Allen F. Anderson

Development and Validation of the International Knee Documentation Committee Subjective Knee Form

A committee of international knee experts created the International Knee Documentation Committee Subjective Knee Form, which is a knee-specific, rather than a disease-specific, measure of symptoms, function, and sports activity. The purpose of this study was to evaluate the reliability and validity of the new International Knee Documentation Committee Subjective Knee Form. To provide evidence for reliability and validity, we administered the final version of the form, along with the Short Form-36, to 533 patients with a variety of knee problems. Analyses were performed to determine reliability, validity, and differential item function related to age, sex, and diagnosis. Factor analysis revealed a single dominant component, making it reasonable to combine all questions into a single score. Internal consistency and test-retest reliability were 0.92 and 0.95, respectively. Based on test-retest reliability, the value for a true change in the score was 9.0 points. The International Knee Documentation Committee Subjective Knee Form score was related to concurrent measures of physical function (r = 0.47 to 0.66) but not to emotional function (r = 0.16 to 0.26). Analysis of differential item function indicated that the questions functioned similarly for men versus women, young versus old, and for those with different diagnoses. In conclusion, the International Knee Documentation Committee Subjective Knee Form is a reliable and valid knee-specific measure of symptoms, function, and sports activity that is appropriate for patients with a wide variety of knee problems. Use of this instrument will permit comparisons of outcome across groups with different knee problems.

Responsiveness of the International Knee Documentation Committee Subjective Knee Form

Background and Purpose The International Knee Documentation Committee Subjective Knee Form was developed to measure change in symptoms, function, and sports activity in patients treated for a variety of knee conditions. Although previous research has demonstrated reliability and validity of the form, its responsiveness has not been evaluated. The purpose of this study was to determine responsiveness of the International Knee Documentation Committee Subjective Knee Form. Study Design Cohort study (diagnosis); Level of evidence, 1. Methods Patients who participated in the original validation study for the International Knee Documentation Committee Subjective Knee Form completed the form and a 7-level global rating of change scale that ranged from greatly worse to greatly better after a mean of 1.6 years (range, 0.5-2.3 years). Analyses included calculation of the standardized response mean and mean change in International Knee Documentation Committee Subjective Knee Form score compared to the patients perception of change on the global rating of change scale. In addition, a receiver operating characteristic curve was plotted to determine the change in score that best distinguished patients who improved from those who did not. Results The overall standardized response mean was 0.94, which is considered large. With the exception of those who were slightly worse or unchanged, the mean change in the International Knee Documentation Committee Subjective Knee Form score compared to the patients’ perceived global ratings of change was as expected (greatly worse,–15.1; somewhat worse,–8.4; slightly worse, 20.6; no change, 10.7; slightly better, 5.9; somewhat better, 18.1; greatly better, 38.7). The receiver operating characteristic curve analysis revealed that a change score of 11.5 points had the highest sensitivity, and a change score of 20.5 points had the highest specificity to distinguish between those who were or were not improved. Conclusion The International Knee Documentation Committee Subjective Knee Form is a responsive measure of symptoms, function, and sports activity for patients with a variety of knee conditions.

The International Knee Documentation Committee Subjective Knee Evaluation Form Normative Data

Background The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument. Purpose To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form. Study Design Cross-sectional survey. Methods The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18-24 years, 25-34 years, 35-50 years, and 51-65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size. Results Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 ± 18), 25 to 34 years (89 ± 16), 35 to 50 years (85 ± 19), and 51 to 55 years (77 ± 23); mean scores were also determined for women aged 18 to 24 years (86 ± 19), 25 to 34 years (86 ± 19), 35 to 50 years (80 ± 23), and 51 to 65 years (71 ± 26). Scores were higher for the subset of respondents with no history of current or prior knee problems. Conclusion Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age-and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.

Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients a preliminary report

Background: Fear of iatrogenic growth disturbance has prevented the routine use, in children, of anatomic methods of anterior cruciate ligament replacement that have proven successful in adults. To minimize the risk of growth disturbance, extra-articular or modified physeal sparing procedures have been performed to stabilize the knee, but these procedures do not provide isometry. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature athletes. Methods: From 1993 to 1999, twelve patients with a mean age (and standard deviation) of 13.3 ± 1.4 years underwent replacement of the anterior cruciate ligament with a quadruple hamstring tendon graft performed with an arthroscopic technique and intraoperative fluoroscopic imaging for precise tunnel placement. The femoral and tibial tunnels went through the epiphyses but avoided the physes. Eight of the twelve patients also had a meniscal repair. All patients returned for follow-up, at a mean of 4.1 ± 1.9 years (range, two to 8.2 years) after surgery. Results: The mean amount of growth from the time of surgery to the time of follow-up was 16.5 ± 10.0 cm (range, 8 to 38 cm). The difference between the lengths of the lower limbs, as measured on orthoradiographs, was not clinically relevant. The mean score on the International Knee Documentation Committee (IKDC) subjective knee form was 96.5 ± 4.4 points (range, 86 to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a mean side-to-side difference of 1.5 ± 1.1 mm. The rating according to the criteria of the objective 2001 IKDC knee form was normal for seven patients and nearly normal for five. Conclusions: Transepiphyseal replacement of the anterior cruciate ligament, a technically demanding procedure with a small margin of error, should be attempted only by accomplished knee surgeons. The preliminary results in this small series, however, demonstrate that this surgical technique can be performed in prepubescent patients with efficacy and relative safety. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects.

Peterson’s pioneering experience with the first clinical application of autologous chondrocyte implantation showed improvement in clinical outcomes, durable as much as 11 years, for a difficult patient population. An assessment of the general applicability of this technology in the United States requires long-term, multicenter followup. The purpose of this multicenter cohort study was to assess the clinical outcomes of patients treated with autologous chondrocyte implantation for lesions of the distal femur. Modified 10-point scales of the Cincinnati knee rating system were used to measure outcomes assessments at baseline and at 5 years. Eighty-seven percent (87 of 100) of patients completed 5-year followup assessments. Patients were an average 37 years of age, had a mean total defect size of 4.9 cm2, and had low baseline overall condition scores. At least one prior cartilage repair procedure had failed in 70% of the patients. At followup, 87 patients reported a mean improvement of 2.6 points in the overall condition score, including 62 with improved conditions, six with no change in condition, and 19 with worsened conditions. Of the 62 patients who improved, the mean overall condition score improved 4.1 points at followup. Patients treated with autologous chondrocyte implantation for large cartilage defects in the distal femur reported improvement in outcome scores at 5 years followup. Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Isolated posterior cruciate ligament reconstruction Long-term results

From 1973 to 1987, 28 patients seen at our institution sustained isolated posterior cruciate ligament tears. Of these 28 patients, 25 were reevaluated at an average followup of 7 years and 1 month after secondary recon struction of the posterior cruciate ligament using the semitendinosus and gracilis tendons alone or with an extraarticular procedure. Subjectively, 22 of 25 patients related no restrictions regarding activities of daily living, with 14 of 25 patients being able to return to their previous competitive level in sports. Objective evaluation after reconstruction re vealed no change in the preoperative and postoperative posterior drawer examination in 13 of 25 patients, a finding confirmed by KT-1000 arthrometer measure ments. Radiographic evaluation revealed degenerative changes predominantly involving the medial and patel lofemoral compartments in 15 of 25 patients. Despite optimistic subjective reporting, this long-term retrospective study reveals that this procedure incon sistently limits posterior instability and therefore cannot be recommended.

Arthroscopic Shoulder Stabilization Using Transglenoid Sutures A Four-Year Minimum Followup

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been per formed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 pa tients (74%) had good or excellent results, and 3 pa tients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or rec reational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.

Osteochondritis Dissecans of the Femoral Condyles Long-term Results of Excision of the Fragment

Nineteen patients with 20 osteochondritis dissecans lesions were evaluated between 2 and 20 years after excision of a partially detached (grade III) or loose (grade IV) fragment from the femoral condyles. Evalu ation with the Hughston rating scale for osteochondritis dissecans revealed one excellent result, four good, four fair, six poor, and five failure results. Eleven pa tients had developed osteochondritis dissecans before skeletal maturity. In contrast to what has been stated in the literature, the results in these patients were no better than in those who developed osteochondritis dissecans as adults. The short-term results of excision are good, but the long-term results are extremely poor. Consequently, we recommend bone grafting and re placement of the fragment when it is technically pos sible because the long-term results are better than those after excision.

Treatment Outcomes of Autologous Chondrocyte Implantation for Full-Thickness Articular Cartilage Defects of the Trochlea

Background The treatment of trochlear cartilage lesions is challenging given the likely presence of other patellofemoral joint pathologies, the topography of the area, and the limited available treatment options. Only 1 other study has examined the effectiveness of autologous chondrocyte implantation for lesions of the patellofemoral joint. Hypothesis Patients treated with autologous chondrocyte implantation for moderate to large isolated lesions located on the trochlea will report improvement in the modified overall condition scale score of the Cincinnati Knee Rating System at a minimum 2-year follow-up. Study Design Case series; Level of evidence, 4. Methods Using modified scales of the Cincinnati Knee Rating System, 40 Cartilage Repair Registry patients rated their overall condition and symptoms at baseline and at a mean follow-up of 59 ± 18 months. Factors likely to affect outcomes also were analyzed. Results At baseline, patients were between ages 16 to 48 years, had a mean total defect size of 4.5 cm2, and reported an overall condition score of 3.1 points (poor). Many failed a prior marrow-stimulation procedure (48%). Other procedures performed before baseline included tibiofemoral osteotomy in 23% and lateral release or Fulkerson for patella maltracking in 13%. Forty-three percent were receiving workers’ compensation at baseline. Patients reported statistically significant improvement in their mean overall condition (3.1 points preoperatively to 6.4 points postoperatively), pain (2.6 to 6.2 points), and swelling (3.9 to 6.3 points) scores. Eleven patients experienced 17 subsequent procedures, and no patients had a failed implantation. Conclusion Autologous chondrocyte implantation appears to improve function and reduce symptoms in young to middle-aged patients with symptomatic, full-thickness articular cartilage lesions of the trochlea.

Antegrade drilling for osteochondritis dissecans of the knee

Twenty-four knees with osteochondritis dissecans of the femoral condyles failed a conservative program and were treated with antegrade drilling. To our knowledge, this represents the largest reported series using this technique. The average age at the time of surgery was 13 years 6 months. Seventeen patients had open physes, and four were skeletally mature. Nineteen lesions involved the medial femoral condyle, and five involved the lateral femoral condyle. The average follow-up was 5 years. Postoperative evaluation included rating by the International Knee Documentation Committee (IKDC) form and the Hughston Rating Scale for osteochondritis dissecans. Twenty of the 24 lesions healed after antegrade drilling, and the average time of healing was 4 months. According to the criteria on the IKDC grading form, 14 were normal, 6 nearly normal, three abnormal, and one severely abnormal. The results of the Hughston Rating Scale were similar: 15 were excellent, seven good, one fair, and one poor. Only two of the four skeletally mature patients healed after antegrade drilling. Antegrade drilling is an effective method of treatment for osteochondritis dissecans of the knee that occurs in adolescents with open physes. This operation is not as likely to result in a successful outcome in patients with closed physes; consequently, other methods should be considered in skeletally mature patients.