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Sun B, Vivekanantha P, Khalik HA, de Sa D. Several factors predict the achievement of the patient acceptable symptom state and minimal clinically important difference for patient-reported outcome measures following anterior cruciate ligament reconstruction: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39248212 DOI: 10.1002/ksa.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 09/10/2024]
Abstract
PURPOSE To summarize the predictors of the patient acceptable symptom state (PASS), minimal clinically important difference (MCID) and minimal important change (MIC) for patient-reported outcome measures (PROMs) following anterior cruciate ligament reconstruction (ACLR). METHODS MEDLINE, PubMed and Embase were searched from inception to 5 January 2024. The authors adhered to PRISMA/R-AMSTAR guidelines, and the Cochrane Handbook for Systematic Reviews of Interventions. Data on statistical associations between predictive factors and PROMs were extracted. Inverse odds ratios (ORs) and confidence intervals (reverse group comparison) were calculated when appropriate to ensure comparative consistency. RESULTS Thirteen studies comprising 21,235 patients (48.1% female) were included (mean age 29.3 years). Eight studies comprising 3857 patients identified predictors of PASS, including lateral extra-articular tenodesis (LET) (OR = 11.08, p = 0.01), hamstring tendon (HT) autografts (OR range: 2.02-2.63, p ≤ 0.011), age over 30 (OR range: 1.37-2.28, p ≤ 0.02), male sex (OR range: 1.03-1.32, p ≤ 0.01) and higher pre-operative PROMs (OR range: 1.04-1.21). Eight studies comprising 18,069 patients identified negative predictors of MCID or MIC, including female sex (OR = 0.93, p = 0.034), absence of HT autografts (OR = 0.70, p < 0.0001), higher pre-operative PROMs (OR = 0.76-0.84, p ≤ 0.01), meniscectomy (OR = 0.67, p = 0.014) and collision sports (OR = 0.02-0.60, p ≤ 0.05). CONCLUSION Higher pre-operative PROMs, age over 30, male sex, LETs and HT autografts predicted PASS achievement. Lower pre-operative PROMs, male sex, non-collision sports, and lack of meniscectomies predicted MCID/MIC achievement. This review provides a comprehensive understanding of the predictors of clinically significant post-ACLR outcomes, thus improving clinical decision-making and the management of patient expectations. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Bryan Sun
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Prushoth Vivekanantha
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Hetsroni I, Mann G, Arami E, van Stee M, Marom N, Ohana N. Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling. J ISAKOS 2024; 9:540-548. [PMID: 38580054 DOI: 10.1016/j.jisako.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE To compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. METHODS Ninety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value < 0.05 indicated statistical significance. RESULTS Forty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5-10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ± 1.9 mm vs. 2.8 ± 2.3 mm (p < 0.01), pivot shift grade 2-3 in 4% vs. 34% (p < 0.01), return to preinjury Tegner level in 51% vs. 36% (p = 0.1) and to preinjury Marx score in 29% vs. 11% (p = 0.02), and IKDC-subjective 88 ± 10 vs. 82 ± 13 vs (p < 0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r = -0.314, p < 0.01; r = -0.263, p < 0.01; r = -0.218, p = 0.03, respectively). CONCLUSION Young men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. LEVEL OF EVIDENCE III (Retrospective cross-sectional comparative study).
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Affiliation(s)
- Iftach Hetsroni
- Department of Orthopedic Surgery, Meir Medical Center, Kfar Saba 44281, Israel; Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv 69978, Israel.
| | - Gideon Mann
- Department of Orthopedic Surgery, Meir Medical Center, Kfar Saba 44281, Israel; Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv 69978, Israel.
| | - Eyal Arami
- Department of Orthopedic Surgery, Barzilai Medical Center, Ashkelon 7845637, Israel; The Joyce & Irving Goldman Faculty of Medicine, Ben-Gurion University of the Negev, Beer Sheva 8443944, Israel.
| | - Mischa van Stee
- Physiotherapy Service, Meir Medical Center, Kfar Saba 44281, Israel.
| | - Niv Marom
- Department of Orthopedic Surgery, Meir Medical Center, Kfar Saba 44281, Israel; Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv 69978, Israel.
| | - Nissim Ohana
- Department of Orthopedic Surgery, Meir Medical Center, Kfar Saba 44281, Israel; Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv 69978, Israel.
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Hoffer AJ, McConkey MO, Lodhia P, Leith JM. Not all patient-reported outcome measures are equivalent at two years compared to one year after anterior cruciate ligament reconstruction based on a retrospective analysis. J ISAKOS 2024; 9:510-518. [PMID: 38492849 DOI: 10.1016/j.jisako.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE This article aims to assess for clinically important differences in patient-reported outcome measures (PROMs) at one and two years post anterior cruciate ligament reconstruction (ACLR). METHODS A retrospective comparison of prospectively collected PROMs for a single cohort who underwent a primary ACLR with or without associated meniscal surgery from 2016 to 2020 was assessed. Six externally validated PROMs were collected preoperatively and at standardized times postoperatively. Descriptive statistics and paired equivalence testing of PROMs at one and two years after surgery was completed using previously published or calculated minimal clinically important differences as upper and lower equivalence limits. A repeated measures analysis of PROMs that were not clinically equivalent at one and two years after surgery was completed to assess for a clinically significant difference. Subgroup analyses based on sex, age and associated meniscal injury were completed. RESULTS One-hundred and forty-five participants with a mean age of 28.7 years (standard deviation: 9.9 years) were included in the final analysis. All PROMs were clinically equivalent at two years compared to one year after ACLR except the quality of life and sport and recreation domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The quality of life (mean difference (MD):12.3, P < 0.01, effect size (η2): 0.65) and sport and recreation (MD: 8.78, P < 0.01, η2: 0.50) domains of the KOOS were clinically different at two years compared to one year postoperatively. No major differences were found in the subgroup analyses compared to the entire included sample. CONCLUSION While most PROMs were equivalent at two years compared to one year after ACLR, the quality of life and sport and recreation domains of the KOOS, which reflect knee performance during higher demand activities, exhibited a clinically significant difference. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexander J Hoffer
- Department of Surgery, University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada.
| | - Mark O McConkey
- Department of Orthopaedics, Gordon and Leslie Diamond Health Care Centre 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Parth Lodhia
- Department of Orthopaedics, Gordon and Leslie Diamond Health Care Centre 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Jordan M Leith
- Department of Orthopaedics, Gordon and Leslie Diamond Health Care Centre 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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Raj S, Ridha A, Searle HKC, Khatri C, Ahmed I, Metcalfe A, Smith N. Quadriceps tendon versus hamstring tendon graft for primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised trials. Knee 2024; 49:226-240. [PMID: 39043018 DOI: 10.1016/j.knee.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/13/2024] [Accepted: 07/02/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is most commonly performed with hamstring tendon (HT) or bone-patellar tendon-bone (BTB) autografts, although the quadriceps tendon (QT) autograft has recently increased in popularity. This systematic review and meta-analysis review compares QT and HT autografts for primary ACLR with a sole focus on randomised controlled trials (RCTs). METHODS A prospective protocol was registered on PROSPERO (CRD42023427339). The search included MEDLINE, Embase and Web of Science until February 2024. Only comparative RCTs were included. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score. Secondary outcomes included: other validated patient-reported outcome measures (PROMs), objective strength scores, complications, and return to sport and work. RESULTS From 2,609 articles identified, seven were included (n = 474 patients). This meta-analysis did not identify a significant difference in post-operative IKDC scores (5 articles; p = 0.73), Lysholm scores (3 studies; p = 0.80) or Tegner activity scales (2 studies; p = 0.98). There were no differences in graft failure rates (4 studies; p = 0.92) or in overall adverse events (4 studies; p = 0.83) at 24 months post-ACLR as per meta-analysis. Donor site morbidity scores were significantly lower in the QT group (MD -4.67, 95% CI -9.29 to -0.05; 2 studies, 211 patients; p = 0.05, I2 = 34%). CONCLUSION There were no differences between QT and HT in PROMs, graft failure rates or overall complications based on low- to moderate-quality evidence. There may possibly be lower donor site morbidity with the QT autograft, however, the evidence is not sufficient to draw definitive conclusions.
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Affiliation(s)
- Siddarth Raj
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom.
| | - Ali Ridha
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Henry K C Searle
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Chetan Khatri
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Imran Ahmed
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Andrew Metcalfe
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Nicholas Smith
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
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Giusto JD, Cohen D, Dadoo S, Grandberg C, Lott A, Hughes JD, Ayeni OR, Musahl V. Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: A systematic review and economic analysis. J ISAKOS 2024; 9:689-698. [PMID: 38604570 DOI: 10.1016/j.jisako.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
IMPORTANCE Anterolateral augmentation during primary anterior cruciate ligament (ACL) reconstruction (ACLR) may lower rates of ACL graft failure. However, differences in costs between two techniques, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are unclear. OBJECTIVE To perform a systematic review and subsequent cost-effectiveness analysis comparing LET versus ALLR in the setting of primary ACLR. The hypothesis was that LET is more cost-effective than ALLR. EVIDENCE REVIEW A systematic review was conducted on studies in which patients underwent primary ACLR with a concomitant LET or ALLR with minimum 24 months follow-up published between January 2013 and July 2023. Primary outcomes included ACL graft failure rates and Knee Injury and Osteoarthritis Outcome Survey-Quality of Life (KOOS-QoL) subscale scores, which were used to determine health utilities measured by quality-adjusted life years (QALYs) gained. A decision tree model with one-way and two-way sensitivity analyses compared the cost of primary ACLR with a concomitant LET, independent autograft ALLR, or independent allograft ALLR. Costs were estimated using a combination of QALYs, institution prices, literature references, and a survey sent to 49 internationally recognized high-volume knee surgeons. FINDINGS A total of 2505 knees undergoing primary ACLR with concomitant LET (n=1162) or ALLR (n=1343) were identified from 22 studies. There were 77 total ACL graft failures with comparable failure rates between patients receiving LET versus ALLR (2.9% vs. 3.2%, P=0.690). The average QALYs gained was slightly higher for those who received LET (0.77) compared to ALLR (0.75). Survey results revealed a 5 minute longer median self-reported operative time for ALLR (20 min) than LET (15 min). The estimated costs for LET, autograft ALLR, and allograft ALLR were $1,015, $1,295, and $3,068, respectively. CONCLUSIONS AND RELEVANCE Anterolateral augmentation during primary ACLR with LET is more cost-effective than independent autograft and allograft ALLR given the lower costs and comparable clinical outcomes. Surgeons may utilize this information when determining the optimal approach to anterolateral augmentation during primary ACLR, although differences in preferred technique and health care systems may influence operative efficiency and material costs. LEVEL OF EVIDENCE Systematic review; Level of evidence, IV.
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Affiliation(s)
- Joseph D Giusto
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Dan Cohen
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
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Dan Milinkovic D, Schmidt S, Fluegel J, Gebhardt S, Zimmermann F, Balcarek P. Preoperative subjective assessment of disease-specific quality of life significantly influenced the likelihood of achieving the minimal clinically important difference after surgical stabilization for recurrent lateral patellar instability. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39031883 DOI: 10.1002/ksa.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 07/22/2024]
Abstract
PURPOSE To evaluate which factors exert a predictive value for not reaching the minimal clinically important difference (MCID) in patients who underwent a tailored operative treatment for recurrent lateral patellar dislocation (RLPD). METHODS A total of 237 patients (male/female 71/166; 22.4 ± 6.8 years) were included. The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) and subjective rating of knee function and pain (numeric analogue scale [NAS]; 0-10) were used to evaluate patients' outcomes from pre- to postoperatively. Gender, age at the time of surgery, body mass index (BMI), nicotine abuse, psychiatric diseases, cartilage status and pathoanatomic risk factors were evaluated as potential predictors for achieving the MCID using univariate logistic regression analysis. RESULTS The MCID for the BPII 2.0 was calculated at 9.5 points. Although the BPII 2.0 and NAS for knee function and pain improved significantly in the total cohort from pre- to postoperatively (all p < 0.001), 29 patients did not reach the MCID at the final follow-up. The analysis yielded that only the preoperative NAS for function and BPII 2.0 score values were significant predictors for reaching the MCID postoperatively. The optimal threshold was calculated at 7 (NAS function) and 65.2 points (BPII 2.0). Age at the time of surgery should be considered for patients with a preoperative BPII 2.0 score >62.5. CONCLUSION The probability of reaching BPII 2.0 MCID postoperatively depends only on the preoperative BPII 2.0 value and subjective rating of knee function, as well as age at the time of surgery for patients undergoing surgical treatment of RLPD. Here, presented results can assist clinicians in advising and presenting patients with potential outcomes following treatment for this often complex and multifactorial pathology. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Danko Dan Milinkovic
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | | | | | - Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation, University of Greifswald, Greifswald, Germany
| | - Felix Zimmermann
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany
- Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, University Medicine Göttingen, Göttingen, Germany
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Gopinatth V, Garcia JR, Reid IK, Knapik DM, Verma NN, Chahla J. Blood Flow Restriction Enhances Recovery After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy 2024:S0749-8063(24)00416-X. [PMID: 38889851 DOI: 10.1016/j.arthro.2024.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating neuromuscular and clinical outcomes of blood flow restriction (BFR) training after anterior cruciate ligament reconstruction (ACLR) compared with non-BFR rehabilitation protocols. METHODS A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic reviews and Meta Analyses guidelines by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials databases from inception through December 2023 to identify Level I and II RCTs evaluating outcomes of BFR training after ACLR compared with non-BFR rehabilitation. A meta-analysis was performed using random-effects models with standardized mean difference (SMD) for pain, muscle strength, and muscle volume, whereas mean difference was calculated for patient-reported outcome measures. RESULTS Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation compared with 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with most patients being male (63.3%, n = 138/218). The length of the BFR rehabilitation protocol was most commonly between 8 and 12 weeks (range, 14 days to 16 weeks). Most studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared with non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, P = .02, I2: 58%), International Knee Documentation Committee score (mean difference: 10.97, P ≤ .00001, I2: 77%), and pain (SMD: 1.52, P = .04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, P = .43, I2: 76%). CONCLUSIONS The use of BFR after ACLR led to improvements in pain, International Knee Documentation Committee score, and isokinetic muscle strength, with variable outcomes on the basis of quadriceps strength, volume, and thickness when compared with non-BFR rehabilitation. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of Level I and II studies.
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Affiliation(s)
- Varun Gopinatth
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jose R Garcia
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Isabel K Reid
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A..
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Kaur M, Chmielewski TL, Saliba S, Hart J. How Does Physical and Psychological Recovery Vary Among Competitive and Recreational Athletes After Anterior Cruciate Ligament Reconstruction? Sports Health 2024:19417381241249413. [PMID: 38736252 DOI: 10.1177/19417381241249413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND The recovery and rehabilitation journey after anterior cruciate ligament reconstruction (ACLR) surgery can be different for competitive and recreational athletes as their motivation and goals toward sports are different. HYPOTHESIS Competitive athletes would present with better patient-reported outcomes and higher muscle strength compared with recreational athletes postsurgery. Second, competitive athletes would recover better (patient-reported outcome [PRO] measures and muscle strength) compared with recreational athletes at later stages. STUDY DESIGN Cross-sectional laboratory-based study. LEVEL OF EVIDENCE Level 2. METHODS A total of 245 patients with unilateral ACLR were categorized as competitive or recreational athletes and grouped into early (4-6.9 months) or late (7-10 months) stages of recovery. PRO were collected for psychological response (Tampa Scale Kinesiophobia; Anterior Cruciate Ligament-Return to Sport after Injury), perceived knee function (International Knee Documentation Committee subjective form [IKDC]), and quality of life (Knee injury and Osteoarthritis Outcome Score; Veteran Rand-12). Isokinetic, concentric knee extension strength was measured bilaterally with a multimodal dynamometer (System 4, Biodex Medical Systems) at a speed of 90° and 180°/s. RESULTS Competitive athletes had significantly higher scores for IKDC (P = 0.03), and quadriceps peak torque at 90°/s (P = 0.01) and 180°/s (P < 0.01) compared with recreational athletes. Competitive athletes had higher quadriceps strength at 90°/s (P < 0.01) and 180°/s (P = 0.02) in the late group. Recreational athletes displayed higher sports participation in the late group. CONCLUSION Outcomes of ACLR may differ based on preinjury athletic level. Whereas competitive athletes had higher knee and muscle function than recreational athletes, psychological measures were not different among groups. CLINICAL RELEVANCE There is a need for more individualized care for patients with ACLR since there is variability among patient goals postsurgery. This information might help set realistic expectations for competitive and recreational athletes after surgery.
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Affiliation(s)
- Mandeep Kaur
- School of Health Professions, Department of Physical Therapy and Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas
| | | | - Susan Saliba
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia
| | - Joe Hart
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, North Carolina
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Qiu J, Ong MTY, Choi CY, He X, Lau LCM, Fu SC, Fong DTP, Yung PSH. Associations of patient characteristics, rate of torque development, voluntary activation of quadriceps with quadriceps strength, and knee function before anterior cruciate ligament reconstruction. Res Sports Med 2024; 32:491-503. [PMID: 36254570 DOI: 10.1080/15438627.2022.2132860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/28/2022] [Indexed: 10/24/2022]
Abstract
Good preoperative knee function (KF) and quadriceps strength (QS) relate to good prognoses after anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate the associations between patient characteristics, rate of torque development (RTD), voluntary activation (VA) of the quadriceps against preoperative KF and QS. A cross-sectional study was conducted. Forty patients with a primary, unilateral ACL injury who had finished the preoperative rehabilitation and scheduled for an ACLR were included. KF was evaluated using the International Knee Documentation Committee score. QS was measured by maximal voluntary isometric contractions. RTD was divided into the early (RTD0-50) and the late (RTD100-200) phases. Quadriceps VA was measured using the superimposed burst technique. Our results showed that patients with poor preoperative KF had more deficits in RTD0-50 (P = 0.025), higher BMI(P = 0.043), and more meniscus injuries (MI) (P = 0.001) than those with good KF. Patients with asymmetrical QS showed lower BMI (P = 0.020) and shorter time from injury (TFI) (P = 0.027) than those with symmetrical QS. Additionally, a higher pre-injury Tegner score combined with greater RTD100-200 contributed to greater QS on the injured limb (R2 = 0.357, P = 0.001). To conclude, BMI, TFI, concomitant MI, pre-injury physical activity level, and quadriceps RTD are related to QS and KF before ACLR.
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Affiliation(s)
- Jihong Qiu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michael Tim-Yun Ong
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi-Yin Choi
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xin He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lawrence Chun-Man Lau
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Bram JT, Stevens AC, Greenberg E, DeFrancesco CJ, Gans I, Parisien RL, Ganley TJ. Postoperative Strength Differences at Short-Term Follow-Up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:1591-1598. [PMID: 37898305 DOI: 10.1016/j.arthro.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft. METHODS This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts. RESULTS A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36). CONCLUSIONS There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic study.
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Affiliation(s)
- Joshua T Bram
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Alexandra C Stevens
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Elliot Greenberg
- Department of Physical Therapy, Specialty Care and Surgery Center, Bucks County, The Children's Hospital of Philadelphia, Chalfont, Pennsylvania, U.S.A
| | - Christopher J DeFrancesco
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Itai Gans
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Robert L Parisien
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Theodore J Ganley
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A..
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11
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Daniel AV, Sheth CD, Shubert DJ, Smith PA. Primary Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: A Case Series of 252 Patients. J Knee Surg 2024; 37:381-390. [PMID: 37451280 DOI: 10.1055/a-2129-8893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) using suture tape augmentation to internally brace is a relatively new technique. The primary goal of this study was to prospectively collect patient-reported outcomes (PROs) and surgical history from patients who underwent primary ACLR with internal bracing to determine if internal bracing resulted in a low graft failure rate while maintaining acceptable PROs. A total of 252 patients with a mean age of 23.6 years (95% confidence interval [CI]: 22.1-25.1) and a mean follow-up of 37.9 months (95% CI: 35.8-40.0) were included in this study. Patients who underwent primary ACLR with internal brace augmentation between July 12, 2016 and July 31, 2021 were eligible. A total of 222 patients were contacted via telephone and administered the visual analog scale (VAS), the single assessment numeric evaluation (SANE), the Lysholm knee score scale, and, if applicable, the short version ACL return to sport after injury (SV-ACL-RSI) survey. Additionally, patients were asked to give an updated orthopaedic history. Thirty additional patients were included from either our institution's registry or by completing their surveys in-office or by e-mail. The minimal clinically important difference (MCID) and patient-acceptable symptom states (PASS) were calculated based on our patient population and applied to each individual patient. The patients' electronic health record (EHR) was searched for pre- and postoperative clinical data including KT-1000 arthrometer measurements. Two patients (0.8%) had subsequent graft failures and one patient (0.4%) required a revision surgery. MCID was achieved in 242 patients (96.0%) for the Lysholm, 227 patients (90.1%) for the SANE, and 146 patients (57.9%) for the VAS. PASS was achieved in 214 patients (84.9%) for the Lysholm, 198 patients (78.6%) for the SANE, and 199 (80.0%) patients for the VAS, postoperatively. Of note, 65 patients (25.8%) exceeded the PASS threshold for the VAS preoperatively. A total of 127 patients (84.4%) met the cutoff of ≥60/100 for the SV-ACL-RSI survey postoperatively. Postoperative KT-1000 measurements showed near-identical side-to-side differences at both the 13.6-kg pull and manual maximum pull. When stratifying patients based on age at the time of surgery, it was noted that patients younger than 25 years had significantly higher SANE scores (91.6 [95% CI: 90.2-92.9] vs. 82.6 [95% CI: 79.0-86.2]; p < 0.0001) and lower VAS pain scores (0.7 [95% CI: 0.5-0.8] vs. 1.2 [95% CI: 0.8-1.5]; p = 0.004). Primary ACLR with internal bracing led to acceptable patient outcomes and a graft failure rate of less than 1%. LEVEL OF EVIDENCE:: case series, IV.
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Affiliation(s)
- Adam V Daniel
- Department of Orthopaedic Surgery, Columbia Orthopaedic Group, Columbia, Missouri
| | - Chirag D Sheth
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, Missouri
| | - Daniel J Shubert
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, Missouri
| | - Patrick A Smith
- Department of Orthopaedic Surgery, Columbia Orthopaedic Group, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, Missouri
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12
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Sheean AJ, DeFoor MT, Spindler KP, Arner JW, Athiviraham A, Bedi A, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ, Spindler KP, Bedi A. The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions. Sports Health 2024:19417381241226896. [PMID: 38374636 DOI: 10.1177/19417381241226896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
CONTEXT Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed. EVIDENCE ACQUISITION Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR. CONCLUSION The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT) B.
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Affiliation(s)
| | | | | | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Asheesh Bedi
- NorthShore University Health System, Skokie, Illinois
| | | | | | | | | | | | | | - Asheesh Bedi
- NorthShore University Health System, Skokie, Illinois
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13
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Qiao Y, Wu C, Wu X, Li Z, Chen J, Xu C, Zhao S, Zhao J. The Value of Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State for Commonly Used Patient-Reported Outcomes in Recurrent Patellar Instability Patients After Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer. Arthroscopy 2024; 40:115-123. [PMID: 37419222 DOI: 10.1016/j.arthro.2023.06.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/28/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE To identify the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient-acceptable symptomatic state (PASS) for commonly used patient-reported outcomes (PROs) in recurrent patellar instability patients after medial patellofemoral ligament reconstruction (MPFLR) and tibial tubercle transfer (TTT), and to determine the impact of potential prognostic factors on the likelihood of achieving these values. METHODS From April 2015 to February 2021, patients who underwent MPFLR and TTT were retrospectively reviewed. PROs included Kujala, Knee Injury and Osteoarthritis Outcome (KOOS), Lysholm, International Knee Documentation Committee (IKDC), and Tegner score. Relevant anchor questions were provided. A distribution- or anchor-based method was adopted to determine the MCID, SCB, and PASS. Minimal detectable change (MDC) was included to confirm the validity. Univariate regression analyses were conducted to determine the potential prognostic factors. RESULTS One hundred forty-two patients were included. The MCID were 9.1 (Kujala), 11.1 (Lysholm), 0.9 (Tegner), 9.9 (IKDC), 9.0 (KOOS-Pain), 10.8 (KOOS-Symptoms), 10.0 (KOOS-Activities of Daily Living [ADL]), 17.8 (KOOS-Sports and Recreation [Sports/Rec]), and 12.7 (KOOS-Quality of Life [QoL]). The SCB were 14.5 (Kujala), 12.5 (Lysholm), 1.5 (Tegner), 14.5 (IKDC), 13.9 (KOOS-Pain), 14.3 (KOOS-Symptoms), 18.4 (KOOS-ADL), 47.5 (KOOS-Sports/Rec), and 15.0 (KOOS-QoL). The PASSs were 85.5 (Kujala), 75.5 (Lysholm), 3.5 (Tegner), 73.2 (IKDC), 87.5 (KOOS-Pain), 73.2 (KOOS-Symptoms), 92.0 (KOOS-ADL), 77.5 (KOOS-Sports/Rec), and 53.1 (KOOS-QoL). All SCBs were valid except KOOS-QoL. All MCIDs were valid at the 95% confidence interval (CI) except KOOS scores, the majority of which were valid at the 90% CI. A younger age was an independent prognostic factor of reaching PASS for Lysholm, IKDC, Tegner, and KOOS-ADL score. A higher baseline score was a negative prognostic factor for achieving MCID or SCB but had a slightly positive influence on the achievement of PASS. CONCLUSIONS This study established the MCID, SCB, and PASS for commonly used PROs and confirmed their validity in recurrent patellar instability patients after MPFLR and TTT. Younger age and lower baseline scores were prognostic factors of achieving MCID and SCB, whereas patients with higher baseline scores were more likely to report satisfaction. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Yi Qiao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiulin Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ziyun Li
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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14
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Ninkovic S, Manojlovic M, Roklicer R, Bianco A, Carraro A, Matic R, Trivic T, Drid P. The influence of body mass index on physical activity engagement following anterior cruciate ligament reconstruction: A systematic literature review. Heliyon 2023; 9:e22994. [PMID: 38125506 PMCID: PMC10731226 DOI: 10.1016/j.heliyon.2023.e22994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Background The objective of this study was to summarize available literature that explored the impact of body mass index (BMI) on physical activity participation among individuals who were subjected to the anterior cruciate ligament reconstruction (ACLR). Methods A total of three electronic databases, including Web of Science, Scopus, and PubMed, were comprehensively searched to identify relevant investigations. The following inclusion criteria were applied: (1) study design was observational; (2) participants underwent the ACLR; (3) BMI was estimated as a predictor variable; and (4) outcomes evaluated referred to physical activity. The risk of bias was assessed with the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results After a database search, 787 studies were found, and only 10 of them met each of the eligibility criteria and were included in the qualitative analysis. Regarding respondents' characteristics, 7171 individuals underwent ACLR, 4080 males and 3091 females, with a mean age of 25.5 years. Most importantly, the average BMI of the examined population was 24.9 kg/m2. In all studies, physical activity was evaluated subjectively using the Tegner activity scale and the Marx activity scale. The main findings unambiguously demonstrated that a negative relationship between BMI and physical activity engagement was observed. More specifically, there is convincing evidence that BMI over 25 kg/m2 harmfully affected subjectively assessed physical activity in individuals with a history of ACLR. Conclusion The results obtained in the presented research indicated that increased values of BMI were a factor that correlated with reduced physical activity levels in the ACLR population. Hence, taking into account the clinical and health implications of reduced physical activity participation, stimulation of a healthy lifestyle, such as a combination of adequately designed physical exercise and nutrition, seems necessary for the analyzed population.
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Affiliation(s)
- Srdjan Ninkovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Department of Orthopedic Surgery and Traumatology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Marko Manojlovic
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Roberto Roklicer
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
- Faculty of Education, Free University of Bozen-Bolzano, Brixen-Bressanone, Italy
| | - Antonino Bianco
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
| | - Attilio Carraro
- Faculty of Education, Free University of Bozen-Bolzano, Brixen-Bressanone, Italy
| | - Radenko Matic
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Tatjana Trivic
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Patrik Drid
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
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15
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Zhang Y, Nan K, Zhao Y, Zhang X, Song Q, Fan L, Shi Z, Dang X. Addition of Tibial Tubercle Osteotomy to Combined MPFL Reconstruction and Lateral Retinacular Release not Recommended for Recurrent Patellar Dislocation in Patients with 15 to 20 mm TT-TG. J Knee Surg 2023; 36:1349-1356. [PMID: 36564044 DOI: 10.1055/s-0042-1757593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Surgery is the primary treatment for recurrent patellar dislocation. However, there is still a lack of consensus regarding the choice of combined surgical methods due to the complexity of the anatomical factors. This study aimed to investigate the efficacy and radiological changes in medial patellofemoral ligament reconstruction (MPFLR) and lateral retinacular release (LRR) with and without tibial tubercle osteotomy (TTO) for recurrent patellar dislocation in patients with a tibial tubercle-trochlear groove (TT-TG) distance of 15 to 20 mm. Fifty-four patients were enrolled in this retrospective study between 2010 and 2014. The average patient age was 21.6 ± 5.0 years. All patients underwent MPFLR and LRR, and in 18 patients, these procedures were combined with TTO. Patients were evaluated preoperatively and postoperatively for patellar lateral shift, patellar tilt angle, TT-TG distance, Q-angle, Caton-Deschamps index (CDI), Kujala, and Lysholm scores. The minimally clinical important difference was used to compare clinical outcomes between two groups. In the mean follow-up of 82.6 ± 15.9 months, functional scores improved significantly in both groups (p < 0.01). There were no significant differences in postoperative function scores between the two groups (Kujala, p = 0.25, mean difference = 1.5, 95% confidence interval [CI]: -1.4-4.4; Lysholm, p = 0.76, mean difference = -0.6, 95% CI: -5.9-4.7). Additionally, TTO significantly decreased Q-angle (23.6 ± 2.4 vs. 17.4 ± 2.9, p < 0.01), TT-TG (17.1 ± 1.5 vs. 10.4 ± 1.8, p < 0.01), and CDI (1.18 ± 0.12 vs. 1.08 ± 0.07, p < 0.01). Combined MPFLR and LRR with and without TTO are both effective techniques for recurrent patellar dislocation. Additional osteotomy can correct patellar alta and tibial tubercle lateralization. However, given that there were no significant differences in postoperative functional scores or recurrence rate between groups, we may not recommend TTO in addition to MPFLR and LRR in patients with TT-TG of 15 to 20 mm. Long-term and prospective cohort studies are required to assess further outcomes.
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Affiliation(s)
- Yuankai Zhang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Kai Nan
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
- Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Yan Zhao
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Xin Zhang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Qichun Song
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Lihong Fan
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Zhibin Shi
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Xiaoqian Dang
- The First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
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16
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Yavari E, Moosa S, Cohen D, Cantu-Morales D, Nagai K, Hoshino Y, de Sa D. Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:4299-4311. [PMID: 37329370 DOI: 10.1007/s00167-023-07481-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/02/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR. METHODS CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate. RESULTS Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI - 1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups. CONCLUSION Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ehsan Yavari
- Michael G. DeGroote School of Medicine, McMaster University, Waterloo Regional Campus, Kitchener, ON, N2G 1C5, Canada.
| | - Sabreena Moosa
- Michael G. DeGroote School of Medicine, McMaster University, Waterloo Regional Campus, Kitchener, ON, N2G 1C5, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, MUMC 4E14, Hamilton, ON, L8S 4L8, Canada
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17
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Morris EJ, Gray K, Gibbons PJ, Grayson J, Sullivan J, Amorim AB, Burns J, McKay MJ. Evaluating the Use of PROMs in Paediatric Orthopaedic Registries. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1552. [PMID: 37761513 PMCID: PMC10528097 DOI: 10.3390/children10091552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.
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Affiliation(s)
- Eleanor J. Morris
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
- Sydney Children’s Hospitals Network, The Children’s Hospital at Westmead, Sydney 2145, Australia;
| | - Kelly Gray
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney 2109, Australia;
| | - Paul J. Gibbons
- Sydney Children’s Hospitals Network, The Children’s Hospital at Westmead, Sydney 2145, Australia;
| | - Jane Grayson
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
| | - Justin Sullivan
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
| | - Anita B. Amorim
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
| | - Joshua Burns
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
- Sydney Children’s Hospitals Network, Paediatric Gait Analysis Service of New South Wales, Sydney 2145, Australia
| | - Marnee J. McKay
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (E.J.M.); (J.G.); (J.S.); (A.B.A.); (M.J.M.)
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Kuhns BD, Sholtis CD, Reuter JM, Goldblatt J, Bronstein R, Baumhauer JF, Maloney MD, Mannava S. Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231187327. [PMID: 37655256 PMCID: PMC10467379 DOI: 10.1177/23259671231187327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement. Purpose/Hypothesis The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement. Study Design Case series; Level of evidence, 4. Methods Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS. Results In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF. Conclusion Preoperative athletic participation significantly affected the ability to achieve PASS.
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Affiliation(s)
- Benjamin D. Kuhns
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Connor D. Sholtis
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - John M. Reuter
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - John Goldblatt
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert Bronstein
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Judith F. Baumhauer
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael D. Maloney
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Sandeep Mannava
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
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Kung JE, Kaveeshwar S, Rocca M, Rivkin D, Hartline J, Packer JD, Meredith SJ, Leong NL, Henn RF. PROMIS cluster analysis predicts two-year outcomes in knee surgery patients. J Orthop 2023; 39:59-65. [PMID: 37125017 PMCID: PMC10139851 DOI: 10.1016/j.jor.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023] Open
Abstract
Aims & objectives Meaningful clinical interpretation of orthopaedic patient-reported outcome scores remains challenging. Grouping scores may be more meaningful than individual score analysis. The purpose of this study was to determine if grouping knee surgery patients into four preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) clusters would have prognostic value for two-year postoperative outcomes. Materials & methods 488 of 697 (70%) patients undergoing elective knee surgery at a single urban institution were enrolled in an orthopaedic registry and completed two-year follow up. Patients were administered questionnaires for PROMIS, International Knee Documentation Committee Score (IKDC), Marx Activity Rating Scale (MARS), and Surgical Satisfaction (SSQ-8). A k-means cluster analysis was performed to identify preoperative PROMIS clusters. Chi-square or Kruskal-Wallis tests were conducted for bivariate analyses. Least-squares multiple linear regression models were performed to identify if cluster group was an independent predictor. Results Cluster analysis revealed four clusters of patients. Psychological distress was most significant in determining classification. More impaired clusters were associated with higher rates of arthroplasty, African American race, preoperative opioid use, lower income, higher comorbidity index, and other sociodemographic and operative factors. Worse preoperative cluster status was associated with higher chance of achieving minimally clinically important change (MCID) on all metrics except PROMIS Pain Interference (PI), IKDC, and MARS. Multivariable analysis confirmed better preoperative cluster as predictive of better PROMIS Physical Function (PF), PI, IKDC scores, and satisfaction. Worse preoperative cluster was predictive of greater improvement on PF and PI but not IKDC. Conclusion Preoperative PROMIS clusters have prognostic value in predicting outcomes for knee surgery patients. Better preoperative cluster function predicts superior outcomes. While worse preoperative cluster predicts worse outcome, all clusters still significantly improve, so worse preoperative cluster is not a contraindication to surgery.
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Affiliation(s)
- Justin E. Kung
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
- Orthopedic Surgery, Prisma Health Midlands/University of South Carolina, Columbia, SC, USA
| | - Samir Kaveeshwar
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Rocca
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Rivkin
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jacob Hartline
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan D. Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sean J. Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie L. Leong
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R. Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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20
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Bodkin SG, Bruce AS, Werner BC, Diduch DR, Brockmeier SF, Miller MD, Gwathmey FW, Hart JM. Influence of interim functional assessments on patient outcomes at the time of return to activity following ACL-reconstruction. Phys Ther Sport 2023; 61:179-184. [PMID: 37105085 DOI: 10.1016/j.ptsp.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To compare patient outcomes at the time of the return to activity (RTA) progression between those with a prior interim assessment and those without. DESIGN Retrospective, Cohort Study. SETTING Controlled Laboratory. PARTICIPANTS Patients following Anterior Cruciate Ligament Reconstruction (ACLR) were recruited through an ongoing RTA assessment program. Patients were stratified into two testing groups = "Single RTA test": only assessment between 6 and 9 months post-ACLR and "Repeat RTA test": prior assessment performed >2-months before their RTA assessment. Patients were matched based on time post-surgery, age, activity level, and graft type. MAIN OUTCOME MEASURE Self-reported knee function and isokinetic knee flexor and extensor strength/symmetry were compared between groups. RESULTS 392 patients were identified. Once matched, 138 patients (21.1 ± 7.0 years, 7.3 ±0 .9 mo post-ACLR) were analyzed. Repeat RTA test patients demonstrated higher measures of self-reported knee function (P = .04) and greater knee flexion strength (P = .006) and symmetry (P = .05). CONCLUSION Patients with interim functional assessments reported greater self-reported knee function and higher hamstring strength at the time of RTA compared to patients that completed their only assessment within this time point. Early functional assessments may identify individualized deficits that can be addressed while patients are under supervision of rehabilitation specialists.
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Affiliation(s)
- Stephan G Bodkin
- Department of Physical Therapy and Athletic Training, University of Utah, 290 S 1850 E HPER-W Rm113. Salt Lake City, UT, 84112, USA.
| | - Amelia S Bruce
- Department of Kinesiology, University of Virginia, Charlottesville, VA Memorial Gymnasium Rm 206 210 Emmet St So, Charlottesville, VA, 22903, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 400 Ray C. Hunt Drive, Suite 330 PO Box 800159, Charlottesville, VA, 22908, USA
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 400 Ray C. Hunt Drive, Suite 330 PO Box 800159, Charlottesville, VA, 22908, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 400 Ray C. Hunt Drive, Suite 330 PO Box 800159, Charlottesville, VA, 22908, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 400 Ray C. Hunt Drive, Suite 330 PO Box 800159, Charlottesville, VA, 22908, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 400 Ray C. Hunt Drive, Suite 330 PO Box 800159, Charlottesville, VA, 22908, USA
| | - Joe M Hart
- Department of Orthopaedic Surgery, University of North Carolina Chapel Hill, NC 102 Mason Farm Rd Second Floor, Chapel Hill, NC, 27514, USA
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Batista JP, Maestu R, Barbier J, Chahla J, Kunze KN. Propensity for Clinically Meaningful Improvement and Surgical Failure After Anterior Cruciate Ligament Repair. Orthop J Sports Med 2023; 11:23259671221146815. [PMID: 37065184 PMCID: PMC10102942 DOI: 10.1177/23259671221146815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 04/18/2023] Open
Abstract
Background Primary repair of the anterior cruciate ligament (ACL) confers an alternative to ACL reconstruction in appropriately selected patients. Purpose To prospectively assess survivorship and to define the clinically meaningful outcomes after ACL repair. Study Design Case series; Level of evidence, 4. Methods Included were consecutive patients with Sherman grade 1-2 tears who underwent primary ACL repair with or without suture augmentation between 2017 and 2019. Patient-reported outcomes (Lysholm, Tegner, International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score [KOOS] subscales) were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. The minimal clinically important difference (MCID) was calculated using a distribution-based method, whereas the Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were calculated using an anchor-based method. Plain radiographs and magnetic resonance imaging (MRI) were obtained at 6 months, 1 year, and 2 years postoperatively. Results A total of 120 patients were included. The overall failure rate was 11.3% at 2 years postoperatively. Changes in outcome scores required to achieve the MCID ranged between 5.1 and 14.3 at 6 months, 4.6 and 8.4 at 1 year, and 4.7 and 11.9 at 2 years postoperatively. Thresholds for PASS achievement ranged between 62.5 and 89 at 6 months, 75 and 89 at 1 year, and 78.6 and 93.2 at 2 years postoperatively. Threshold scores (absolute/change based) for achieving the SCB ranged between 82.8 and 96.4/17.7 and 40.1 at 6 months, between 94.7 and 100/23 and 45 at 1 year, and between 95.3 and 100/29.4 and 45 at 2 years. More patients achieved the MCID and PASS at 1 year compared with 6 months and 2 years. For SCB, this trend was also observed for non-KOOS outcomes, while for KOOS subdomains, more patients achieved the SCB at 2 years. High-intensity signal of the ACL repair (odds ratio [OR], 31.7 [95% CI, 1.5-73.4]; P = .030) and bone contusions on MRI (OR, 4.2 [95% CI, 1.7-25.2]; P = .041) at 1 year postoperatively were independently associated with increased risk of ACL repair failure. Conclusion The rate of clinically meaningful outcome improvement was high early after ACL repair, with the greatest proportion of patients achieving the MCID, PASS, and SCB at 1 year postoperatively. Bone contusions involving the posterolateral tibia and lateral femoral condyle as well as high repair signal intensity at 1 year postoperatively were independent predictors of failure at 2 years postoperatively.
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Affiliation(s)
| | - Rodrigo Maestu
- Centro de Tratamiento de Enfermedades
Articulares, Buenoa Aires, Argentina
| | - Jose Barbier
- Centro Artroscópico Jorge Batista SA,
Buenos Aires, Argentina
| | - Jorge Chahla
- Division of Sports Medicine, Department
of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois,
USA
| | - Kyle N. Kunze
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, New York, USA
- Kyle N. Kunze, M.D,
Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th
Street, New York, NY 10021, USA ()
(Twitter: @kylekunzemd)
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Ye Z, Zhang T, Wu C, Qiao Y, Su W, Chen J, Xie G, Dong S, Xu J, Zhao J. Predicting the Objective and Subjective Clinical Outcomes of Anterior Cruciate Ligament Reconstruction: A Machine Learning Analysis of 432 Patients: Response. Am J Sports Med 2023; 51:NP17-NP18. [PMID: 37002726 DOI: 10.1177/03635465231161060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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Zaid HHG, Hua X, Chen B, Yang Q, Yang G, Cheng W. Tourniquet Use Improves Intraoperative Parameters, Leading to Similar Postoperative Outcomes Compared With No Tourniquet Use in Anterior Cruciate Ligament Reconstruction: A Prospective, Double-Blind, Randomized Clinical Trial. Arthroscopy 2023; 39:626-637.e3. [PMID: 36334854 DOI: 10.1016/j.arthro.2022.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/27/2022] [Accepted: 10/20/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine the effect of tourniquet use in arthroscopic anterior cruciate ligament reconstruction in terms of: (1) intraoperative visualization with operative time and consumption of sterile saline, and (2) intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum creatine phosphokinase (CPK) and hemoglobin (Hb) concentrations, clinical outcomes, and graft healing. METHODS In this prospective randomized clinical trial, patients were assigned to tourniquet inflation (tourniquet-up) or tourniquet deflation (tourniquet-down) groups. Primary outcomes were intraoperative visualization with operative time and sterile saline consumption. Secondary outcomes were intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum CPK, Hb concentration, subjective and objective functional scores, and graft healing. RESULTS Intraoperative visualization was satisfactory in 100 of 100 cases in the tourniquet-up group and 64 of 100 cases in the tourniquet-down group (P < .05). The mean operative time was 58.4 ± 5.7 minutes in the tourniquet-up group and 72.5 ± 8.6 minutes in the tourniquet-down group (P < .05). The mean sterile saline consumption was 6.4 ± 2.5 L in the tourniquet-up group and 8.7 ± 4.6 L in the tourniquet-down group (P < .05). The respective amounts of estimated intraoperative and postoperative blood loss were 95.3 ± 25.1 mL and 240.3 ± 44.5 mL in the tourniquet-up group and 230.2 ± 22.3 mL and 75.6 ± 15.3 mL in the tourniquet-down group (P < .05). Our results showed no significant difference in postoperative pain, opioid consumption, percentage of patients using opioids, swelling, mean serum CPK and Hb levels, subjective and objective functional scores, or graft healing (P > .05) between the 2 groups. CONCLUSIONS Tourniquet use during anterior cruciate ligament reconstruction significantly improves intraoperative visualization, shortens operative time, and decreases intraoperative sterile saline consumption and blood loss without serious adverse events or greater complication rates based on early postoperative outcomes. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Hamood H G Zaid
- First Affiliated Hospital of Xiamen University, Xiamen City, China; College of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou City, China
| | - Xu Hua
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Bingyi Chen
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Quanyuan Yang
- First Affiliated Hospital of Xiamen University, Xiamen City, China
| | - Guo Yang
- First Affiliated Hospital of Xiamen University, Xiamen City, China.
| | - Weinan Cheng
- First Affiliated Hospital of Xiamen University, Xiamen City, China.
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Mukai S, Nakagawa Y, Nishitani K, Sakai S, Nakamura R, Takahashi M. Mosaicplasty With High Tibial Osteotomy for Knee Subchondral Insufficiency Fracture Had Better Magnetic Resonance Observation of Cartilage Repair Tissue Scores With Less Bone Marrow Edema and Better Plug Union and Less Plug Necrosis Compared With Mosaicplasty Alone. Arthroscopy 2023; 39:337-346. [PMID: 36064155 DOI: 10.1016/j.arthro.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 07/20/2022] [Accepted: 07/28/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE To determine the magnetic resonance imaging (MRI) findings after mosaicplasty (MOS) for knee subchondral insufficiency fracture (SIFK), and to analyze the relationship between MRI findings and clinical outcomes. METHODS We retrospectively reviewed the cases of consecutive patients who underwent MOS for SIFK with/without high tibial osteotomy (HTO) between January 1998 and December 2015. The MRI findings at 12 months after the surgery were assessed by the modified magnetic resonance observation of cartilage repair tissue (MOCART) score to determine the degree of bone marrow edema (BME), plug union, and plug necrosis. The clinical outcomes were assessed by Lysholm score to clarify the minimal clinically important difference (MCID) and patient acceptable symptom state analysis. RESULTS In total, 58 patients (17 men and 41 women) were enrolled in this study. Among them, 30 knees were treated by MOS alone and 28 knees were treated by MOS with HTO. The MOCART scores of patients who received MOS alone were significantly lower in BME score (P = .0060), plug union score (P = .0216), and in plug necrosis score (P = .0326) than patients who received MOS with HTO. BME lesion was less likely to persist among elderly (odds ratio 1.20, P = .0248) and female (OR 41.8, P = .0118) patients. The MCID of Lysholm score was 6.6 in MOS alone and 8.4 in MOS with HTO cases, but there were no significant association between MRI findings and the postoperative Lysholm score. CONCLUSIONS The MOS with HTO cases had better MOCART scores with less BME, better plug union, and less plug necrosis compared with MOS alone cases. Female and older patients had better resolution of BME, but there was no significant correlation between MRI findings and the postoperative Lysholm score. All cases in both groups showed improvement of Lysholm score exceeding MCID; thus, MOS may be effective as a joint preserving surgery for SIFK. LEVEL OF EVIDENCE Level IV, clinical case series.
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Affiliation(s)
- Shogo Mukai
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
| | - Yasuaki Nakagawa
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kohei Nishitani
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan; Department of Orthopedic Surgery, Kyoto University, Kyoto, Japan
| | - Sayako Sakai
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Ryouta Nakamura
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Motoi Takahashi
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Nascimento BFD, Lima MBDR, Dias Júnior JM, Antunes Filho J, Campos TVDO, Mendes Júnior AF. Calculation of the Minimal Important Clinical Difference of the Lysholm and IKDC Scores After Anterior Cruciate Ligament Reconstruction. Rev Bras Ortop 2023; 58:79-84. [PMID: 36969791 PMCID: PMC10038720 DOI: 10.1055/s-0042-1756330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/26/2022] [Indexed: 03/26/2023] Open
Abstract
Objective To calculate the minimal important clinical difference (MICD) value for the Lysholm and International Knee Documentation Committee (IKDC) scores in a sample of patients submitted to anterior cruciate ligament reconstruction. Methods Primary, observational, retrospective, analytical study of participants submitted to anterior cruciate ligament reconstruction from March 2019 to December 2020 by the same surgeon, with a minimum follow-up of 6 months, analysis of knee function in the pre- and postoperative period by the Lysholm and IKDC scores, and answer to an anchor question at 6 months postoperatively for the calculation of the MICD of each score. Results A total of 59 patients participated in the study, with a mean age of 27.1 ± 5.7 years old. In the comparison between pre- and postoperative scores of all groups, there was an increase in values with statistical significance after intervention. The MICD was 5.5 for the Lysholm score, and the MICD value for the IKDC score could not be determined. Conclusion For the Lysholm score, the calculation of the MICD value by the anchor question method in the sample evaluated was 5.5. It was not possible to determine the value of the MICD for the IKDC score.
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Affiliation(s)
- Bruno Fajardo do Nascimento
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Mariana Bandeira da Rocha Lima
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Jair Moreira Dias Júnior
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | | | | | - Adriano Fernando Mendes Júnior
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
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Arthroscopic Anatomical Double-Bundle Medial Patellofemoral Complex Reconstruction Improves Clinical Outcomes in Treating Recurrent Patellar Dislocation Despite Trochlear Dysplasia, Elevated Tibial Tubercle-Trochlear Groove Distance, and Patellar Alta. Arthroscopy 2023; 39:102-111. [PMID: 35840069 DOI: 10.1016/j.arthro.2022.06.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/25/2022] [Accepted: 06/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical outcomes of arthroscopically assisted double-bundle medial patellofemoral complex reconstruction (MPFC-R). METHODS A retrospective review was carried out among adult patients who experienced at least 2 patellar dislocations and underwent primary arthroscopically assisted MPFC-R between January 2014 and November 2019. Dejour classification, tibial tubercle-trochlear groove (TT-TG) distance, and patellar height (with Insall-Salvati index) were measured. Pre- and postoperative patellar tilt were compared. Information on outcome scores, ability to return to sports, postoperative recurrent dislocations, and complications was recorded. RESULTS A total of 42 MPFC-Rs in 39 patients were included. Mean age at surgery was 22.2 ± 7.6 years; 69.2% of patients were female. Mean follow-up was 47.3 ± 20.2 months. Seventy-four percent of cases had Dejour B (19.0%), C (33.3%), and D (21.4%) trochlear dysplasia; mean TT-TG distance was 19.6 ± 3.5 mm, and mean Insall-Salvati index was 1.21 ± 0.17. Mean patellar tilt decreased from 27.6 ± 11.6° to 9.4 ± 6.5° (P < .001). All patients had statistically significant (P < .001) improvement in mean International Knee Documentation Committee (IKDC) (44.9 ± 18.2 to 87.5 ± 6.9), Lysholm (61.4 ± 16.6 to 94.1 ± 6.4), Kujala (56.0 ± 16.8 to 92.9 ± 5.3), and Tegner score (2.7 ± 1.3 to 4.6 ± 1.4). The majority of patients (96.9%) returned to sports, with 90.3% returning to the same or greater level of activity. No postoperative dislocations or subluxations were reported. CONCLUSIONS Arthroscopically assisted double-bundle MPFC-R is a promising procedure to treat recurrent patellar instability at 2- to 7-year mid-term follow-up, despite the presence of trochlear dysplasia, elevated TT-TG distance and patellar alta. The improvement of IKDC score exceeded the minimal clinically important difference in 95.2% patients, and 66.7% surpassed the patient acceptable symptomatic state based on postoperative IKDC score with no redislocations being reported at latest follow-up. LEVEL OF EVIDENCE Level IV, case series, retrospective.
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Alfaro Micó J, Morales-Santias M, Garcia Miralles S, Bustamante Suarez de Puga D, Más Martínez J, Sanz-Reig J. [Translated article] Three years follow-up outcome of 4-strand semitendinous-gracilis anterior ligament reconstruction in women: A matched-cohort study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T43-T49. [PMID: 36243391 DOI: 10.1016/j.recot.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/01/2022] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyse the outcomes in women following ACL reconstruction and compare these outcomes with men. MATERIAL AND METHODS Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state. RESULTS A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men. CONCLUSIONS At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.
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Affiliation(s)
- J Alfaro Micó
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, Spain
| | - M Morales-Santias
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, Spain
| | - S Garcia Miralles
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, Spain
| | | | - J Más Martínez
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, Spain
| | - J Sanz-Reig
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, Spain.
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Alfaro Micó J, Morales-Santias M, Garcia Miralles S, Bustamante Suarez de Puga D, Más Martínez J, Sanz-Reig J. Outcome of 4-strand semitendinosus-gracilis anterior ligament reconstruction in women: A matched-cohort study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:43-49. [PMID: 35452859 DOI: 10.1016/j.recot.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/12/2022] [Accepted: 04/01/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyze the outcomes in women following ACL reconstruction and compare these outcomes with men. MATERIAL AND METHODS Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state. RESULTS A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men. CONCLUSIONS At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.
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Affiliation(s)
- J Alfaro Micó
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, España
| | - M Morales-Santias
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, España
| | - S Garcia Miralles
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, España
| | | | - J Más Martínez
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, España
| | - J Sanz-Reig
- Traumatología Vistahermosa, Clínica HLA Vistahermosa, Alicante, España.
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Lee D, Lencer AJ, Gibbs BS, Paul RW, Tjoumakaris FP. Disruptions in standard care: anterior cruciate ligament reconstruction outcomes during the SARS-COV2 pandemic. PHYSICIAN SPORTSMED 2022; 50:515-521. [PMID: 34424824 DOI: 10.1080/00913847.2021.1971494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The SARS-COV2 pandemic led to massive disruptions of care for orthopedic patients. Although many elective procedures were put on hold, a cohort of patients who underwent surgery prior to the outbreak of the pandemic were rendered unable to participate in standard post-operative care. The purpose of this study was to determine the methods of post-operative care in arthroscopic anterior cruciate ligament reconstruction patients who received care during an early height of the pandemic to those who received standard of care in the prior year. We aimed to correlate those results with 1-year clinical outcomes in the form of subjective surveys. METHODS Retrospective chart review was used to identify patients who underwent primary anterior cruciate ligament reconstruction in February and March of 2020 (case) and 2019 (control) at a single institution. Workman's compensation patients were excluded. Identified patients were asked to report post-operative care received, satisfaction with care, and complete the IKDC and Lysholm outcome measures. Surveys were conducted minimum 1-year post-operative. RESULTS 236 patients were identified, including 103 in 2020 and 133 in 2019. Follow-up data was collected for 73 patients (70.9%) in 2020 and 97 patients (72.9%) in 2019. Fifty-one COVID cohort patients (69.9%) had at least one clinical visit conducted via telehealth, compared to zero in the control. There were no differences in IKDC (82.8 ± 13.2 vs 85.0 ± 12.0, P = 0.29) and Lysholm (89.2 ± 11.3 vs 89.6 ± 10.8, P = 0.82) between groups. There were no differences in patient satisfaction with the care received (82.9 ± 22.4 vs 81.9 ± 21.8, P = 0.79). CONCLUSION Despite disruptions in care, anterior cruciate ligament reconstruction patients have excellent 1-year outcomes during the pandemic. Telehealth follow-up appointments may be appropriate for anterior cruciate ligament reconstruction patients beyond the pandemic and do not seem to adversely affect short-term patient reported outcome measures.
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Affiliation(s)
- Donghoon Lee
- Department of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Adam J Lencer
- Department of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Brian S Gibbs
- Department of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Ryan W Paul
- Department of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Fotios P Tjoumakaris
- Department of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Ye Z, Zhang T, Wu C, Qiao Y, Su W, Chen J, Xie G, Dong S, Xu J, Zhao J. Predicting the Objective and Subjective Clinical Outcomes of Anterior Cruciate Ligament Reconstruction: A Machine Learning Analysis of 432 Patients. Am J Sports Med 2022; 50:3786-3795. [PMID: 36285651 DOI: 10.1177/03635465221129870] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sports levels, baseline patient-reported outcome measures (PROMs), and surgical procedures are correlated with the outcomes of anterior cruciate ligament reconstruction (ACLR). Machine learning may be superior to conventional statistical methods in making repeatable and accurate predictions. PURPOSE To identify the best-performing machine learning models for predicting the objective and subjective clinical outcomes of ACLR and to determine the most important predictors. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A total of 432 patients who underwent anatomic double-bundle ACLR with hamstring tendon autograft between January 2010 and February 2019 were included in the machine learning analysis. A total of 15 predictive variables and 6 outcome variables were selected to validate the logistic regression, Gaussian naïve Bayes machine, random forest, Extreme Gradient Boosting (XGBoost), isotonically calibrated XGBoost, and sigmoid calibrated XGBoost models. For each clinical outcome, the best-performing model was determined using the area under the receiver operating characteristic curve (AUC), whereas the importance and direction of each predictive variable were demonstrated in a Shapley Additive Explanations summary plot. RESULTS The AUC and accuracy of the best-performing model, respectively, were 0.944 (excellent) and 98.6% for graft failure; 0.920 (excellent) and 91.4% for residual laxity; 0.930 (excellent) and 91.0% for failure to achieve the minimal clinically important difference (MCID) of the Lysholm score; 0.942 (excellent) and 95.1% for failure to achieve the MCID of the International Knee Documentation Committee (IKDC) score; 0.773 (fair) and 70.5% for return to preinjury sports; and 0.777 (fair) and 69.2% for return to pivoting sports. Medial meniscal resection, participation in competitive sports, and steep posterior tibial slope were top predictors of graft failure, whereas high-grade preoperative knee laxity, long follow-up period, and participation in competitive sports were top predictors of residual laxity. High preoperative Lysholm and IKDC scores were highly predictive of not achieving the MCIDs of PROMs. Young age, male sex, high preoperative IKDC score, and large graft diameter were important predictors of return to preinjury or pivoting sports. CONCLUSION Machine learning analysis can provide reliable predictions for the objective and subjective clinical outcomes (graft failure, residual laxity, PROMs, and return to sports) of ACLR. Patient-specific evaluation and decision making are recommended before and after surgery.
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Affiliation(s)
- Zipeng Ye
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianlun Zhang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ferreira A, Saithna A, Carrozzo A, Guy S, Vieira TD, Barth J, Sonnery-Cottet B. The Minimal Clinically Important Difference, Patient Acceptable Symptom State, and Clinical Outcomes of Anterior Cruciate Ligament Repair Versus Reconstruction: A Matched-Pair Analysis From the SANTI Study Group. Am J Sports Med 2022; 50:3522-3532. [PMID: 36259683 DOI: 10.1177/03635465221126171] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been increasing interest in anterior cruciate ligament (ACL) repair because of theoretical advantages over ACL reconstruction; however, the contemporary literature has failed to provide high-quality evidence to demonstrate these advantages. PURPOSE To compare the clinical and functional outcomes of ACL repair versus ACL reconstruction at a minimum follow-up of 2 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent ACL repair were propensity matched (based on demographics, time between injury and surgery, knee laxity parameters, presence of meniscal lesions, preoperative activity level, and sport participation), in a 1:1 ratio, to those who underwent ACL reconstruction during the same period. Isokinetic testing was used to evaluate strength deficits at 6 months postoperatively. Knee laxity parameters were evaluated at 12 months. Complications, return to sport, and patient-reported outcome scores were recorded at final follow-up. RESULTS In total, 75 matched pairs (150 patients) were evaluated. The repair group had significantly better mean hamstring muscle strength at 6 months compared with the reconstruction group (1.7% ± 12.2% vs -10.0% ± 12.8%, respectively; P < .0001). At a mean final follow-up of 30.0 ± 4.8 months, the repair group had a significantly better mean Forgotten Joint Score-12 (FJS-12) score compared with the reconstruction group (82.0 ± 15.1 vs 74.2 ± 21.7, respectively; P = .017). Noninferiority criteria were met for ACL repair, compared with ACL reconstruction, with respect to the subjective International Knee Documentation Committee score (86.8 ± 9.0 vs 86.7 ± 10.1, respectively; P < .0001) and side-to-side anteroposterior laxity difference (1.1 ± 1.4 vs 0.6 ± 1.0 mm, respectively; P < .0001). No significant differences were found for other functional outcomes or the pivot-shift grade. There were no significant differences in the rate of return to the preinjury level of sport (repair group: 74.7%; reconstruction group: 60.0%; P = .078). A significant difference was observed regarding the occurrence of ACL reruptures (repair group: 5.3%; reconstruction group: 0.0%; P = .045). Patients who experienced a failure of ACL repair were significantly younger than those who did not (26.8 vs 40.7 years, respectively; P = .013). There was no significant difference in rupture rates between the repair and reconstruction groups when only patients aged >21 years were considered (2.9% vs 0.0%, respectively; P = .157). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) thresholds were defined for the ACL repair group. A significantly greater proportion of patients in the repair group achieved the PASS for the FJS-12 compared with their counterparts in the reconstruction group (77.3% vs 60.0%, respectively; P = .034). CONCLUSION ACL repair was associated with some advantages over ACL reconstruction including superior hamstring muscle strength at 6 months and significantly better FJS-12 scores. However, the failure rate was significantly higher after ACL repair, and younger patients were particularly at risk.
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Affiliation(s)
- Alexandre Ferreira
- Centre Orthopedique Santy, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Adnan Saithna
- Arizona Brain and Spine Center, Scottsdale, Arizona, USA
| | - Alessandro Carrozzo
- Centre Orthopedique Santy, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France.,Department of Orthopaedics and Traumatology, Sapienza University of Rome, Rome, Italy
| | - Sylvain Guy
- Centre Orthopedique Santy, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopedique Santy, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
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Macri EM, Young JJ, Ingelsrud LH, Khan KM, Terluin B, Juhl CB, Whittaker JL, Culvenor AG, Crossley KM, Roos EM. Meaningful thresholds for patient-reported outcomes following interventions for anterior cruciate ligament tear or traumatic meniscus injury: a systematic review for the OPTIKNEE consensus. Br J Sports Med 2022; 56:1432-1444. [PMID: 35973755 DOI: 10.1136/bjsports-2022-105497] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We synthesised and assessed credibility (ie, trustworthiness) of thresholds that define meaningful scores for patient-reported outcome measures (PROMs) following interventions for anterior cruciate ligament (ACL) tear or traumatic meniscus injury. DESIGN Systematic review, narrative synthesis. DATA SOURCES We searched five databases, handsearched references of included studies and tracked citations. ELIGIBILITY Included studies investigated: individuals with ACL tear or meniscus injury; mean age <35 years; and PROM thresholds calculated using any method to define a minimal important change (MIC) or a meaningful post-treatment score (Patient Acceptable Symptom State (PASS) or Treatment Failure). RESULTS We included 18 studies (15 ACL, 3 meniscus). Three different methods were used to calculate anchor-based MICs across 9 PROMs, PASS thresholds across 4 PROMs and treatment failure for 1 PROM. Credibility was rated 'high' for only one study-an MIC of 18 for the Knee injury and Osteoarthritis Outcome Score Quality-of-life (KOOS-QOL) subscale (using the MID Credibility Assessment Tool). Where multiple thresholds were calculated among 'low' credibility thresholds in ACL studies, MICs converged to within a 10-point range for KOOS-Symptoms (-1.2 to 5.4) and function in daily living (activities of daily living, ADL 0.5-8.1) subscales, and the International Knee Documentation Committee Subjective Knee Form (7.1-16.2). Other PROM thresholds differed up to 30 points. PASS thresholds converged to within a 10-point range in KOOS-ADL for ACL tears (92.3-100), and KOOS-Symptoms (73-78) and KOOS-QOL (53-57) in meniscus injuries. CONCLUSION Meaningful PROM thresholds were highly susceptible to study heterogeneity. While PROM thresholds can aid interpretability in research and clinical practice, they should be cautiously interpreted.
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Affiliation(s)
- Erin M Macri
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.,Dept General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - James J Young
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Research Division, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | | | - Karim M Khan
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Berend Terluin
- Department of General Practice, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Carsten Bogh Juhl
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, Denmark
| | - Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.,Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Adam G Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Kay M Crossley
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Ewa M Roos
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
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Cusano A, Kanski G, Uyeki C, Adams K, Cote MP, Muench LN, Connors JP, Garvin P, Messina JC, Berthold DP, Kissenberth MJ, Mazzocca AD. Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction. J Shoulder Elbow Surg 2022; 31:1426-1435. [PMID: 35122950 DOI: 10.1016/j.jse.2021.12.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/20/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown. METHODS Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups. RESULTS Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts. CONCLUSION When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.
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Affiliation(s)
- Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA.
| | - Gregory Kanski
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Colin Uyeki
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Kyle Adams
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Lukas N Muench
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - John Patrick Connors
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Patrick Garvin
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - James C Messina
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Daniel P Berthold
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | | | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
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Forsythe B, Chahla J, Korrapati A, Lavoie-Gagne O, Forlenza E, Diaz CC, Chung CB, Bae WC, Bach BR, Cole B, Yanke AB, Verma NN. Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial. Arthroscopy 2022; 38:2255-2264. [PMID: 35042007 DOI: 10.1016/j.arthro.2022.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts. METHODS A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft. RESULTS Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P = .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P = .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P = .02). CONCLUSIONS Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point. LEVEL OF EVIDENCE I, randomized control trial.
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Affiliation(s)
- Brian Forsythe
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A..
| | - Jorge Chahla
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Avinaash Korrapati
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Enrico Forlenza
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Connor C Diaz
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Christine B Chung
- Department of Radiology, University of California, San Diego, California, U.S.A
| | - Won C Bae
- Department of Radiology, University of California, San Diego, California, U.S.A
| | - Bernard R Bach
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Brian Cole
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
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Maheshwer B, Polce EM, Parvaresh KC, Paul K, Yanke AB, Forsythe B, Bush-Joseph CA, Bach BR, Cole BJ, Verma NN, Kogan M, Chahla J. Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients. J Pediatr Orthop 2022; 42:e641-e648. [PMID: 35297390 DOI: 10.1097/bpo.0000000000002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE Level IV: case series.
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Affiliation(s)
- Bhargavi Maheshwer
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH
| | - Evan M Polce
- University of Wisconsin College of Medicine, Madison, WI
| | | | - Katlynn Paul
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Adam B Yanke
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Monica Kogan
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Jeon YS, Lee JW, Kim SH, Kim SG, Kim YH, Bae JH. Determining the Substantial Clinical Benefit Values for Patient-Reported Outcome Scores After Primary ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671221091795. [PMID: 35547609 PMCID: PMC9083051 DOI: 10.1177/23259671221091795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Little is known about the threshold of patient-reported outcomes (PROs) at which patients perceive to have attained a substantial clinical benefit (SCB) after anterior cruciate ligament reconstruction (ACLR). Purpose: To determine the SCB value of PROs 1 year after ACLR in the general population and to determine factors that predict SCB attainment. Study Design: Case series; Level of evidence, 4. Methods: The Lysholm, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), Tegner, and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scores were examined postoperatively in 88 patients who underwent ACLR. At the 12-month follow-up visit, the patients answered 2 independent anchor questions about daily discomfort and functional recovery. Receiver operating characteristic (ROC) curve analysis was used to differentiate PRO scores between patients who responded as having no difficulty versus some difficulty with daily knee discomfort (anchor question 1) and between patients with substantial recovery versus nonsubstantial recovery of knee function (anchor question 2). The area under the ROC curve (AUC) was calculated to assess reliability, and the differences between the AUC values were compared. Multivariate logistic regression analyses were performed to determine predictors affecting SCB attainment. Results: There were 76 patients enrolled in this study. The 12-month Lysholm, IKDC-SKF, Tegner, and ACL-RSI scores that corresponded to the SCB were 88.0, 85.1, 6.5, and 64.2 for anchor question 1 and 84.5, 77.7, 5.5, and 57.1 for anchor question 2, respectively. The AUC values obtained from the ROC curve analyses showed acceptable to excellent reliability (anchor question 1: Lysholm, 0.90; IKDC-SKF, 0.86; Tegner, 0.71; ACL-RSI, 0.92; anchor question 2: Lysholm, 0.80; IKDC-SKF, 0.90; Tegner, 0.82; ACL-RSI, 0.82) and were all statistically significant ( P < .001 to P = .028). For all PROs, younger age (Odds Ratio (OR), 0.88-0.94; P < .001 to P = .027) and greater muscle strength (OR, 1.03-1.07; P < .001 to P = .023) were predictive factors of SCB attainment. Conclusion: The postoperative Lysholm, IKDC-SKF, Tegner, and ACL-RSI scores showed acceptable to excellent reliability in predicting the SCB after ACLR in the general population. Age at surgery and thigh muscle strength influenced SCB attainment for all PROs.
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Affiliation(s)
- Young-Sik Jeon
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ja-Woon Lee
- Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Soo-Hyun Kim
- Department of Orthopedic Surgery, Naval Maritime Medical Center, Jinju, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, National Medical Center, Seoul, Republic of Korea
| | - Young-Ha Kim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Bae
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Maximum subjective outcome improvement is reported by 3 Months following arthroscopic partial meniscectomy: A systematic review. J Orthop 2022; 31:78-85. [PMID: 35496357 PMCID: PMC9043384 DOI: 10.1016/j.jor.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/03/2022] [Accepted: 04/11/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To review patient outcomes in the literature following arthroscopic partial meniscectomy (APM) in order to identify when patients report reaching subjective maximal improvement postoperatively. Methods A systematic review of the literature from January 2004 to August 2019 was conducted using PRISMA guidelines to identify articles evaluating patient-reported outcome measures (PROMs) up to a minimum of 6 months after APM in patients >18 years old. Studies were excluded if additional interventions were performed such as repairs, ligamentous reconstruction or repair, cartilaginous manipulation, or revision surgery. PROMs were pooled between studies at preoperative, 3 months, 6 months, 1 year, and 2 year time points. Weighted averages were used within a mixed model method in order to account for the differences in sample size and variance among studies. Significant improvements in PROMs at various time intervals were statistically analyzed using minimal clinically important difference. Results A total of 12 studies including 1663 patients who underwent APM were selected for the review. The pooled cohort consisted of 1033 (62%) males and 630 (38%) females. Significant improvements were demonstrated from preoperative scores to 3 months postoperatively in Knee Injury and Osteoarthritis Outcome Score subcategories, Lysholm, and visual analog scale scores while no differences were found for Tegner and International Knee Documentation Committee scores. Although statistically significant improvement in PROMs remained at all postoperative time points compared to preoperative scores, no significant differences were observed after 3 months postoperatively. Conclusions Patients undergoing APM had significant mean changes in legacy PROMs by 3 months postoperatively that exceeded given minimal clinically important difference values, without further clinically important improvement reported up to 2 years postoperatively. Study design Level III, systematic review.
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Feng J, Cao Y, Tan L, Liang J, He C, He J, Wu S. Anterior cruciate ligament reconstruction with lateral extra-articular tenodesis reduces knee rotation laxity and graft failure rate: A systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2022; 30:10225536221095969. [PMID: 35465765 DOI: 10.1177/10225536221095969] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) reduces rotational laxity of the knee, and to compare the clinical results of this treatment with those of ACLR alone. METHODS PubMed, Embase, and Cochrane Library were searched by two researchers for clinical studies comparing ACLR with and without LET. Studies with only evidence levels I and II and studies in which anterior lateral ligament reconstruction was performed with grafts were excluded. The risk of bias of the studies was assessed using the Cochrane risk-of-bias and modified Downs & Black tools. The outcomes included (1) functional outcomes; (2) knee laxity measures; (3) knee injury osteoarthritis and outcome score; and (4) complications. The outcomes of the two groups were extracted, summarized and compared. RESULTS A total of 234 studies were retrieved and 223 were excluded. Eleven clinical studies with 1745 patients were included in our meta-analysis. Compared to the patients who underwent ACLR alone, the patients who underwent ACLR with LET had reduced pivot-shift (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.31 to 0.74, p = 0.0009), and lower graft failure rate (OR 0.34, 95% CI 0.20 to 0.55, p < 0.0001). CONCLUSION Compared with ACLR only, ACLR combined with LET can effectively reduce rotation laxity of the knee joint, and reduce the graft failure rate in high-risk patients. However, the effects on the function and activity level of patients cannot be confirmed.
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Affiliation(s)
- Jing Feng
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Yangbo Cao
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Lingjie Tan
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Jiehui Liang
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Chunrong He
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Jinshen He
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
| | - Song Wu
- Department of Orthopaedic Surgery, 504354Third Xiangya Hospital of Central South University, Changsha, China
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Schneider MB, Kung JE, Zhang T, Rocca MS, Foster MJ, Meredith SJ, Leong NL, Packer JD, Henn RF. Patient Perception of Being "Completely Better" After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:1215-1221. [PMID: 35225001 DOI: 10.1177/03635465221074331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Contextualizing patient-reported outcomes (PROs) by defining clinically relevant differences is important. Considering that anterior cruciate ligament reconstruction (ACLR) ideally results in the restoration of normal knee function, an assessment of patients' perception of being "completely better" (CB) may be of particular value. PURPOSE The purpose of this study was to assess the prevalence and characteristics of patients who self-report a CB status after ACLR. Additionally, we aimed to determine whether PROs were associated with a CB status after ACLR as well as to determine CB status thresholds for 2-year and change in values. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS We retrospectively analyzed data from an orthopaedic registry at a single institution. Patients were administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and International Knee Documentation Committee (IKDC) Subjective Knee Form preoperatively and at 2 years after ACLR. Additionally, patients completed a CB anchor question at 2 years after ACLR. Thresholds for 2-year and change in PRO scores associated with achieving a CB status were identified with 90% specificity. RESULTS Overall, 95 of the 136 patients (69.9%) considered their condition to be CB at 2 years after surgery. The 2-year and change in PROMIS PF, PROMIS PI, and IKDC scores were significantly better in the CB group than in the non-CB group. Thresholds associated with a CB status for 2-year PROMIS PF, PROMIS PI, and IKDC scores were more reliable than those for changes in scores and were ≥63, ≤44, and ≥80, respectively. Thresholds for the change in PROMIS PF, PROMIS PI, and IKDC scores were ≥19, ≤-16, and ≥44, respectively. CONCLUSION The majority of patients reported that they were CB at 2 years after ACLR. This study may serve as a reference for orthopaedic surgeons and researchers when considering outcomes after ACLR.
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Affiliation(s)
- Matheus B Schneider
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Justin E Kung
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tina Zhang
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael S Rocca
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael J Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie L Leong
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Walsh JM, Huddleston HP, Alzein MM, Wong SE, Forsythe B, Verma NN, Cole BJ, Yanke AB. The Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State after Medial Patellofemoral Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e661-e678. [PMID: 35494257 PMCID: PMC9042905 DOI: 10.1016/j.asmr.2021.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 12/12/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Adam B. Yanke
- Address correspondence to Adam B. Yanke, M.D., Ph.D., Rush University Medical Center, 1611 W. Harrison St., Chicago, IL 60612, U.S.A.
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Deviandri R, der Veen HCV, Lubis AM, Postma MJ, van den Akker-Scheek I. Translation and Psychometric Analysis of the Indonesian Versions of the Lysholm and Tegner Scores for Patients With Anterior Cruciate Ligament Injuries. Orthop J Sports Med 2022; 10:23259671211066506. [PMID: 35097144 PMCID: PMC8793459 DOI: 10.1177/23259671211066506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The Lysholm knee score and Tegner activity scale are frequently used patient-reported outcome measures in patients with anterior cruciate ligament (ACL) injuries because of their excellent psychometric properties. These questionnaires were originally developed in the English language. Purpose: To translate and cross-culturally adapt these measures into the Indonesian language and study their validity and reliability so that they can be used in the Indonesian-speaking population with ACL injuries. Study Design: Cohort study (diagnosis/symptom prevalence); Level of evidence, 2. Methods: After a forward-backward translation procedure and cross-cultural adaptation, validity and reliability were investigated. A total of 253 patients with an ACL injury were sent 4 questionnaires (36-Item Short Form Health Survey, Kujala anterior knee pain scale, Indonesian Lysholm knee score [I-LK], and Indonesian Tegner activity scale [I-TS]). The responses of those patients were analyzed. Following COSMIN guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement errors were determined. The Bland-Altman method was used to explore absolute agreement. Results: A total of 106 patients (42% response rate) were included in this study. Construct validity was considered to be good, as more than 75% of the predefined hypotheses on correlations between the I-LK, I-TS, and other measures were confirmed. Reliability proved excellent, with a high test-retest correlation for both questionnaires (intraclass correlation coefficient = 0.99). Bland-Altman analysis showed no systematic bias between testing and retesting. The internal consistency of the I-LK was good (Cronbach alpha = 0.73). For the I-LK and I-TS, floor and ceiling effects were less than 15% (floor: 0% and 4.7%, respectively; ceiling: 12.3% and 3.8%, respectively); the standard error of measurement was 1.8 and 0.9, respectively; the minimal detectable change at the individual level was 5.1 and 0.6, respectively; and the minimal detectable change at the group level was 2.4 and 0.5, respectively. Conclusion: Both the I-LK and I-TS appear to be good evaluation tools for Indonesian-speaking patients with an ACL injury.
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Affiliation(s)
- Romy Deviandri
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Physiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia
- Division of Orthopedics-Sports Injury, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - Hugo C. van der Veen
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Andri M.T. Lubis
- Department of Orthopedics, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Maarten J. Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, the Netherlands
- Department of Pharmacology and Therapy, Universitas Airlangga, Surabaya, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Agarwalla A, Gowd AK, Liu JN, Garcia GH, Jan K, Naami E, Wysocki RW, Fernandez JJ, Cohen MS, Verma NN. Return to Sport Following Distal Triceps Repair. J Hand Surg Am 2022; 48:507.e1-507.e8. [PMID: 35074247 DOI: 10.1016/j.jhsa.2021.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 09/18/2021] [Accepted: 11/10/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE The purpose of this investigation was to examine the timeline of return-to-sport following distal triceps repair; evaluate the degree of participation and function upon returning to sport; and identify risk factors for failure to return to sport. METHODS Patients who underwent distal triceps repair with a minimum of 1 year of follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire and were scored on a visual analog scale for pain; the Mayo Elbow Performance Index; the Quick Disabilities of the Arm, Shoulder, and Hand; and the Single Assessment Numerical Evaluation. RESULTS Out of 113 eligible patients who had a distal triceps repair, 81 patients (71.7%) were contacted. Sixty-eight patients (84.0%) who participated in sports prior to surgery were included at 6.0 ± 4.0 years after surgery, and the average age was 46.6 ± 11.5 years. Sixty-one patients (89.7%) resumed playing at least 1 sport by 5.9 ± 4.4 months following distal triceps repair. However, 18 patients (29.5%) returned to a lower level of activity intensity. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand; Mayo Elbow Performance; visual analog scale for pain; and Single Assessment Numerical Evaluation scores were 8.2 ± 14.0, 89.5 ± 13.4, 2.0 ± 1.7, and 82.2 ± 24.3, respectively. No patients underwent revision surgery at the time of final follow-up. CONCLUSIONS Distal triceps repair enables 89.7% of patients to return to sport by 5.9 ± 4.4 months following surgery. However, 29.5% of patients were unable to return to their preinjury level of activity. It is imperative that patients are appropriately educated to manage postoperative expectations regarding sport participation following distal triceps repair. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Joseph N Liu
- Department of Orthopedic Surgery, Loma Linda Medical Center, Loma Linda, CA
| | | | - Kyleen Jan
- School of Medicine, University of Illinois, Chicago, IL
| | - Edmund Naami
- School of Medicine, University of Illinois, Chicago, IL
| | - Robert W Wysocki
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - John J Fernandez
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Mark S Cohen
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Nikhil N Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL.
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Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1871-1879. [PMID: 34870732 PMCID: PMC9159288 DOI: 10.1007/s00167-021-06819-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection. METHODS In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients' outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR. RESULTS Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6-16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work. CONCLUSION Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients' expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low. LEVEL OF EVIDENCE IV.
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Ting CH, Scholes C, Zbrojkiewicz D, Bell C. Baseline Analysis of Patients Presenting for Surgical Review of Anterior Cruciate Ligament Rupture Reveals Heterogeneity in Patient-Reported Outcome Measures. J Knee Surg 2022; 35:159-166. [PMID: 32629513 DOI: 10.1055/s-0040-1713658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite the establishment of successful surgical techniques and rehabilitation protocols for anterior cruciate ligament (ACL) reconstruction, published return to sport rates are less than satisfactory. This has led orthopaedic surgeons and researchers to develop more robust patient selection methods, and investigate prognostic patient characteristics. No previous studies have integrated baseline characteristics and responses to patient-reported outcome measures (PROMs) of patients with ACL rupture presenting for surgical review. Patients electing to undergo ACL reconstruction under the care of a single orthopaedic surgeon at a metropolitan public hospital were enrolled in a clinical quality registry. Patients completed Veterans RAND 12-item Health Survey (VR-12) Physical Component Summary and Mental Component Summary scores, Tegner activity scale, and International Knee Documentation Committee (IKDC) questionnaires at presentation. Total scores were extracted from the electronic registry, and a machine learning approach (k-means) was used to identify subgroups based on similarity of questionnaire responses. The average scores in each cluster were compared using analysis of variance (ANOVA; Kruskal-Wallis) and nominal logistic regression was performed to determine relationships between cluster membership and patient age, gender, body mass index (BMI), and injury-to-examination delay. A sample of 107 patients with primary ACL rupture were extracted, with 97 (91%) available for analysis with complete datasets. Four clusters were identified with distinct patterns of PROMs responses. These ranged from lowest (Cluster 1) to highest scores for VR-12 and IKDC (Cluster 4). In particular, Cluster 4 returned median scores within 6 points of the patient acceptable symptom state for the IKDC score for ACL reconstruction (70.1, interquartile range: 59-78). Significant (p < 0.05) differences in PROMs between clusters were observed using ANOVA, with variance explained ranging from 40 to 69%. However, cluster membership was not significantly associated with patient age, gender, BMI, or injury-to-examination delay. Patients electing to undergo ACL reconstruction do not conform to a homogenous group but represent a spectrum of knee function, general physical and mental health, and preinjury activity levels, which may not lend itself to uniform treatment and rehabilitation protocols. The factors driving these distinct responses to PROMs remain unknown but are unrelated to common demographic variables.
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Affiliation(s)
- Chee Han Ting
- Department of Orthopaedics, QEII Jubilee Hospital, Coopers Plains, Queensland, Australia
| | | | - David Zbrojkiewicz
- Department of Orthopaedics, QEII Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Christopher Bell
- Department of Orthopaedics, QEII Jubilee Hospital, Coopers Plains, Queensland, Australia
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Cinque ME, Kunze KN, Williams BT, Moatshe G, LaPrade RF, Chahla J. Higher Incidence of Radiographic Posttraumatic Osteoarthritis With Transtibial Femoral Tunnel Positioning Compared With Anteromedial Femoral Tunnel Positioning During Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:255-263. [PMID: 33769902 DOI: 10.1177/0363546521993818] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear. PURPOSE To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA. STUDY DESIGN Systematic review and Meta-analysis. METHODS The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches. RESULTS There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up. CONCLUSION TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and >10-year follow-up).
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Affiliation(s)
- Mark E Cinque
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Brady T Williams
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Jorge Chahla
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Stone AV, Murphy ML, Jacobs CA, Lattermann C, Hawk GS, Thompson KL, Conley CEW. Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure. Cartilage 2022; 13:19476035221087703. [PMID: 35333656 PMCID: PMC9137305 DOI: 10.1177/19476035221087703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/19/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs. DESIGN Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders. RESULTS A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654). CONCLUSION Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses. LEVEL OF EVIDENCE Level III, retrospective therapeutic study.
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Affiliation(s)
- Austin V. Stone
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Meredith L. Murphy
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Cale A. Jacobs
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Christian Lattermann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory S. Hawk
- Department of Statistics, University of Kentucky, Lexington, KY, USA
| | | | - Caitlin E. W. Conley
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
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Katagiri H, Nakagawa Y, Miyatake K, Ozeki N, Kohno Y, Amemiya M, Sekiya I, Koga H. Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft. J Knee Surg 2021; 36:613-621. [PMID: 34952548 DOI: 10.1055/s-0041-1740927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. METHODS Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test. RESULTS Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). STUDY DESIGN This was a level 3 retrospective study. CONCLUSION Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.
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Affiliation(s)
- Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopedic Surgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Saitama, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutake Ozeki
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Yuji Kohno
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Masaki Amemiya
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Ichiro Sekiya
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Bruder J, Ballenberger N, Villas B, Haugan C, McKenzie K, Patel Z, Zalpour C, Mevawala A, Handl M, Guptill C. MusicCohort: Pilot feasibility of a protocol to assess students' physical and mental health in a Canadian post-secondary school of music. BMC Res Notes 2021; 14:441. [PMID: 34863309 PMCID: PMC8642914 DOI: 10.1186/s13104-021-05829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Music-related physical and mental health conditions are common among post-secondary music students, with many studies reporting a prevalence greater than 70%. However, there is currently no consensus on appropriate, validated assessments for this population. The aim of this pilot study was to test the feasibility of an assessment protocol developed for a German longitudinal study with Canadian post-secondary music students, and to compare the health of music students to non-music students. Using a cross-sectional design, first-semester music and non-music control students were recruited at two campuses at the same university. Both groups completed questionnaires and physical testing, including range of motion, core strength, and pressure pain threshold. Nineteen music students and 50 non-music student controls participated in this study. Results The German protocol is feasible in a Canadian post-secondary setting. Canadian music students demonstrated similar health outcomes to those in the parent study. All participants demonstrated poorer mental and physical quality of life than the Canadian norms, though this was not statistically significant. The results of this study should be confirmed in a larger study. Future studies with larger sample sizes can provide further insight into the health of Canadian music students, providing a basis for prevention and intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s13104-021-05829-9.
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Affiliation(s)
- Julius Bruder
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Nikolaus Ballenberger
- Department of Economics and Social Sciences, Hochschule Osnabrück, Albrechtstr. 30, 49076, Osnabrück, Germany
| | - Bethany Villas
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Charlotte Haugan
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Kimiko McKenzie
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Zalak Patel
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Christoff Zalpour
- Department of Economics and Social Sciences, Hochschule Osnabrück, Albrechtstr. 30, 49076, Osnabrück, Germany
| | - Amynah Mevawala
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Melisa Handl
- Faculty of Law, University of Ottawa, Ottawa, Canada
| | - Christine Guptill
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, 3071 Guindon Hall, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
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Maheshwer B, Wong SE, Polce EM, Paul K, Forsythe B, Bush-Joseph C, Bach BR, Yanke AB, Cole BJ, Verma NN, Chahla J. Establishing the Minimal Clinically Important Difference and Patient-Acceptable Symptomatic State After Arthroscopic Meniscal Repair and Associated Variables for Achievement. Arthroscopy 2021; 37:3479-3486. [PMID: 33964390 DOI: 10.1016/j.arthro.2021.04.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) after arthroscopic meniscal repair and identify the factors associated with achieving these outcomes. METHODS This is a retrospective study with prospectively collected data. Patient-reported outcome measures (PROMs) were collected from April 2017 to March 2020. All patients who underwent arthroscopic meniscal repair and completed both preoperative and postoperative PROMs were included in the analysis. MCID and PASS were calculated via half the standard deviation of the delta PRO change from baseline (for International Knee Documentation Committee Score [IKDC]) and via anchor-based methodology (Knee Injury and Osteoarthritis Outcome Score [KOOS] subscales). RESULTS Sixty patients were included in the final analysis. The established MCID threshold values were 10.9 for IKDC, 12.3 for KOOS Symptoms, 11.8 for KOOS Pain, 11.4 for KOOS Activities of Daily Living (ADL), 16.7 for KOOS Sport, and 16.9 for KOOS Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 69.0 for IKDC, 75.0 for KOOS Symptoms, 80.6 for KOOS Pain, 92.7 for KOOS ADL, 80.0 for KOOS Sport, and 56.3 for KOOS QoL. Higher preoperative PRO scores were associated with lower likelihood of achieving MCID. Concomitant ligament procedures were associated with a higher likelihood of achieving PASS. Tears to both menisci were associated with decreased likelihood of achieving MCID and PASS for IKDC. Horizontal tears were associated with decreased likelihood of achieving PASS for IKDC and KOOS. Complex tears were associated with decreased likelihood of achieving MCID for KOOS. CONCLUSION Clinically meaningful outcomes such as MCID and PASS were established for meniscal repair surgery using selected PROMs for IKDC and KOOS subscales. Variables more likely to be associated with achieving these outcomes include lower preoperative PRO score and concomitant ligament procedure, whereas higher preoperative PRO score, tearing of both medial and lateral menisci, and horizontal and complex tear classifications were associated with decreased likelihood of achieving these outcomes. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
| | - Stephanie E Wong
- University of California San Francisco Medical Center, San Francisco, CA, U.S.A
| | - Evan M Polce
- University of Wisconsin College of Medicine, Madison, WI, U.S.A
| | | | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Charles Bush-Joseph
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Adam B Yanke
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A..
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Paatela T, Vasara A, Sormaala M, Nurmi H, Kautiainen H, Kiviranta I. Chondral and Osteochondritis Dissecans Lesions Treated by Autologous Chondrocytes Implantation: A Mid- to Long-Term Nonrandomized Comparison. Cartilage 2021; 13:1105S-1112S. [PMID: 32602351 PMCID: PMC8808789 DOI: 10.1177/1947603520935953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the clinical outcome of cartilage repair with autologous chondrocyte implantation (ACI) in patients with osteochondritis dissecans (OCD) lesions and full-thickness cartilage lesions. DESIGN This study included a cohort of 115 consecutive patients with a cartilage lesion of the knee treated with ACI. Of the patients, 35 had an OCD lesion and 80 a full-thickness cartilage lesion. During a follow-up period from 2 to 13 years all treatment failures were identified. The failure rate between OCD lesions and full-thickness cartilage lesions was compared with Kaplan-Meier analysis. Patient-reported outcome was evaluated 2 years postoperatively with the Lysholm score. RESULTS During the follow-up 21 out of 115 patients encountered a treatment failure. The failure rate for full-thickness cartilage lesions was 19.1% and for OCD lesions 43.3% over the 10-year follow-up. Patient-reported outcome improved from baseline to 2 years postoperatively. The improvement from baseline was statistically significant, and the Lysholm score improved more than the minimal clinically important difference. The patient-reported outcome showed no difference between lesion types at 2 years. CONCLUSIONS In the presented retrospective study, the failure rate of first-generation ACI was higher in OCD lesions than in large full-thickness cartilage lesions, suggesting that OCD lesions may associate with properties that affect the durability of repair tissue. Future prospective studies are needed to tell us how to best repair OCD lesions with biological tissue engineering.
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Affiliation(s)
- Teemu Paatela
- Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland,Teemu Paatela, Department of Orthopaedics
and Traumatology, Helsinki University Hospital, PO Box 900, Topeliuksenkatu 5,
Helsinki FI-00029 HUS, Finland.
| | - Anna Vasara
- Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Markus Sormaala
- Department of Radiology, Helsinki
University Hospital, Helsinki, Finland
| | - Heikki Nurmi
- Department of Orthopaedics and
Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio
University Hospital, Kuopio, Finland,Folkhälsan Research Center, Helsinki,
Finland
| | - Ilkka Kiviranta
- Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland,Department of Orthopaedics and
Traumatology, University of Helsinki, Helsinki, Finland
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