A scientific approach to optimal treatment of cruciate ligament injuries

Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group

A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

PURPOSE

A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed.

METHODS

To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method.

RESULTS

In general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated.

CONCLUSION

This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

LEVEL OF EVIDENCE

V.

Non-operative treatment of ACL injury is associated with opposing subjective and objective outcomes over 20 years of follow-up

PURPOSE

The aim of this study was the evaluation of long-term clinical and radiological outcomes of non-operative treatment of anterior cruciate ligament (ACL) deficiency. The hypothesis was that conservative treatment would be associated with a deterioration of subjective and objective measures of joint health and disability over time.

METHODS

From an initial sample of 41 patients conservatively treated for ACL rupture, 10 received secondary ACL reconstruction, 1 was excluded due to contralateral ACL injury, and 1 patient required total knee replacement and a high tibial osteotomy. Seven further patients were lost to follow-up. The remaining 21 patients (15 male, 6 female, mean age 53.1 ± 9.2 years at the last follow-up) were evaluated by the same two examiners 5-7, 10-13 and 20-22 years after the injury. The evaluation was based on objective and subjective scores, instrumented testing, radiographic examination and assessment of sports activity.

RESULTS

While subjective patient satisfaction improved over time, objective scores stayed constant or deteriorated (radiologic evaluation). Instrumented knee laxity testing showed an initial tendency to increasing instability, followed by a decrease in anterior tibial translation in the second half of the observation period. Physical activity levels, particularly in high-risk sports, decreased significantly (p < 0.05) compared to preinjury levels. All patients developed significant arthritic degenerative changes over time compared to the uninjured contralateral knee. No correlation to activities in high- or low-risk pivoting sports was found.

CONCLUSIONS

Patient satisfaction with conservative treatment of ACL injuries is good in spite of objective measures indicating increasing degenerative changes.

LEVEL OF EVIDENCE

IV.

KNEES-ACL has superior responsiveness compared to the most commonly used patient-reported outcome measures for anterior cruciate ligament injury

PURPOSE

For clinical trials, it is essential that measures are sensitive to change. The aim of this study was to conduct a head-to-head comparison of responsiveness of four PROMs used to measure outcome after anterior cruciate ligament (ACL) reconstruction. The PROMs compared were the knee injury osteoarthritis outcome score (KOOS), the international knee documentation committee subjective form (IKDC), the Lysholm score, and the knee numeric-entity evaluation score (KNEES-ACL). We hypothesized that KNEES-ACL would be more responsive than the other PROMs, as KNEES-ACL was created based on patient interviews and validated using Rasch analysis.

METHODS

One-hundred and sixty-six consecutive adults completed the four PROMs before and 3, 6, and 12 months after ACL-reconstructive surgery. Responsiveness was calculated as Cohen's Effect Size and Standardized Response Means. Bootstrapping was used to generate 95% confidence intervals for comparisons of responsiveness across PROMs. Repeated-measures ANOVA was also computed for each PROM.

RESULTS

The largest effect sizes at 12 months were seen for KNEES-ACL_{Sports-Behaviour} (1.35, p < 0.001) and KNEES-ACL_{Sports-Physical} (1.19, p < 0.001), the smallest for KOOS_ADL (0.35, p < 0.001) and KOOS_Symptoms (0.39, p < 0.001). IKDC and Lysholm lay between these with IKDC slightly more responsive. Head-to-head comparisons of similar subscales of KOOS and KNEES-ACL showed substantial differences in effect size in the domains of symptoms (0.69, p < 0.001), daily activities (0.31, p = 0.005), and Sports activity (0.63, p = 0.013) all in favour of KNEES-ACL.

CONCLUSION

These results demonstrate superior responsiveness for KNEES-ACL, which is the only PROM that has been constructed through exhaustive patient feedback and validated for patients with ACL deficiency using the most stringent psychometric methods (Rasch analysis). KNEES-ACL is the most precise and accurate PROM for patients with ACL injury and the most trustworthy instrument for clinicians and clinical researchers.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers

OBJECTIVE

To perform a systematic review of findings from the Scandinavian knee ligament registers with regard to factors that affect patient reported outcome after anterior cruciate ligament (ACL) reconstruction.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases: PubMed, EMBASE, the Cochrane Library and AMED were searched, and 157 studies were identified. Two reviewers independently screened the titles, abstracts and full text articles for eligibility. A modified version of the Downs and Black checklist was applied for quality appraisal.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies published from the Scandinavian registers from their establishment in 2004 and onwards that documented patient reported outcome and provided information on concomitant injuries were eligible.

RESULTS

A total of 35 studies were included. Younger age at ACL reconstruction, male sex, not smoking and receiving a hamstring tendon autograft positively influenced patient reported outcome. Patients with concomitant cartilage and meniscal injuries reported inferior subjective knee function compared with patients with an isolated ACL tear. One study reported that patients treated non-reconstructively reported inferior knee function compared with patients who had ACL reconstruction.

CONCLUSION

Younger age, male sex, not smoking, receiving a hamstring tendon autograft and the absence of concomitant injuries were associated with superior patient reported outcomes after ACL reconstruction.

Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence?

Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.

Factors related to the need for surgical reconstruction after anterior cruciate ligament rupture: a systematic review of the literature

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To summarize and evaluate research on factors predictive of progression to surgery after nonoperative treatment for an anterior cruciate ligament (ACL) rupture.

BACKGROUND

Anterior cruciate ligament rupture is a common injury among young, active individuals. Surgical reconstruction is often required for patients who do not regain satisfactory knee function following nonsurgical rehabilitation. Knowledge of factors that predict the need for surgical reconstruction of the ACL would be helpful to guide the decision-making process in this population.

METHODS

A search was performed for studies predicting the need for surgery after nonoperative treatment for ACL rupture in the Embase, MEDLINE (OvidSP), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials, PubMed, and Google Scholar digital databases from inception to October 2013. Two reviewers independently selected the studies and performed a quality assessment. Best-evidence synthesis was used to summarize the evidence of factors predicting the need for surgical reconstruction after nonoperative treatment for an ACL rupture.

RESULTS

Seven studies were included, 3 of which were of high quality. Based on these studies, neither sex (strong evidence) nor the severity of knee joint laxity (moderate evidence) can predict whether, soon after ACL injury, a patient will need ACL reconstruction following nonoperative treatment. All other factors identified in this review either had conflicting or only minimal evidence as to their level of association with the need for surgical reconstruction. Noteworthy is that 1 high-quality study reported that the spherical shape of the femoral condyle was predictive of the need for ACL reconstruction.

CONCLUSION

Sex and knee joint laxity tests do not predict the need for ACL reconstruction soon after an ACL rupture. Independent validation in future research will be necessary to establish whether knee shape is a predictive factor.

LEVEL OF EVIDENCE

Prognosis, level 1a-.

Dimensionality of the Knee Numeric-Entity Evaluation Score (KNEES-ACL): a condition-specific questionnaire

The benefit of anterior cruciate ligament (ACL) reconstruction has been questioned based on patient-reported outcome measures (PROMs). Valid interpretation of such results requires confirmation of the psychometric properties of the PROM. Rasch analysis is the gold standard for validation of PROMs, yet PROMs used for ACL reconstruction have not been validated using Rasch analysis. We used Rasch analysis to investigate the psychometric properties of the Knee Numeric-Entity Evaluation Score (KNEES-ACL), a newly developed PROM for patients treated for ACL deficiency. Two-hundred forty-two patients pre- and post-ACL reconstruction completed the pilot PROM. Rasch models were used to assess the psychometric properties (e.g., unidimensionality, local response dependency, and differential item functioning). Forty-one items distributed across seven unidimensional constructs measuring impairment, functional limitations, and psychosocial consequences were confirmed to fit Rasch models. Fourteen items were removed because of statistical lack of fit and inadequate face validity. Local response dependency and differential item functioning were identified and adjusted. The KNEES-ACL is the first Rasch-validated condition-specific PROM constructed for patients with ACL deficiency and patients with ACL reconstruction. Thus, this instrument can be used for within- and between-group comparisons.