Remnant-Sparing Anterior Cruciate Ligament Reconstruction Results in Similar Clinical, Functional, and Quality-of-Life Outcomes to Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Purpose

To compare a large cohort of patients who underwent remnant-sparing anterior cruciate ligament reconstruction (rACLR) with a matched group of patients who underwent anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) with respect to clinical laxity, patient-reported outcomes, and functional testing.

Methods

Patients who underwent rACLR between January 2010 and December 2015 were matched according to age, sex, body mass index, and graft type to patients who underwent ACLR. The primary outcome measure was the ACL Quality of Life (ACL-QOL) score at final follow-up of 24 months. Secondary outcomes included functional tests and clinical laxity measurements at 6, 12, and 24 months postoperatively. Concurrent intra-articular pathology at the time of surgery and postoperative complications were also recorded. Statistical analyses included the dependent t test and the Wilcoxon signed rank test.

Results

A total of 210 rACLR patients were successfully matched to a corresponding cohort of 210 ACLR patients. There were no statistically significant differences in ACL Quality of Life (ACL-QOL) or functional testing results between the groups; however, scores in both groups showed a steady and statistically significant improvement over time. A statistically significant difference was noted with respect to the Lachman test findings, favoring the rACLR cohort (Z = -2.79, P = .005); no between-group difference was seen for the pivot-shift test (Z = -0.36, P = .72). The rACLR group had a significantly lower rate of concurrent meniscal and chondral injury. There was no difference in complications between the groups (Z = -0.49, P = .63).

Conclusions

There was no difference in patient-reported or functional testing outcomes in patients undergoing remnant-sparing compared with anatomic single-bundle ACLR. There was, however, a significantly lower rate of positive Lachman test findings after rACLR. Furthermore, the rate of concurrent meniscal and chondral pathology was lower in the rACLR group.

Level of Evidence

Level III, retrospective cohort study.

Palpation and fluoroscopy are valid but unreliable for the assessment of femoral tunnel position after medial patellofemoral ligament reconstruction

OBJECTIVES

The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy.

METHODS

Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment.

RESULTS

The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation.

CONCLUSION

This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted.

LEVEL OF EVIDENCE

Level 2.

Update and validation of the Canadian Behavior, Attitude and Nutrition Knowledge Survey (C-BANKS 2.0)

Aim

Understanding knowledge, attitudes and behaviors related to nutrition is crucial in developing effective intervention strategies to promote healthy eating habits. This study revised and updated the Canadian Behavior, Attitude and Nutrition Knowledge Survey (C-BANKS) to align with the current Canada's Food Guide and dietary guidance and report on its reliability and validity with a new population.

Method

Data from 167 early childhood educators were recruited to test the revised C-BANKS' reliability and validity. Reliability, as measured by internal consistency, was assessed using Cronbach's alpha, while concurrent validity was determined by correlating the C-BANKS 2.0 scores with the CHEERS (Creating Healthy Eating and Active Environments Survey) and Mindful Eating Questionnaire (MEQ). Responsiveness was assessed by comparing a baseline C-BANKS 2.0 score to a post-test score after completing an online healthy eating and physical activity educational intervention.

Results

The adapted C-BANKS 2.0 questionnaire demonstrated good internal consistency (Cronbach's alpha >0.70) and construct validity with related measures CHEERS and MEQ (p < 0.05). The C-BANKS 2.0 demonstrated strong responsiveness. Specifically, C-BANKS 2.0 scores increased after the nutrition education intervention (p < 0.001). Additionally, there were no signs of floor or ceiling effects.

Conclusion

The adapted C-BANKS 2.0 demonstrated satisfactory internal consistency, construct validity, and responsiveness to measure of nutrition knowledge, attitudes, and behaviors in an early childhood educator population. The revised C-BANKS 2.0 provides insight into the key factors that influence dietary habits thereby informing the design and evaluation of effective nutrition community intervention programs.

The Impact of COVID-19 on Eating Environments and Activity in Early Childhood Education and Care in Alberta, Canada: A Cross-Sectional Study

Early childhood education and care (ECEC) environments influence children's early development and habits that track across a lifespan. The purpose of this study was to explore the impact of COVID-19 government-mandated guidelines on physical activity (PA) and eating environments in ECEC settings. This cross-sectional study involved the recruitment of 19 ECEC centers pre-COVID (2019) and 15 ECEC centers during COVID (2020) in Alberta, Canada (n = 34 ECEC centers; n = 83 educators; n = 361 preschoolers). Educators completed the CHEERS (Creating Healthy Eating and activity Environments Survey) and MEQ (Mindful Eating Questionnaire) self-audit tools while GT3X+ ActiGraph accelerometers measured preschooler PA. The CHEERS healthy eating environment subscale was greater during COVID-19 (5.97 ± 0.52; 5.80 ± 0.62; p = 0.02) and the overall score positively correlated with the MEQ score (r = 0.20; p = 0.002). Preschoolers exhibited greater hourly step counts (800 ± 189; 649 ± 185), moderate-to-vigorous PA (MVPA) (9.3 ± 3.0 min/h; 7.9 ± 3.2 min/h) and lower sedentary times (42.4 ± 3.9 min/h; 44.1 ± 4.9 min/h) during COVID-19 compared to pre-COVID, respectively (p < 0.05). These findings suggest the eating environment and indices of child physical activity were better in 2020, which could possibly be attributed to a change in government-mandated COVID-19 guideline policy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

Common Physical Examination Tests for Patellofemoral Instability Demonstrate Weak Inter-Rater Reliability

Purpose

The purpose of this study was to assess the inter-rater reliability of 3 common physical examination assessments, the Q-angle, J-sign, and apprehension test, used to evaluate patients presenting with recurrent lateral patellofemoral instability.

Methods

A consecutive sample of 38 subjects with recurrent lateral patellofemoral instability in 2013 were included in this reliability study. Two orthopaedic surgeons performed the physical examination maneuvers blinded to each other. The physical examination tests were performed bilaterally and included the Q angle, the J-sign, and the apprehension test. To measure the inter-rater reliability, an intraclass correlation coefficient (ICC 2,κ) was used for both legs independently for Q-angle measurements. A Cohen’s kappa was used to measure the inter-rater reliability for the J-sign and the apprehension test.

Results

The measurement of the Q-angle demonstrated poor reliability (ICC 2,κ 0.18-0.44). The assessment of the J-sign demonstrated fair to moderate reliability (κ = 0.31 – 0.41), and the evaluation of apprehension demonstrated fair to substantial reliability (κ = 0.30 – 0.65). All 3 clinical tests demonstrated substantial variability comparing the reliability on the right and left limbs. Assessment of the quality of apprehension demonstrated good agreement between the examiners.

Conclusions

In this study of patients with recurrent lateral patellofemoral instability the common physical examination tests, Q-angle, J-sign, and apprehension demonstrated weak inter-rater reliability. These results indicate that these tests are not reliable for communication between health care practitioners or as evaluations for clinical research.

Level of Evidence

Level IV, therapeutic case series.

Patellar Apprehension Is Reduced in Most but Not All Patients After Successful Patellar Stabilization

BACKGROUND

The clinical sign of patellar laxity and the associated symptom of apprehension are mainstays of the physical examination of patellofemoral instability. The apprehension test is widely used as a diagnostic tool and also as an outcome following patellofemoral stabilization surgery. Despite widespread use, the validity, reliability, and responsiveness of the apprehension test have not been established.

PURPOSE

The primary purpose was to evaluate patellar apprehension in patients with recurrent patellofemoral instability to determine if the apprehension test is valid, reliable, and responsive to change after medial patellofemoral ligament (MPFL) reconstruction. The secondary purposes were to concurrently validate patient-rated to surgeon-rated apprehension and to correlate patient-rated apprehension with pathoanatomic characteristics and quality-of-life scores.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 89 patients underwent an MPFL reconstruction and were assessed preoperatively and at 6, 12, and 24 months postoperatively. The patellar apprehension test was performed in neutral extension and 30° of knee flexion. Patient- and surgeon-rated apprehension were graded on a 10-cm visual analog scale (VAS), and the quality of the apprehension symptoms were recorded. Risk factors for patellofemoral instability were documented, and the Banff Patellofemoral Instability Score 2.0 (BPII 2.0) was used to measure disease-specific quality of life.

RESULTS

The patient-rated and surgeon-rated apprehension VAS scores were statistically significantly reduced from pre- to postoperatively (P < .001, large effect size) for the neutral extension and 30° of flexion apprehension tests. Postoperatively, over 56% of patients reported a negative apprehension test. Up to 15.7% of patients with positive preoperative apprehension did not demonstrate a reduction postoperatively. Patients consistently graded their apprehension symptoms higher in both quantity and quality than the surgeon. The intraclass correlation coefficient (ICC [2, k]) assessing the preoperative patient and surgeon VAS scores revealed moderate interrater reliability in neutral extension (r = 0.60) and weak interrater reliability in 30° of flexion (r = 0.42). The postoperative ICC (2, k) demonstrated strong interrater reliability for both neutral extension (r = 0.74) and 30° of flexion (r = 0.73). The symptoms of apprehension (physical, emotional, and/or physiological) decreased substantially after surgery. The correlation of postoperative patient-rated apprehension VAS and BPII 2.0 scores demonstrated that less residual patellar apprehension was associated with higher BPII scores in neutral extension (r = -0.35, P = .001). There were no statistically significant correlations revealed between the patient-rated postoperative apprehension VAS and pathoanatomic risk factors. BPII 2.0 scores improved pre- to postoperatively from a mean of 27.6 (SD, 15.7) to 74.3 (SD, 18.3). Three patients (3.4%) sustained a patellar dislocation postoperatively.

CONCLUSION

The patellar apprehension test demonstrated strong validity and responsiveness to change. Interrater reliability ranged from weak to strong. There was a statistically significant reduction in apprehension after patellofemoral stabilization in the majority of patients. Patients graded their apprehension symptoms significantly higher in both quantity and quality than the surgeon. Persistent patellar apprehension after stabilization was correlated with lower quality-of-life scores. No relationship could be found between persistent apprehension and patellofemoral risk factors. These results suggest that use of the apprehension tests as an outcome is inappropriate until further validation is performed.

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability

PURPOSE

The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors.

METHODS

Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores.

RESULTS

Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship.

CONCLUSION

This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Generalized joint hypermobility does not influence clinical outcomes following isolated MPFL reconstruction for patellofemoral instability

PURPOSE

Generalized joint hypermobility (GJH) has frequently been described as a risk factor for patellofemoral instability; however, only a few primary research studies have demonstrated any evidence of a relationship. The primary purpose of this study was to determine if isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with GJH compared those without, as measured by disease-specific quality-of-life (QOL), symptom scores and functional outcomes. The secondary purpose was to determine if clinical and patient-reported outcomes were influenced by patient demographic factors in the presence of joint hypermobility.

METHODS

Between 2009 and 2014, data were collected on 174/193 knees (92% follow-up) following an isolated medial patellofemoral ligament reconstruction (MPFL-R). Patients with a Beighton score of 4 or greater were classified as positive for GJH, and any score of 3 or less was classified as negative. Pre- and post-operative Banff Patella Instability Instrument (BPII) scores were compared using a two-sample t test to determine the influence of GJH on QOL. The relationship between the Beighton score, and demographic and clinical factors was explored using correlational analysis. Functional testing including balance and single-leg hop testing was conducted 1 and 2 years post-operatively. Limb symmetry and mean limb-to-limb performance differences were calculated.

RESULTS

In this cohort of isolated MPFL reconstructions, 55.1% had a positive Beighton score. There were seven surgical failures (3.6%). There was no evidence of a relationship between a positive Beighton score and pre-operative BPII scores, post-operative BPII scores or post-operative symptom scores. GJH did not correlate significantly with any post-operative functional testing measures. A positive Beighton score was inversely related to patient age and more prevalent in females.

CONCLUSIONS

This study determined that the presence of GJH did not influence disease-specific quality of life, physical symptom score or functional outcomes following MPFL reconstruction.

LEVEL OF EVIDENCE

III.

Influence of Risky Pathoanatomy and Demographic Factors on Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction: A Regression Analysis

BACKGROUND

Multiple studies have demonstrated that a number of demographic and pathoanatomic characteristics are associated with patellofemoral instability, recurrence of instability, and less satisfactory results following medial patellofemoral ligament reconstruction (MPFL-R). Despite the growing volume of research, the relationship of risk factors to patient-reported outcome after MPFL-R is unclear.

PURPOSE

To determine if certain pathoanatomic and demographic factors predict disease-specific quality-of-life outcome after isolated MPFL-R for symptomatic patellofemoral instability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study analyzed 224 isolated MPFL-Rs. Demographic data were collected, including age at first dislocation, sex, and presence of bilateral instability. Pathoanatomic risk factors included the presence of high-grade trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patella alta ratio, Beighton score, and patellar tilt. Other factors included femoral tunnel position accuracy and WARPS/STAID score. Descriptive analyses were conducted, followed by calculation of individual Spearman rank correlation coefficients for the predictor variables versus the Banff Patellofemoral Instability Instrument (BPII) scores. A multivariable regression with stepwise selection was employed to establish the final model predicting BPII score, with all significant variables for alpha ≤ .05 included in the final model.

RESULTS

The cohort of 224 patients included 66 (29.5%) males and 158 (70.5%) females, with a mean age of 24.1 years and a mean body mass index of 23.9 kg/m². The mean age of first patellar dislocation was 15.7 years, and 41.4% of patients had bilateral instability. Pathoanatomic variables within the cohort included the following: high-grade trochlear dysplasia = 41%; mean TT-TG = 14.6 mm, with 16.8% of patients demonstrating a TT-TG ≥18 mm; mean Caton-Deschamps ratio = 1.09, with 22% of patients demonstrating a ratio ≥1.2; and positive Beighton score = 37.5%. The mean BPII score at postoperative 2 years was 67.1 out of 100. A stepwise elimination in the regression model demonstrated no statistically significant 3- or 2-way relationships. Assessment of individual variables indicated that bilateral symptoms (P = .004), higher age at first dislocation (P = .024), and femoral tunnel position >10 mm from the Schöttle point (P = .042) were statistically significant predictors of lower quality-of-life scores. The R² value for the regression analysis model was 0.07.

CONCLUSION

In this large cohort of patients undergoing isolated MPFL-R for symptomatic lateral patellofemoral instability, a multivariable forward stepwise regression demonstrated that bilateral symptoms, femoral tunnel position, and age at first dislocation were statistically significant predictors of lower postoperative BPII scores. No anatomic risk factors were predictive of quality-of-life outcome score 2 years after MPFL-R surgery. The R² value indicated that there were many other important contributing factors affecting BPII outcome scores than those explored in this study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

Evaluating quality of care for patients with rotator cuff disorders

Background

Measuring quality in healthcare is vital in evaluating patient outcomes and system performance. The availability of reliable and valid information about the quality of care for patients presenting with rotator cuff disorders (RCD) in Alberta, Canada is scarce. The objective of this study is to measure quality of care for patients with RCD in order to identify areas of improvement.

Methods

This study employs descriptive survey research design. Between March 2015 and November 2016, a convenience sample of patients presenting with chronic, full-thickness rotator cuff tears to two sport medicine centres in Calgary and Edmonton, Alberta completed two questionnaires: the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) and the Rotator Cuff Quality-of-Life Index (RC-QOL). Data collected using both questionnaires were used to make judgments about quality of care. Quality of care was evaluated using six dimensions of quality defined by the Alberta Quality Matrix for Health: accessibility, acceptability, efficiency, effectiveness, appropriateness, and safety. Data was also used to compare current patient clinical pathways to ideal clinical pathway algorithms and used to make judgments about the appropriateness and safety of healthcare practices.

Results

One hundred seventy-one patients participated in the study. The longest mean waiting times for medical services in Alberta were for magnetic resonance imaging (MRI) received in the public sector (103 days) and consultation by orthopaedic surgeon (172 days). Patient satisfaction with respect to quality of care was lowest for emergency room physician and highest for orthopaedic surgeon visits. Patients were treated by a mean of 2.5 physicians (SD: 0.77, range: 2–7). The total aggregate average cost per patient was $4541.19. The mean RC-QOL score for all patients was 42 (SD: 22). Only 54 patients (64%) requiring surgery were able to consult with a surgeon within benchmark timeframes. A comparison of current to ideal clinical pathway algorithms found that 38 patients (22%) experienced indirect clinical pathways, whereby care was fragmented and patients received care from multiple and often, redundant healthcare professionals.

Conclusion

There is a discrepancy between current and ideal clinical pathways whereby some patients are experiencing quality of care that is inefficient, disjointed, and less than ideal.

Quality-of-Life Outcomes of Patients following Patellofemoral Stabilization Surgery: The Influence of Trochlear Dysplasia

Trochlear dysplasia is a well-described risk factor for recurrent patellofemoral instability. Despite its clear association with the incidence of patellofemoral instability, it is unclear whether the presence of high-grade trochlear dysplasia influences clinical outcome after patellofemoral stabilization. The purpose of this study was to assess whether trochlear dysplasia influenced patient-reported, disease-specific outcomes in surgically treated patellar instability patients, when risk factors were addressed in accordance with the à la carte surgical approach to the treatment of patellofemoral instability. The study design is of a case series. A total of 318 patellar stabilization procedures were performed during the study period. Of these procedures, 260 had adequate lateral radiographs and complete Banff Patellar Instability Instrument (BPII) scores available for assessment. A Pearson r correlation was calculated between four characteristics of trochlear dysplasia, the BPII total and the BPII symptoms, and physical complaints scores, a mean of 24 months following patellofemoral stabilization. Independent t-tests were performed between stratified trochlear dysplasia groups (no/low grade and high grade) and all BPII measures. There was a statistically significant correlation between measures of trochlear dysplasia and quality-of-life physical symptoms scores, an average of 2 years following patellofemoral stabilization surgery. The BPII symptoms and physical complaints domain score, as well as the individual weakness and stiffness questions, correlated with the classification of trochlear dysplasia as well as the presence of a trochlear bump (p < 0.05). Independent t-tests demonstrated statistically significant differences between the no/low-grade and high-grade dysplasia groups for the BPII stiffness (p = 0.002), BPII weakness (p = 0.05) and BPII symptom, and physical complaints values (p = 0.04). Two additional measures-the 24-month postoperative total BPII score (p = 0.11) and BPII pain score (p = 0.07)-demonstrated trends toward statistical significance. This research has established a statistically significant correlation between trochlear dysplasia and disease-specific quality-of-life outcomes following patellofemoral stabilization surgery. There was a significant correlation between patient-reported physical symptoms after surgery and high-grade trochlear dysplasia.

Accuracy and Learning Curve of Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction

The purpose of this study was to assess the accuracy of femoral tunnel placement in a medial patellofemoral ligament reconstruction (MPFL-R) cohort. The secondary purpose was to establish the evidence of a learning curve to achieve acceptable femoral tunnel placement during MPFL-R. Two surgeons, using lateral radiographs, assessed 73 subjects post-MPFL-R. Femoral tunnel accuracy and direction of tunnel error were measured in relation to Schöttle's point (A-T distance). Interrater reliability (intraclass correlation coefficient 2,k) of these measures was calculated. Learning curve of accurate femoral tunnel placement was examined by dividing the patient cohort into quartiles. A one-way analysis of variance was used to assess the quartiles for accuracy of femoral tunnel position and surgical time. In relation to Schöttle's point, 66/73 (90.4%) femoral tunnels were categorized as being in a "good" or "excellent" position and 7/73 (9.6%) were categorized as being in a "poor" position. Evidence of an MPFL-R learning curve was established via a statistically significant difference in the mean A to T distance for the four quartiles (F [3, 69] = 6.41, p = 0.001). There was also a statistically significant difference in the surgical time for the four quartiles (F [3, 69] = 8.71, p = 0.001). In this series, accurate femoral tunnels were placed more than 90% of the time during MPFL-R. A clear learning curve for accurate femoral tunnel placement was demonstrated both with respect to distance of the tunnel from Schöttle point and with regard to surgical time. Level of evidence was IV.

Further validation and reliability testing of the Rotator Cuff Quality of Life Index (RC-QOL) according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines

BACKGROUND

The Rotator Cuff Quality of Life Index (RC-QOL) was developed to evaluate quality of life in patients with rotator cuff disorders (RCD). The purpose of this study was to provide additional reliability, validity, and responsiveness testing in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

METHODS

Preliminary patient interviews included 15 patients. Seventy patients (mean age, 58; standard deviation, 9 years) with RCD were evaluated. Methodology testing included internal consistency, test-retest reliability, measurement error, content validity, and construct validity. Responsiveness, interpretability, and generalizability were also analyzed.

RESULTS

The Cronbach α was 0.96 (95% confidence interval, 0.89-0.99; range, 0.72-0.94). The intraclass correlation coefficient for the RC-QOL was 0.87 (95% confidence interval, 0.79-0.85; range, 0.77-0.88). The standard error of measurement was 8 (range, 7-13). The smallest detectable change was 3 (range, 2-4). Content validity was confirmed through standardized patient interviews. All a priori hypotheses were confirmed. No floor or ceiling effects were present. The minimally clinical important difference ranged between 7 and 14 points. The study met the COSMIN criteria for interpretability and generalizability.

CONCLUSION

The RC-QOL is a reliable and valid measure of health-related quality of life in patients with chronic RCD. The results of this study added to the methodologic quality assessment of the RC-QOL, completing 7 of 10 COSMIN criteria.

Factor Analysis and Item Reduction of the Banff Patella Instability Instrument (BPII): Introduction of BPII 2.0

BACKGROUND

Clinical management of patellofemoral (PF) instability is a challenge, particularly considering the number of variables that should be taken into consideration for treatment. Quality of life is an important measure to consider with this patient population.

PURPOSE

To factor analyze and reduce the total number of items in the Banff Patella Instability Instrument (BPII). Subsequent to the factor analysis, the new, item-reduced BPII 2.0 was tested for validity, reliability, and responsiveness.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Quality of life was measured for PF instability patients (N = 223) through use of the original BPII at their initial consultation. Data from the BPII scores were used in a principal components analysis (PCA) to factor analyze and reduce the total number of items in the original BPII, to create a revised BPII 2.0. The BPII 2.0 underwent content validation (Cronbach alpha, patient interviews, and grade-level checking), construct validation (analysis of variance comparing the initial visit and the 6-, 12-, and 24-month postoperative visits, eta-square), convergent validation (Pearson r correlation to the original BPII), responsiveness testing (eta-square, anchor-based distribution testing), and reliability testing (intraclass correlation coefficient [ICC]).

RESULTS

The BPII was successfully reduced from 32 to 23 items with excellent Cronbach alpha values in the new BPII 2.0: initial visit = 0.91; 6-month postoperative visit = 0.96; 12-month postoperative visit = 0.97; and 24-month postoperative visit = 0.76. Grade-level reading for all items was assessed as below grade 12. The BPII 2.0 was able to discriminate between all time periods with significant differences between groups (P < .05). Eta-square was 0.40, demonstrating a medium to large effect size. The BPII significantly correlated with the BPII 2.0 (0.82, 0.90, 0.90, and 0.94 at the initial visit and 6-, 12-, and 24-month postoperative visits, respectively), providing evidence of convergent validity. A significant correlation was found between the 7-point scale and 24-month postoperative BPII 2.0 scores, a sign of anchor-based responsiveness. ICC (2,k) was 0.97, indicating strong reliability.

CONCLUSION

The BPII 2.0 is valid, reliable, and responsive for assessment of patients with PF instability, both surgically and nonsurgically treated.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology

Background

Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm.

Methods

A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting.

Results

In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic.

Conclusion

This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0165-8) contains supplementary material, which is available to authorized users.

A Generalizability Theory Study of Athletic Taping Using the Technical Skill Assessment Instrument

Context:

Athletic taping skills are highly valued clinical competencies in the athletic therapy and training profession. The Technical Skill Assessment Instrument (TSAI) has been content validated and tested for intrarater reliability.

Objective:

To test the reliability of the TSAI using a more robust measure of reliability, generalizability theory, and to hypothetically and mathematically project the optimal number of raters and scenarios to reliably measure athletic taping skills in the future.

Setting:

Mount Royal University.

Design:

Observational study.

Patients or Other Participants:

A total of 29 university students (8 men, 21 women; age = 20.79 ± 1.59 years) from the Athletic Therapy Program at Mount Royal University.

Intervention(s):

Participants were allowed 10 minutes per scenario to complete prophylactic taping for a standardized patient presenting with (1) a 4-week-old second-degree ankle sprain and (2) a thumb that had been hyperextended. Two raters judged student performance using the TSAI.

Main Outcome Measure(s):

Generalizability coefficients were calculated using variance scores for raters, participants, and scenarios. A decision study was calculated to project the optimal number of raters and scenarios to achieve acceptable levels of reliability. Generalizability coefficients were interpreted the same as other reliability coefficients, with 0 indicating no reliability and 1.0 indicating perfect reliability.

Results:

The result of our study design (2 raters, 1 standardized patient, 2 scenarios) was a generalizability coefficient of 0.67. Decision study projects indicated that 4 scenarios were necessary to reliably measure athletic taping skills.

Conclusions:

We found moderate reliability coefficients. Researchers should include more scenarios to reliably measure athletic taping skills. They should also focus on the development of evidence-based practice guidelines and standards of athletic taping and should test those standards using a psychometrically sound instrument, such as the TSAI.

Validity and reliability of the Standardized Orthopedic Assessment Tool (SOAT): a variation of the traditional objective structured clinical examination

CONTEXT

Health care professions have replaced traditional multiple choice tests or essays with structured and practical, performance-based examinations with the hope of eliminating rater bias and measuring clinical competence.

OBJECTIVE

To establish the validity and reliability of the Standardized Orthopedic Assessment Tool (SOAT) as a measure of clinical competence of orthopaedic injury evaluation.

DESIGN

Descriptive laboratory study.

SETTING

University.

PATIENTS OR OTHER PARTICIPANTS

A total of 60 undergraduate students and 11 raters from 3 Canadian universities and 1 standardized patient.

INTERVENTION(S)

Students were required to complete a 30-minute musculoskeletal evaluation in 1 of 2 randomly assigned mock scenarios involving the knee (second-degree medial collateral ligament sprain) or the shoulder (third-degree supraspinatus muscle strain).

MAIN OUTCOME MEASURE(S)

We measured interreliability with an intraclass correlation coefficient (ICC) (2,k) and stability of the tool with standard error of measurement and confidence intervals. Agreement was measured using Bland-Altman plots. Concurrent validity was measured using a Pearson product moment correlation coefficient whereby the raters' global rating of a student was matched to the cumulative mean grade score.

RESULTS

The ICCs were 0.75 and 0.82 for the shoulder and knee cases, respectively. Bland-Altman plots indicated no systematic bias between raters. In addition, Pearson product moment correlation analysis demonstrated a strong relationship between the overall cumulative mean grade score and the global rating score of the examinees' performances.

CONCLUSIONS

This study demonstrated good interrater reliability of the SOAT with a standard error of measurement that indicated very modest stability, strong agreement between raters, and correlation indicative of concurrent validity.

A Generalizability Theory Study of Athletic Taping Using the Technical Skill Assessment Instrument

Context : Athletic taping skills are highly valued clinical competencies in the athletic therapy and training profession. The Technical Skill Assessment Instrument (TSAI) has been content validated and tested for intrarater reliability. Objective : To test the reliability of the TSAI using a more robust measure of reliability, generalizability theory, and to hypothetically and mathematically project the optimal number of raters and scenarios to reliably measure athletic taping skills in the future. Setting : Mount Royal University. Design : Observational study. Patients or Other Participants : A total of 29 university students (8 men, 21 women; age = 20.79 ± 1.59 years) from the Athletic Therapy Program at Mount Royal University. Intervention(s) : Participants were allowed 10 minutes per scenario to complete prophylactic taping for a standardized patient presenting with (1) a 4-week-old second-degree ankle sprain and (2) a thumb that had been hyperextended. Two raters judged student performance using the TSAI. Main Outcome Measure(s) : Generalizability coefficients were calculated using variance scores for raters, participants, and scenarios. A decision study was calculated to project the optimal number of raters and scenarios to achieve acceptable levels of reliability. Generalizability coefficients were interpreted the same as other reliability coefficients, with 0 indicating no reliability and 1.0 indicating perfect reliability. Results : The result of our study design (2 raters, 1 standardized patient, 2 scenarios) was a generalizability coefficient of 0.67. Decision study projects indicated that 4 scenarios were necessary to reliably measure athletic taping skills. Conclusions : We found moderate reliability coefficients. Researchers should include more scenarios to reliably measure athletic taping skills. They should also focus on the development of evidence-based practice guidelines and standards of athletic taping and should test those standards using a psychometrically sound instrument, such as the TSAI.

Initial validity and reliability of the Banff Patella Instability Instrument

BACKGROUND

Patellofemoral instability is a well-recognized problem, but there are currently no published patient-reported quality of life outcome measures that are disease specific for the treatment of this population.

PURPOSE

To establish the content validity, initial construct validity, and initial reliability of the Banff Patella Instability Instrument (BPII).

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

The content of the BPII was validated using a modified 3-stage Ebel procedure and analysis of floor and ceiling effects. As a measure of internal consistency, the Cronbach α was utilized to assess how reliably the 32 items of the questionnaire measured a similar construct. Test-retest reliability of the BPII was calculated using an intraclass correlation coefficient (ICC). Construct validity was evaluated on 150 questionnaires completed by patients with a confirmed diagnosis of patellofemoral instability. A one-way between-group analysis of variance was employed to determine if the BPII was able to differentiate between patients presenting at the initial orthopaedic consultation relative to patients presenting at 6 months and 12 months postoperatively.

RESULTS

Content validity was clearly established as each item in the BPII achieved a minimum of 83.3% agreement (range, 83.3%-100%) for relevance among the expert panelists. The average agreement was 96.9%; 24 items achieved 100% agreement. There was no evidence of floor or ceiling effects. Reliability (internal consistency) of the BPII was established at the initial orthopaedic consultation (α = .91), 6 months postoperatively (α = .97), and 12 months postoperatively (α = .97). Test-retest analysis resulted in an ICC of 0.98 between tests. Construct validity was established as there was a statistically significant difference in BPII scores at the initial orthopaedic consultation and 6-month and 12-month postoperative appointments (F2,146 = 75.62; P < .001).

CONCLUSION

The BPII demonstrates content validity, strong initial reliability, and a statistically significant level of construct validity in patients with patellofemoral instability. This population includes patients with recurrent patellofemoral instability as well as surgically stabilized patients.

Utilization and cost of a new model of care for managing acute knee injuries: the Calgary Acute Knee Injury Clinic

BACKGROUND

Musculoskeletal disorders (MSDs) affect a large proportion of the Canadian population and present a huge problem that continues to strain primary healthcare resources. Currently, the Canadian healthcare system depicts a clinical care pathway for MSDs that is inefficient and ineffective. Therefore, a new inter-disciplinary team-based model of care for managing acute knee injuries was developed in Calgary, Alberta, Canada: the Calgary Acute Knee Injury Clinic (C-AKIC). The goal of this paper is to evaluate and report on the appropriateness, efficiency, and effectiveness of the C-AKIC through healthcare utilization and costs associated with acute knee injuries.

METHODS

This quasi-experimental study measured and evaluated cost and utilization associated with specific healthcare services for patients presenting with acute knee injuries. The goal was to compare patients receiving care from two clinical care pathways: the existing pathway (i.e. comparison group) and a new model, the C-AKIC (i.e. experimental group). This was accomplished through the use of a Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ).

RESULTS

Data from 138 questionnaires were analyzed in the experimental group and 136 in the comparison group. A post-hoc analysis determined that both groups were statistically similar in socio-demographic characteristics. With respect to utilization, patients receiving care through the C-AKIC used significantly less resources. Overall, patients receiving care through the C-AKIC incurred 37% of the cost of patients with knee injuries in the comparison group and significantly incurred less costs when compared to the comparison group. The total aggregate average cost for the C-AKIC group was $2,549.59 compared to $6,954.33 for the comparison group (p <.001).

CONCLUSIONS

The Calgary Acute Knee Injury Clinic was able to manage and treat knee injured patients for less cost than the existing state of healthcare delivery. The combined results from this study show that the C-AKIC is an appropriate, effective, and efficient model of clinical care for patients presenting with acute knee injuries.

Content validity of the Rodeo-SCAT

The purpose of this study was to establish the content validity of the Rodeo SCAT for the sport of rodeo and bull riding. The study design was comprised of expert consensus and content validation. A modified Ebel procedure was employed to content validate the rodeo SCAT. Content validation using this method includes experts agreeing on the importance of each item that comprises the rodeo SCAT. This 3-stage process involved: 1) face validation by a local committee: 2) initial expert consensus measurement via distance; and 3) a face-to-face discussion for items that did not originally achieve 80% consensus of the group. Experts were chosen from the Canadian Professional Rodeo Sport Medicine Team (Canada) and the Justin Sports Medicine Team (USA). 27 out of a total possible 68 items achieved 80% consensus in the second stage. In the third stage, 4 of the 68 items were removed with consensus from the expert group. All remaining items achieved 80% consensus for inclusion. In summary, the rodeo SCAT is content valid and thus, appropriate for use in the sport of rodeo context or environment.

Initial reliability of the Standardized Orthopedic Assessment Tool (SOAT)

CONTEXT

Orthopaedic assessment skills are critical to the success of athletic therapists and trainers. The Standardized Orthopedic Assessment Tool (SOAT) has been content validated.

OBJECTIVE

To establish interrater reliability of the SOAT.

PATIENTS OR OTHER PARTICIPANTS

Thirty-two college students, 10 raters, and 2 standardized patients (SPs) from Calgary, Alberta, Canada.

DESIGN

Randomized observational study.

INTERVENTION(S)

Students were allowed 30 minutes to complete a mock orthopaedic assessment of an SP with an injury specific to a region of the body (shoulder, knee, or ankle). Using the region-specific SOAT, raters and SPs evaluated students' orthopaedic assessment skills.

MAIN OUTCOME MEASURE(S)

The sum totals of the SOAT for 2 raters and 1 SP were used to calculate each student's performance scores for respective scenarios. Scale reliability analysis (Cronbach alpha) was completed on the SOAT for each of the 3 body-region examinations.

RESULTS

The mean overall reliability of 3 SOATs (ie, ankle, knee, and shoulder) was positive: alpha = .85 with the SP scores factored into the equation and alpha = .86 without the SP scores factored into the equation. Reliability for the ankle region was highest (alpha = .91), followed by the knee (alpha = .83) and the shoulder (alpha = .82).

CONCLUSIONS

The study sample size was small, but the results will enable further study with generalization to a broader audience of athletic therapists and athletic trainers. Because a baseline measure of reliability was established using a robust statistical analysis, future researchers can employ more stringent statistical analysis and focus on the effects of various pedagogical techniques to teach and learn the underlying construct of clinical competence in orthopaedic assessment.

Development of content-valid technical skill assessment instruments for athletic taping skills

BACKGROUND AND PURPOSE

The content validity of technical skill assessment instruments (TSAI) for the skills of athletic taping has not been reported. The purpose of this paper is to outline and present the process of content validation for nine TSAIs for athletic taping. Local and national validators were selected from Canadian Athletic Therapists' Association (CATA)-accredited athletic therapy (AT) programs to serve as content validators.

METHODS

The process of content validation began with the creation of a detailed task analysis via mail and simple validation by local validators. Subsequently, the detailed task analysis was committee validated by a group of 10 validators from across Canada. Validators judged the importance and difficulty of each item, and a face-to-face committee-validator meeting established consensus on the majority of checklist items. Through a modified Ebel procedure, frequency distribution was used in the formation of the final TSAIs.

RESULTS

Initial consensus for pre-taping assessment and technical skill performance items was low. Upon committee discussion and lack of agreement, the decision to remove pretaping assessment items was made. Initial results of importance and difficulty for athletic taping technical skills were low prior to the committee meeting. Results of importance and difficulty improved substantially following the face-to-face committee-validators meeting. Consensus on fail points improved from initial to final committee validation.

CONCLUSION

The process of simple and committee validation can be seen as effective methods to establish the content validity of instruments used for the evaluation of athletic taping.