scholarly journals Baseline Analysis of Patients Presenting for Surgical Review of Anterior Cruciate Ligament Rupture Reveals Heterogeneity in Patient-Reported Outcome Measures

2020 ◽  
Author(s):  
Chee Han Ting ◽  
Corey Scholes ◽  
David Zbrojkiewicz ◽  
Christopher Bell
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Outcome Measures ◽  
Cruciate Ligament ◽  
Patient Reported Outcome Measures ◽  
Patient Reported Outcome ◽  
Cluster Membership ◽  
Patient Reported ◽  
Rehabilitation Protocols ◽  
Anterior Cruciate

AbstractDespite 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.

Patient-reported outcome measures following anterior cruciate ligament reconstruction are not related to dynamic knee extension angle

2018 ◽  
Vol 3 (1) ◽  
pp. 33-37 ◽  
Author(s):  
Kanto Nagai ◽  
Elmar Herbst ◽  
Tom Gale ◽  
Yasutaka Tashiro ◽  
James J Irrgang ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Patient Reported Outcome Measures ◽  
Knee Extension ◽  
Patient Reported Outcome ◽  
Cruciate Ligament Reconstruction ◽  
Knee Hyperextension ◽  
Patient Reported ◽  
Anterior Cruciate

ObjectivesControversy still exists on whether knee hyperextension affects the outcome following anterior cruciate ligament reconstruction (ACL-R). Therefore, the purpose of the present study was to determine if maximum knee extension angle of ACL-R knees and contralateral uninjured knees during walking is related to the clinical outcome following ACL-R. It was hypothesised that maximum knee extension angle would not be significantly correlated with patient-reported outcome measures (PROMs) following ACL-R.MethodsForty-two patients (age at surgery: 23±9 years, 23 male and 19 female) underwent unilateral ACL-R. Twenty-four months after surgery, subjects performed level walking on a treadmill while biplane radiographs were acquired at 100 Hz. Three-dimensional tibiofemoral motion was determined using a validated model-based tracking process. Tibiofemoral rotations were calculated from foot strike through early stance. The primary kinematic outcome measure was maximum knee extension angle of ACL-R and contralateral uninjured knees during walking, with positive values indicating hyperextension. The side-to-side difference (SSD) in maximum knee extension angle was calculated by subtracting the angle of the contralateral uninjured knee from that of the ACL reconstructed knee. PROMs (International Knee Documentation Committee Subjective Knee Form, Knee Injury and Osteoarthritis Score and Marx Activity Rating Scale) were obtained at 24 months after surgery. Correlations between PROMs and maximum dynamic knee extension angle in ACL-R and contralateral knee were evaluated (P<0.05).ResultsMaximum knee extension angle during walking was 2.3±4.5° in ACL-R knees and 4.3±4.2° in contralateral uninjured knees at 24 months after surgery, indicating hyperextension during walking on average. SSD in maximum knee extension angle was −2.0±3.7°. No significant correlation was observed between maximum knee extension angle and the PROMs.ConclusionMaximum knee extension angle during walking was not significantly correlated with PROMs, suggesting that clinically, physiologic knee hyperextension can be restored after ACL-R and not adversely affect PROMs.Level of evidenceLevel III.

Prospective Evaluation of the Patient Acceptable Symptom State to Identify Clinically Successful Anterior Cruciate Ligament Reconstruction

2019 ◽  
Vol 47 (5) ◽  
pp. 1159-1167 ◽  
Author(s):  
José F. Vega ◽  
Cale A. Jacobs ◽  
Gregory J. Strnad ◽  
Lutul Farrow ◽  
Morgan H. Jones ◽  
...  
Keyword(s):  
Outcome Measures ◽  
Cruciate Ligament ◽  
High Sensitivity ◽  
Patient Reported Outcome Measures ◽  
Patient Reported Outcome ◽  
Patient Reported ◽  
Related Quality ◽  
Patient Acceptable Symptom State ◽  
Anterior Cruciate

Background: The length of most patient-reported outcome measures creates significant response burden, which hampers follow-up rates. The Patient Acceptable Symptom State (PASS) is a single-item, patient-reported outcome measure that asks patients to consider all aspects of life to determine whether the state of their joint is satisfactory; this measure may be viable for tracking outcomes on a large scale. Hypothesis: The PASS question would identify clinically successful anterior cruciate ligament reconstruction (ACLR) at 1-year follow-up with high sensitivity and moderate specificity. We defined “clinically successful” ACLR as changes in preoperative to postoperative scores on the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale and the KOOS knee-related quality of life subscale in excess of minimal clinically important difference or final KOOS pain or knee-related quality of life subscale scores in excess of previously defined PASS thresholds. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients enrolled in a prospective longitudinal cohort completed patient-reported outcome measures immediately before primary ACLR. At 1-year follow-up, patients completed the same patient-reported outcome measures and answered the PASS question: “Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?” Results: A total of 555 patients enrolled in our cohort; 464 were eligible for this study. Of these, 300 patients (64.7%) completed 1-year follow-up, of whom 83.3% reported satisfaction with their knee after surgery. The PASS question demonstrated high sensitivity to identify clinically successful ACLR (92.6%; 95% CI, 88.4%-95.6%). The specificity of the question was 47.1% (95% CI, 35.1%-59.5%). The overall agreement between the PASS and our KOOS-based criteria for clinically successful intervention was 81.9%, and the kappa value indicated moderate agreement between the two methods (κ = 0.44). Conclusion: The PASS question identifies individuals who have experienced clinically successful ACLR with high sensitivity. The limitation of the PASS is its low specificity, which we calculated to be 47.1%. Answering “no” to the PASS question meant that a patient neither improved after surgery nor achieved an acceptable final state of knee health. The brevity, interpretability, and correlation of the PASS question with significant improvements on various KOOS subscales make it a viable option in tracking ACLR outcomes on a national or global scale.

Effects of Surgical Factors on Cartilage Can Be Detected Using Quantitative Magnetic Resonance Imaging After Anterior Cruciate Ligament Reconstruction

2017 ◽  
Vol 45 (5) ◽  
pp. 1075-1084 ◽  
Author(s):  
Keiko Amano ◽  
Alan K. Li ◽  
Valentina Pedoia ◽  
Matthew F. Koff ◽  
Aaron J. Krych ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Magnetic Resonance ◽  
Cruciate Ligament ◽  
Relaxation Times ◽  
Patient Reported Outcome Measures ◽  
Patient Reported Outcome ◽  
Meniscal Tears ◽  
T2 Relaxation ◽  
Patient Reported ◽  
Anterior Cruciate

Background: Quantitative magnetic resonance (qMR) can be used to measure macromolecules in tissues and is a potential method of observing early cartilage changes in the development of posttraumatic osteoarthritis. Hypothesis/Purpose: We hypothesized that specific patient and surgical factors affecting cartilage matrix composition after anterior cruciate ligament (ACL) reconstruction (ACLR) can be detected using T1ρ and T2 relaxation times. Our purpose was to demonstrate this ability in a multicenter feasibility study. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 patients who underwent ACLR underwent bilateral MRI at baseline before surgery and 6 months postoperatively. Operative findings were recorded. T1ρ and T2 relaxation times were calculated for 6 cartilage regions: the medial femur, lateral femur, medial tibia, lateral tibia, patella, and trochlea. A paired t test compared relaxation times at baseline and 6 months, univariate regression identified regions that influenced patient-reported outcome measures, and analysis of covariance was used to determine the surgical factors that resulted in elevated relaxation times at 6 months. Results: The injured knee had significantly prolonged T1ρ and T2 relaxation times in the tibiofemoral compartment at baseline and 6 months but had shorter values in the patellofemoral compartment compared with the uninjured knee. Prolonged T1ρ and T2 times at 6 months were noted for both the injured and uninjured knees. At 6 months, prolongation of T1ρ and T2 times in the tibial region was associated with lower patient-reported outcome measures. ACLR performed within 30 days of injury had significantly shorter T1ρ times in the tibial regions, and lateral meniscal tears treated with repair had significantly shorter T1ρ times than those treated with excision. Conclusion: Prolonged relaxation times in multiple regions demonstrate how the injury affects the entire joint after an ACL tear. Changes observed in the uninjured knee may be caused by increased loading during rehabilitation, especially in the patellofemoral articular cartilage and distal femur. Relaxation times in the tibial regions may be predictive of patient symptoms at 6 months. These same regions are affected by surgical timing as early as 30 days after injury, but this may partially be reflective of the severity of the preoperative injury and the choice of treatment of meniscal tears.

scholarly journals IS PERCUTANEOUS MEDIAL COLLATERAL LIGAMENT (MCL) RELAXATION DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION A SAFE OPTION FOR GAINING ACCESS TO THE MEDIAL KNEE COMPARTMENT IN CHILDREN?

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0004
Author(s):  
John A. Schlechter ◽  
Tanner Harrah ◽  
Bryn Gornick ◽  
Benjamin Sherman
Keyword(s):  
Anterior Cruciate Ligament ◽  
Children And Adolescents ◽  
Medial Collateral Ligament ◽  
Cruciate Ligament ◽  
Adult Population ◽  
Deep Infection ◽  
Patient Reported Outcome ◽  
Collateral Ligament ◽  
Patient Reported ◽  
Anterior Cruciate

Introduction: With participation in youth sports anterior cruciate ligament (ACL) injuries are a common occurrence. Nearly 70% of ACL tears in children and adolescents have an associated meniscus tear. Percutaneous medial collateral ligament (MCL) relaxation has been described as utilitarian in accessing the medial meniscus for diagnostic assessment and treatment in the adult population to increase medial compartment working space in arthroscopic surgery. The technique has not been evaluated in the pediatric population. The purpose of this study was to compare the outcomes of children and adolescents that underwent anterior cruciate ligament reconstruction (ACLR) with and without percutaneous relaxation of the medial collateral ligament (MCL) for meniscal tear management. Methods: A retrospective review was performed of patients aged 8 to 19 years old that had undergone knee arthroscopy for an (ACLR) with meniscus pathology. Those that underwent MCL relaxation were grouped together and compared to a matched cohort that did not have MCL relaxation performed. Preoperative, operative and postoperative data was analyzed. The primary measurement was obtained using a validated patient reported outcome score (Pedi-IKDC), secondary outcome measures were defined as superficial or deep infection, saphenous nerve dysesthesias, ACL graft failure and return to the operating room. Statistical analysis of the two cohorts was performed. Results: Fifty-four patients were included in the study (27 in each group) with average age 15 years (range 10-19). Average follow-up for the MCL relaxation group was 22.4 months versus 58 months for the non-MCL relaxation group. The average Pedi-IKDC score was 93.3 for the MCL relaxation group and 91.4 for the non-MCL relaxation group (p=0.34). There was no difference in patient demographics, return to the operating room (p=0.49), saphenous nerve dysesthesia (p=0.49), superficial or deep infection (p=0.32). Conclusion: ACL reconstruction in children and adolescents with MCL relaxation for the management of medial meniscal tears appears to be a safe option. Equivocal patient reported outcome scores as compared to the control group were found with no increase in post-operative complications. In children with ACL tears, appropriate diagnosis and management of medial meniscal pathology is important to maintain secondary restraint to anterior tibial translation and prevent premature graft failure. Pediatric knees can have tight medial compartments, making access difficult, potentially leading to poor visualization and iatrogenic chondral damage. Percutaneous medial collateral ligament (MCL) relaxation has been described in the adult population to increase medial compartment working space without long term sequela. We report similar findings in an all pediatric cohort.

Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospectively Collected Data

2021 ◽  
pp. 036354652110273
Author(s):  
Joshua S. Everhart ◽  
Sercan Yalcin ◽  
Kurt P. Spindler
Keyword(s):  
Systematic Review ◽  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Knee Function ◽  
Increased Risk ◽  
Patient Reported ◽  
The Mean ◽  
Anterior Cruciate

Background: Several long-term (≥20 years) follow-up studies after anterior cruciate ligament (ACL) reconstruction have been published in recent years, allowing for a systematic evaluation of outcomes. Purpose: To summarize outcomes at ≥20 years after ACL reconstruction and identify patient and surgical factors that affect these results. Study Design: Systematic review; Level of evidence, 4. Methods: Prospective studies of primary ACL reconstructions with hamstring or bone–patellar tendon—bone (BTB) autograft via an arthroscopic or a mini-open technique and with a mean follow-up of ≥20 years were identified. When possible, the mean scores for each outcome measure were calculated. Factors identified in individual studies as predictive of outcomes were described. Results: Five studies met the inclusion and exclusion criteria with a total of 2012 patients. The pooled mean follow-up for patient-reported outcome measures was 44.2% (range, 29.6%-92.7%) and in-person evaluation was 33.2% (range, 29.6%-48.9%). Four studies (n = 584) reported graft tears at a mean rate of 11.8% (range, 2%-18.5%) and 4 studies (n = 773) reported a contralateral ACL injury rate of 12.2% (range, 5.8%-30%). Repeat non-ACL arthroscopic surgery (4 studies; n = 177) to the ipsilateral knee occurred in 10.4% (range, 9.5%-18.3%) and knee arthroplasty (1 study; n = 217) in 5%. The pooled mean of the International Knee Documentation Committee subjective knee function (IKDC) score was 79.1 (SD, 21.8 [3 studies; n = 644]). In 2 studies (n?= 221), 57.5% of patients continued to participate in strenuous activities. The IKDC-objective score was normal or nearly normal in 82.3% (n = 496; 3 studies), with low rates of clinically significant residual laxity. Moderate-severe radiographic osteoarthritis (OA) (IKDC grade C or D) was present in 25.9% of patients (n = 605; 3 studies). Medial meniscectomy is associated with increased risk of radiographic OA. Radiographic OA severity is associated with worse patient-reported knee function, but the association with knee pain is unclear. Conclusion: Currently available prospective evidence for ACL reconstruction with hamstring or BTB autograft provides several insights into outcomes at 20 years. The rates of follow-up at 20 years range from 30% to 93%. IKDC-objective scores were normal or nearly normal in 82% and the mean IKDC-subjective score was 79 points.

Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

2018 ◽  
Vol 47 (10) ◽  
pp. 2501-2509 ◽  
Author(s):  
Avinesh Agarwalla ◽  
Richard N. Puzzitiello ◽  
Joseph N. Liu ◽  
Gregory L. Cvetanovich ◽  
Anirudh K. Gowd ◽  
...  
Keyword(s):  
Systematic Review ◽  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Clinical Significance ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Pubmed Database ◽  
Patient Reported ◽  
Clinically Significant ◽  
Anterior Cruciate

Background: Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics. Purpose: To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs). Study Design: Systematic review. Methods: A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference. Results: This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that. Conclusion: After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm. Clinical Relevance: After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

scholarly journals Performance of the PROMIS in Patients After Anterior Cruciate Ligament Reconstruction

2018 ◽  
Vol 6 (5) ◽  
pp. 232596711877450 ◽  
Author(s):  
Elizabeth J. Scott ◽  
Robert Westermann ◽  
Nathalie A. Glass ◽  
Carolyn Hettrich ◽  
Brian R. Wolf ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Physical Function ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Sf 36 ◽  
Significant Difference ◽  
Patient Reported ◽  
Floor Effects ◽  
Anterior Cruciate ◽  
Pro Instruments

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) is designed to advance patient-reported outcome (PRO) instruments by utilizing question banks for major health domains. Purpose: To compare the responsiveness and construct validity of the PROMIS physical function computer adaptive test (PF CAT) with current PRO instruments for patients before and up to 2 years after anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Initially, 157 patients completed the PROMIS PF CAT, Short Form–36 Health Survey (SF-36 physical function [PF] and general health [GH]), Marx Activity Rating Scale (MARS), Knee injury and Osteoarthritis Outcome Score (KOOS activities of daily living [ADL], sport, and quality of life [QOL]), and EuroQol–5 dimensions questionnaire (EQ-5D) at 6 weeks, 6 months, and 2 years after ACL reconstruction. Correlations between instruments, ceiling and floor effects, effect sizes (Cohen d), and standardized response means to describe responsiveness were evaluated. Subgroup analyses compared participants with and without additional arthroscopic procedures using linear mixed models. Results: At baseline, 6 weeks, and 6 months, the PROMIS PF CAT showed excellent or excellent-good correlations with the SF-36 PF ( r = 0.75-0.80, P < .01), KOOS-ADL ( r = 0.63-0.70, P < .01), and KOOS-sport ( r = 0.32-0.69, P < .01); excellent-good correlation with the EQ-5D ( r = 0.60-0.71, P < .01); and good correlation with the KOOS-QOL ( r = 0.52-0.58, P < .01). As expected, there were poor correlations with the MARS ( r = 0.00-0.24, P < .01) and SF-36 GH ( r = 0.16-0.34, P < .01 ). At 2 years, the PROMIS PF CAT showed good to excellent correlations with all PRO instruments ( r = 0.42-0.72, P < .01), including the MARS ( r = 0.42, P < .01), indicating frequent return to preinjury function. The PROMIS PF CAT had the fewest ceiling or floor effects of all instruments tested, and patients answered, on average, 4 questions. There was no significant difference in baseline physical function scores between subgroups; at follow-up, all groups showed improvements in scores that were not statistically different. Conclusion: The PROMIS PF CAT is a valid tool to assess outcomes after ACL reconstruction up to 2 years after surgery, demonstrating the highest responsiveness to change with the fewest ceiling and floor effects and a low time burden among all instruments tested. The PROMIS PF CAT is a beneficial alternative for assessing physical function in adults before and after ACL reconstruction.

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