional Study Comparing Lower Limb Function of Children and Young People with That of Unaffected Peers

Longitudinal fibular deficiency (LFD), or fibular hemimelia, is congenital partial or complete absence of the fibula. We aimed to compare the lower limb function of children and young people with LFD to that of unaffected peers. A cross-sectional study of Australian children and young people with LFD, and of unaffected peers, was undertaken. Twenty-three (12 males) children and young people with LFD (74% of those eligible) and 213 unaffected peers, all aged 7–21 years were subject to the Knee Osteoarthritis Outcome Score (KOOS/KOOS-Child) and the Cumberland Ankle Instability Tool (CAIT/CAIT-Youth). Linear regression models compared affected children and young people to unaffected peers. Participants with LFD scored lower in both outcomes (adjusted p < 0.05). The difference between participants with LFD and unaffected peers was significantly greater among younger participants than older participants for KOOS activities and sports domain scores (adjusted p ≤ 0.01). Differences in the other KOOS domains (pain/symptoms/quality of life) and ankle function (CAIT scores) were not affected by age (adjusted p ≥ 0.08). Children and young people with LFD on average report reduced lower limb function compared to unaffected peers. Knee-related activities and sports domains appear to be worse in younger children with LFD, and scores in these domains become closer to those of unaffected peers as they become older.

Side-to-Side Differences in Varus Thrust and Knee Abduction Moment in High-Functioning Individuals With Chronic Anterior Cruciate Ligament Deficiency

BACKGROUND

There is evidence that frontal plane knee joint motion plays a crucial role in the pathogenesis of knee osteoarthritis, yet investigation of individuals with chronic anterior cruciate ligament-deficient (ACLD) knees remains sparse.

PURPOSE

To investigate (1) if individuals with chronic ACLD knees demonstrate higher biomechanical measures of medial knee load as compared with their anterior cruciate ligament-intact (ACLI) knees, (2) if differences in static knee alignment of the ACLD knee will demonstrate a difference in the magnitude of biomechanical measures of medial knee load when compared with the ACLI knee, and (3) the side-to-side concordance of varus thrust among individuals with chronic ACLD knees.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Participants were sourced from a metropolitan orthopaedic surgeon group. Those who met the inclusion criteria and agreed to participate underwent a 3-dimensional gait analysis assessment to measure knee adduction moment (KAM), knee flexion moment (KFM), KAM peaks, KAM impulse, and varus thrust. Frontal plane knee static alignment was measured with a digital inclinometer fixed to medical calipers. The participants were divided according to their static knee alignment (neutral, varus, and valgus) for subgroup analysis. Peak knee angular velocity and frontal plane knee angle were used to establish if a participant was walking with a knee thrust. An individual was deemed to have knee thrust during gait if the largest frontal plane knee movement coincided with the peak knee angular velocity that occurred within the first 30% of stance phase.

RESULTS

Forty-five participants were recruited. The mean (SD) time from injury was 34.5 (55.6) months. ACLD knees did not demonstrate higher mean KAM and KFM ( P > .5) or early-stance peak KAM ( P = .3-.8) and KAM impulse ( P = .3-.9) as compared with ACLI knees as a whole group or when the varus, neutral, and valgus alignment subgroups were investigated separately. Twenty-three percent (n = 9) of the participants had a varus thrust at the ACLD or ACLI knee, 44% (n = 4) had a varus thrust at the ACLD knee, and 22% (n = 2) had varus thrust at both knees.

CONCLUSION

There were no side-to-side differences in mean KAM and KFM and early-stance peak KAM and KAM impulse among high-functioning individuals with chronic unilateral ACLD knees. There was a low prevalence of varus thrust among high-functioning individuals with chronic unilateral ACLD knees.

Psychometric properties of the Chinese version of the spiritual care-giving scale (C-SCGS) in nursing practice

Background

Spiritual care is defined as recognizing and responding to the needs of the human spirit when the individual is facing trauma, illness, or sadness. Providing spiritual care is one of the core aspects of holistic care, as it is significantly associated with patients’ quality of life. The provision of optimal spiritual care requires good understanding by the nurses. Therefore, it is important to assess this understanding by using a proven, well-validated instrument. The Spiritual Care-Giving Scale (SCGS) is designed to measure nurses’ perceptions of spirituality and spiritual care in Singapore. However, it is unknown whether this scale is valid and reliable for use with nurses in the context of Chinese culture. The purpose of this study is to determine this version’s validity and reliability for use with nurses in China.

Methods

In this quantitative, descriptive, cross-sectional study, after translating the English version of the SCGS into Chinese and making adjustments for culture and values, we assessed the performance of this instrument by administering the C-SCGS to a convenience sample of 400 nurses. The participants also completed the Chinese version of the Spiritual Care Competency Scale (C-SCCS) to assess the concurrent validity of the C-SCGS. The internal consistency and homogeneity of the C-SCGS were also tested, and a factorial analysis was performed.

Results

Completed questionnaires were obtained from 355 participants (response rate: 88.75%). Four factors were confirmed by an exploratory factor analysis (EFA) using Promax with the Kaiser normalization rotation method after the 35-item SCGS was reduced to 34 items, and these factors explained 53.116% of the total variance. The adjusted item–total correlation ranged from 0.527 to 0.760. The Cronbach’s alpha of the factors ranged from 0.836 to 0.941, and the Guttman split-half coefficient was between 0.759 and 0.902. The concurrent validity of the C-SCGS and C-SCCS (r = 0.534, p < 0.01) showed a significant correlation. Nurses’ education showed a significant association with the scores of the C-SCGS.

Conclusion

The C-SCGS was found to be a psychometrically sound measurement to evaluate Chinese-speaking nurses’ perceptions of spirituality and spiritual care.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0662-7) contains supplementary material, which is available to authorized users.

Validity, Reliability, and Responsiveness of the Banff Patellar Instability Instrument (BPII) in a Adolescent Population

BACKGROUND

Health-related quality of life measures for the adolescent patellar instability population are limited. The Banff Patella Instability Instrument (BPII) is a disease-specific health-related quality of life that has been tested on a mixed adult and adolescent population but has not been exclusively tested with an adolescent population. The purpose of this study was to determine the validity, reliability, and responsiveness of the BPII within an adolescent population.

METHODS

Content validation was tested with 3 measures: floor and ceiling effects; the Cronbach alpha; readability grade level. Reliability was measured with an intraclass correlation coefficient (2, k) and the SEM. Responsiveness was measured using a 1-way analysis of variance comparing preoperative BPII scores to postoperative BPII scores at 6, 12, and 24 months. Eta squared was calculated to measure effect size.

RESULTS

The BPII demonstrated no floor or ceiling effects. The Cronbach alpha for the BPII ranged from 0.97 to 0.98 for the preoperative and postoperative time periods. The readability index was a mean grade level of 8.9. Test-retest reliability assessment demonstrated an intraclass correlation coefficient (2, k) of 0.99 indicating strong reliability. The SEM was 1.3. There was a statistically significant difference in BPII scores for the 4 different time interval measures (F3, 176=50.04; P<0.001). Eta squared was 0.46 demonstrating a moderate to large effect.

CONCLUSIONS

The BPII demonstrated validity, reliability, and responsiveness in an adolescent population. Furthermore, it has demonstrated an appropriate cognitive reading grade level of 8.9, commensurate with the mean age (16.08 y) of the population tested.

LEVEL OF EVIDENCE

Level III.

Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial

BACKGROUND

A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment.

PURPOSE

(1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years.

RESULTS

The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation.

CONCLUSION

Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).

Validity and comprehensibility of outcome measures in children with shoulder and elbow disorders: creation of a new Pediatric and Adolescent Shoulder and Elbow Survey (Pedi-ASES)

BACKGROUND

Valid patient-reported outcomes (PROs) for the shoulder and elbow do not exist for children. We assessed children's comprehension of the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form, identified response errors, and modified items to create a new pediatric shoulder and elbow PRO.

METHODS

We recruited 50 children (aged 10-18 years) with shoulder or elbow disorders from a children's hospital-based orthopedic clinic for this qualitative study. A trained researcher conducted cognitive interviews to identify children's comprehension of PROs. In phase 1, 40 children were purposefully sampled on the basis of age and gender, interviewed, and audiotaped. A behavioral scientist analyzed transcripts, modified items, and created the Pediatric and Adolescent Shoulder and Elbow Survey (Pedi-ASES). In phase 2, 10 children were interviewed to gather feedback on and to refine the Pedi-ASES.

RESULTS

The average interview time was 25 minutes (range, 17-44 minutes). There were 242 comments generated about the QuickDASH; 51% of children struggled with complex terminology, and 35% did not understand "tingling." Children generated 309 comments about the ASES, primarily associated with narcotic medications (65%) and shoulder instability (42%). Time frame and format issues were noted. In phase 2, children found the new PRO easier to comprehend and answer.

CONCLUSIONS

Modifications were needed in general instruction, language, format, and response mapping in the original PROs. Children had few difficulties with the Pedi-ASES. Designing PROs that are specific to children will enable researchers and clinicians to more accurately assess health status and clinical outcomes.

Long-term follow-up after bilateral percutaneous epiphysiodesis around the knee to reduce excessive predicted final height

CONTEXT

Percutaneous epiphysiodesis (PE) around the knee to reduce predicted excessive final height. Studies until now included small numbers of patients and short follow-up periods.

OBJECTIVE AND DESIGN

This Dutch multicentre, long-term, retrospective, follow-up study aimed to assess adult height (AH), complications, knee function and patient satisfaction after PE. The primary hypothesis was that PE around the knee in constitutionally tall boys and girls is an effective treatment for reducing final height with low complication rates and a high level of patient satisfaction.

PARTICIPANTS

77 treated adolescents and 60 comparisons.

INTERVENTION

Percutaneous epiphysiodesis.

OUTCOME

AH, complications, knee function, satisfaction.

RESULTS

In the PE-treated group, final height was 7.0 cm (±6.3 cm) lower than predicted in boys and 5.9 cm (±3.7 cm) lower than predicted in girls. Short-term complications in file search were seen in 5.1% (three infections, one temporary nerve injury), one requiring reoperation. Long-term complications in file search were seen in 2.6% (axis deformity 1.3%, prominent head of fibula 1.3%). No significant difference in knee function was found between treated cases and comparisons. Satisfaction was high in both the comparison and PE groups; most patients in the PE group recommended PE as the treatment for close relatives with tall stature.

CONCLUSION

PE is safe and effective in children with predicted excessive AH. There was no difference in patient satisfaction between the PE and comparison group. Careful and detailed counselling is needed before embarking on treatment.

Measurement Properties of a Test Battery to Assess Postural Orientation During Functional Tasks in Patients Undergoing Anterior Cruciate Ligament Injury Rehabilitation

Study Design Cross-sectional study. Background Visual rating of postural orientation during functional tasks may be a valuable tool to track rehabilitation progress following anterior cruciate ligament (ACL) injury. A valid test battery assessing postural orientation as a separate construct is lacking. Objectives To evaluate measurement properties of a test battery to assess postural orientation in patients with ACL injury. Methods The content validity of functional tasks was assessed by expert focus group discussions. Fifty-one patients (45% women) with ACL injury performed 9 functional tasks of varying difficulty. Interpretability, internal consistency, interrater reliability, and measurement error were assessed for segment-specific postural orientation errors (POEs), within-task POEs, and total POE score. Postural orientation errors were scored on video on an ordinal scale from 0 (no POEs) to 3 (major POEs). Results Stair ascent, deep squat, and crossover hop for distance were excluded in focus group discussions. Postural orientation errors in some tasks were excluded due to floor effects. The mini-squat and drop jump were excluded due to poor internal consistency (α≤.184). Interrater reliability values for segment-specific POEs and within-task POEs yielded fair to almost perfect agreement (κ = 0.429-0.875) and almost perfect agreement for total POE score (intraclass correlation coefficient = 0.842), without systematic differences between raters. The smallest detectable changes were 0.7 and 5 points for groups and individuals, respectively. Conclusion The final test battery (single-leg mini-squat, stair descent, forward lunge, single-leg hop for distance) of 4 POEs (foot pronation, medial knee-to-foot position, hip joint POEs, and trunk segment POEs) demonstrated good measurement properties in people with ACL injury. J Orthop Sports Phys Ther 2017;47(11):863-873. doi:10.2519/jospt.2017.7270.

Hypermobility in Adolescent Athletes: Pain, Functional Ability, Quality of Life, and Musculoskeletal Injuries

Study Design Cross-sectional. Background Generalized joint hypermobility (GJH) may increase pain and likelihood of injuries and also decrease function and health-related quality of life (HRQoL) in elite-level adolescent athletes. Objective To assess the prevalence of GJH in elite-level adolescent athletes, and to study the association of GJH with pain, function, HRQoL, and musculoskeletal injuries. Methods A total of 132 elite-level adolescent athletes (36 adolescent boys, 96 adolescent girls; mean ± SD age, 14.0 ± 0.9 years), including ballet dancers (n = 22), TeamGym gymnasts (n = 57), and team handball players (n = 53), participated in the study. Generalized joint hypermobility was classified by Beighton score as GJH4 (4/9 or greater), GJH5 (5/9 or greater), and GJH6 (6/9 or greater). Function of the lower extremity, musculoskeletal injuries, and HRQoL were assessed with self-reported questionnaires, and part of physical performance was assessed by 4 postural-sway tests and 2 single-legged hop-for-distance tests. Results Overall prevalence rates for GJH4, GJH5, and GJH6 were 27.3%, 15.9%, and 6.8%, respectively, with a higher prevalence of GJH4 in ballet dancers (68.2%) and TeamGym gymnasts (24.6%) than in team handball players (13.2%). There was no significant difference in lower extremity function, injury prevalence and related factors (exacerbation, recurrence, and absence from training), HRQoL, or lengths of hop tests for those with and without GJH. However, the GJH group had significantly larger center-of-pressure path length across sway tests. Conclusion For ballet dancers and TeamGym gymnasts, the prevalence of GJH4 was higher than that of team handball players. For ballet dancers, the prevalence of GJH5 and GJH6 was higher than that of team handball players and the general adolescent population. The GJH group demonstrated larger sway in the balance tests, which, in the current cross-sectional study, did not have an association with injuries or HRQoL. However, the risk of having (ankle) injuries due to larger sway for the GJH group must be studied in future longitudinal studies. J Orthop Sports Phys Ther 2017;47(10):792-800. doi:10.2519/jospt.2017.7682.

Self-reported knee pain and disability among healthy individuals: reference data and factors associated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child

OBJECTIVE

To develop normative reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child, as well as investigate socio-demographic, psychological and physical factors associated with knee pain and disability among healthy adults.

METHOD

The KOOS or KOOS-Child (each containing five subscales) was administered to participants aged 8-101 years within the 1000 Norms Project, an observational study of 1000 self-reported healthy individuals. Self-efficacy, physical activity, body mass index (BMI), lower limb alignment, knee frontal plane projection angle (FPPA), knee range of motion (ROM), knee and hip strength, six-minute walk, 30-second chair stand and timed up and down stairs tests were collected. KOOS data were dichotomised using established cut-off scores and logistic regression analyses were conducted for each subscale.

RESULTS

Socio-demographic characteristics were similar to the Australian population. Normative reference data were generated for children (8-17 years) and adults (18-101 years). Female adults were up to twice as likely to report knee pain, symptoms and sport/recreation (Sport/Rec) limitations compared to males (P < .05). Older age, lower self-efficacy, greater BMI, varus lower limb alignment, lower knee flexion ROM and lower hip external rotation (ER) strength were independently associated with knee pain and disability among adults.

CONCLUSIONS

Age- and gender-stratified reference data for the KOOS and KOOS-Child have been developed to guide interpretation of results in practice and research for individuals with knee disorders. Psychological and physical factors are linked with self-reported knee pain/disability among adults, and longitudinal studies to investigate causation are required.

Validity and Comprehensibility of Physical Activity Scales for Children With Sport Injuries

BACKGROUND

Adult physical activity scales are used with children but may not be valid in this population. This study assesses the appropriateness and comprehensibility of currently used physical activity scales in children, identifies sources of response errors, and suggests scale modifications.

METHODS

Cognitive interviews were conducted with 30 children who had a lower extremity injury, purposefully sampled based on age and sex. Interviews were conducted to identify children's comprehension of 6 physical activity questionnaires: Tegner activity scale, Cincinnati Knee Rating System, KOOS-Child, Marx activity scale, HSS Pedi-FABS, and KOS sports activity scale.

RESULTS

The Tegner scale uses complex activity level descriptions (eg, competitive vs. recreational sports, types of sports and inclusion of work-related physical activity). Activity frequency, description of movement, and sport type in the Cincinnati Knee Rating System led to response mapping issues in many children. Most children felt the KOOS-Child pictures depicting activities were helpful, but not all found the 7-day timeframe relevant. Whereas, most children found the Marx scale and HSS Pedi-FABS items clear, concise, and easy to answer. Children reported difficulties differentiating between endurance and duration items used in the HSS Pedi-FABS. The consistent response format of the KOS sports activity scale was considered a positive attribute although children had trouble comprehending terms such as grating and grinding.

CONCLUSIONS

Children found some scales too difficult to answer, whereas others required modifications, particularly in general instruction, language, question format, and mapping (matching an answer to potential options) to adapt to the specific needs of children.

LEVEL OF EVIDENCE

Level II.

The ESSKA paediatric anterior cruciate ligament monitoring initiative

PURPOSE

To survey and describe the treatment of paediatric anterior cruciate ligament (ACL) injuries performed by orthopaedic surgeons affiliated with the European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

METHODS

A closed e-survey was submitted to all registered members and affiliates of ESSKA in July 2013. All recipients were invited to participate in the survey by answering 34 questions online. The list of potential respondents was extracted from the ESSKA office database.

RESULTS

Invitation was sent to 2236 ESSKA members and affiliates, and received 491 (22%) unique responses. Among the respondents, 445 (91%) were orthopaedic surgeons, with 354 (72%) stating that they were involved in treatment of paediatric ACL injuries. The main findings were that there are substantial differences with regard to preferred treatment algorithms, surgical techniques and long-term follow-up procedures. The summed estimate of skeletally immature children with ACL injury seen by the responders in 2012 was minimum 1923 individuals, and a minimum of 102 clinically relevant post-operative growth disturbances were registered.

CONCLUSION

The present survey documents that the incidences of paediatric ACL injuries and idiopathic growth disturbances may be higher than previously estimated. Treatment algorithms and surgical techniques are highly diverse, and consensus could not be identified. It is worrying that only half the surgeons reported to follow-up children until skeletal maturity after surgical treatment. The results of this survey highlight the importance of international multicentre studies on paediatric ACL treatment and the development of an outcome registry to enable prospective data collections.

LEVEL OF EVIDENCE

IV.

Examining the Minimal Important Difference of Patient-reported Outcome Measures for Individuals with Knee Osteoarthritis: A Model Using the Knee Injury and Osteoarthritis Outcome Score

Objective.

To examine the influence of different analytical methods, baseline covariates, followup periods, and anchor questions when establishing a minimal important difference (MID) for individuals with knee osteoarthritis (OA). Second, to propose MID for improving and worsening on the Knee injury and Osteoarthritis Outcome Score (KOOS).

Methods.

Retrospective analysis of prospectively collected data from 272 patients with knee OA undergoing a multidisciplinary nonsurgical management strategy. The magnitude and rate of change as well as the influence of baseline covariates were examined for 5 KOOS subscales over 52 weeks. The MID for improving and worsening were investigated using 4 anchor-based methods.

Results.

Waitlisted for joint replacement and exhibiting unilateral/bilateral symptoms influenced change in KOOS over time. Generally, low correlations between anchors and KOOS change scores limited calculations of MID; thus, they were only proposed for the pain, activities of daily living, and quality of life subscales. The method used to calculate the MID influenced the cutpoint; however, the type of anchor question only influenced the MID when analyzed with a particular mean change method. Depending on patient and clinical characteristics, the subscale, and the analytical approach used, the MID for KOOS improvement ranged from an absolute change of −1.5 to 20.6 points and worsening ranged from −19.17 to 8.5 points.

Conclusion.

MID vary with patient and clinical characteristics, KOOS subscale, and analytical approach. Provided the anchor question is relevant to the patient-reported outcome and baseline status is considered, the anchor does not appear to influence the MID for improvement or worsening when using some anchor-based methods.

Girls with generalized joint hypermobility display changed muscle activity and postural sway during static balance tasks

OBJECTIVES

To study knee muscle activity and static postural sway in girls with generalized joint hypermobility (GJH).

METHOD

Sixteen girls with GJH and 11 girls with non-GJH (NGJH) aged 14 years, randomly recruited among schoolchildren, participated in this study. GJH inclusion criteria were: Beighton score minimum 6/9 and one hypermobile knee; for NGJH: Beighton score maximum 5/9 and no knees with hypermobility. The participants performed a static two-legged balance test with eyes open (2EO) and eyes closed (2EC) and a one-legged stance test with eyes open (1EO). Postural sway (centre of pressure path length, COPL) was calculated, along with rambling and trembling components. Surface electromyography (sEMG) from the quadriceps (Q), hamstrings (H), and gastrocnemius (G) muscles was recorded, expressed as a percentage of the maximum voluntary EMG (%MVE), and the co-contraction index (CCI) of Q, H, and G muscle activity was calculated. Knee function was self-reported using the Knee Injury and Osteoarthritis Outcome Score for children (KOOS-Child).

RESULTS

GJH had a significantly lower lateral HQ CCI and a higher medial/lateral HQ CCI ratio in all balance tasks. Group mean EMG varied from 1.3%MVE in Q (during 2EO) to 15.7%MVE in G (during 1EO). GJH had larger postural sway length than NGJH during 2EC (COPL 1.64 vs. 1.37 m/min, p < 0.001). Rambling and trembling components did not differ between groups.

CONCLUSIONS

Girls with GJH and at least one hypermobile knee performed, compared with NGJH, static balance tasks with higher medial knee muscle activity relative to the lateral activity, and larger postural sway when vision was eliminated. The short- and long-term consequences should be studied further.