Charles L. Cox

Are Articular Cartilage Lesions and Meniscus Tears Predictive of IKDC, KOOS, and Marx Activity Level Outcomes After Anterior Cruciate Ligament Reconstruction? A 6-Year Multicenter Cohort Study

Background: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. Hypothesis: Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. Results: A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on the medial meniscus fared worse; conversely, larger excisions (>50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. Conclusion: Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.

Are Articular Cartilage Lesions and Meniscus Tears Predictive of IKDC, KOOS, and Marx Activity Level Outcomes After Anterior Cruciate Ligament Reconstruction?

Background: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. Hypothesis: Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. Results: A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on the medial meniscus fared worse; conversely, larger excisions (>50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. Conclusion: Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

ACL Reconstruction: Do Outcomes Differ by Sex?

BACKGROUND Anterior cruciate ligament (ACL) reconstruction is frequently performed to restore knee stability and function following ACL injury. Female sex is known to predispose to ACL injury; however, it remains unclear whether female sex predisposes to poor outcomes following ACL reconstruction. We hypothesized that male and female patients exhibit no differences in (1) graft failure risk, (2) contralateral ACL injury risk, (3) knee laxity, and (4) patient-reported outcome scores following ACL reconstruction. METHODS A systematic review of the literature was performed to identify studies in which results of ACL reconstruction were reported by sex at a minimum of two years. Study findings were reviewed, and meta-analysis was performed when data were sufficiently homogenous. RESULTS Thirteen studies were identified from the literature review. Meta-analysis revealed no difference in graft failure risk (eight studies), contralateral ACL rupture risk (three studies), or postoperative knee laxity on physical examination (six studies). There was no evidence of a clinically important difference in patient-reported outcomes according to sex. CONCLUSIONS Results of ACL reconstruction were similar in male and female patients. More high-quality studies are needed to further evaluate these findings.

Anterior Cruciate Ligament Reconstruction Rehabilitation MOON Guidelines

Context: Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies. Evidence Acquisition: The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline. Study Design: Clinical review. Level of Evidence: Level 2. Results: This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks. Conclusion: High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Agreement Among Surgeons on Anterior Cruciate Ligament Tunnel Placement

Background: Little is known about surgeon agreement and accuracy using arthroscopic evaluation of anterior cruciate ligament (ACL) tunnel positioning. Purpose: To investigate agreement on ACL tunnel position evaluated arthroscopically between operating surgeons and reviewing surgeons. We hypothesized that operating and evaluating surgeons would characterize tunnel positions significantly differently. Study Design: Controlled laboratory study. Methods: Twelve surgeons drilled ACL tunnels on 72 cadaveric knees using transtibial (TT), medial portal (MP), or 2-incision (TI) techniques and then completed a detailed assessment form on tunnel positioning. Then, 3 independent blinded surgeon reviewers each arthroscopically evaluated tunnel position and completed the assessment form. Statistical comparisons of tunnel position evaluation between operating and reviewing surgeons were completed. Three-dimensional (3D) computed tomography (CT) scans were performed and compared with arthroscopic assessments. Arthroscopic assessments were compared with CT tunnel location criteria. Results: Operating surgeons were significantly more likely to evaluate femoral tunnel position (92.6% vs 69.2%; P = .0054) and femoral back wall thickness as “ideal” compared with reviewing surgeons. Tunnels were judged ideal by reviewing surgeons more often when the TI technique was used compared with the MP and TT techniques. Operating surgeons were more likely to evaluate tibial tunnel position as ideal (95.5% vs 57.1%; P < .0001) and “acceptable” compared with reviewers. The ACL tunnels drilled using the TT technique were least likely to be judged as ideal on the tibia and the femur. Agreement among surgeons and observers was poor for all parameters (κ = −0.0053 to 0.2457). By 3D CT criteria, 88% of femoral tunnels and 78% of tibial tunnels were placed within applied criteria. Conclusion: Operating surgeons are more likely to judge their tunnels favorably than observers. However, independent surgeon reviewers appear to be more critical than results of 3D CT imaging measures. When subjectively evaluated arthroscopically, the TT technique yields more subjectively poorly positioned tunnels than the TI and MP techniques. Surgeons do not agree on the ideal placement for single-bundle ACL tunnels. Clinical Relevance: This study demonstrates that surgeons do not currently uniformly agree on ideal single-bundle tunnel placement and that the TT technique may yield more poorly placed tunnels.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885

Operative versus nonoperative treatment of acute shoulder dislocation in the athlete.

The purpose of this manuscript is to review evaluation and treatment techniques in patients with glenohumeral instability with specific attention to treatment of anterior shoulder dislocation. Scrutiny of the best available evidence reveals that: 1) there is little quality evidence to advocate one reduction technique over another, 2) premedication with intra-articular lidocaine is preferred over intravenous narcotics and benzodiazepine, 3) recurrence rates are age related and may be associated with higher energy injuries, but other predictors of recurrence are not clear, 4) post-reduction immobilization in internal rotation does not affect recurrence, 5) post-reduction immobilization in external rotation appears to decrease recurrence, 6) arthroscopic or open repair decreases recurrence compared with nonoperative treatment, 7) recurrence after arthroscopic repair using transglenoid sutures or staples is higher compared with open repair, 8) recurrence after arthroscopic repair with suture anchors is comparable with open repair in treatment of isolated Bankart lesions, and 9) further research is needed to clarify risk factors that predict recurrence in order to assist the clinician in deciding upon operative versus nonoperative treatment.

Do newer-generation bioabsorbable screws become incorporated into bone at two years after ACL reconstruction with patellar tendon graft?: A cohort study.

BACKGROUND Bioabsorbable interference screws are used frequently for graft fixation in ACL (anterior cruciate ligament) reconstruction. The resorption properties of many available screws that are marketed as bioabsorbable are not well defined. The CALAXO (Smith & Nephew Endoscopy) and MILAGRO (DePuy Synthes) bioabsorbable screws contain polymers of poly(lactic-co-glycolic acid) (PLGA) plus additives to encourage osseointegration over time. The purpose of this study was to evaluate radiographic and magnetic resonance imaging (MRI) properties and compare patient-reported outcomes at a minimum of two years of follow-up after ACL reconstruction using CALAXO or MILAGRO bioabsorbable interference screws. METHODS A cohort of patients who underwent ACL reconstruction in which the fixation used was either CALAXO or MILAGRO screws returned for repeat radiographs for evaluation of tunnel widening, repeat MRI for evaluation of graft integrity and screw breakdown, and completion of the pain and symptom items of the KOOS (Knee injury and Osteoarthritis Outcome Score) questionnaire. RESULTS At a mean of three years (range, 2.5 to 4.0 years) after surgery, thirty-one patients with sixty-two CALAXO screws and thirty-six patients with seventy-two MILAGRO screws returned for repeat evaluation. Two blinded, independent reviewers found no significant differences between the two screw types when comparing radiographs for tibial or femoral tunnel widening or MRIs for graft integrity, tibial and femoral foreign body reactions, or femoral screw degradation. Both reviewers found a significant difference between the two screw types when comparing tibial screw degradation properties (p < 0.01). All analyzed CALAXO screws were rated as partially intact or degraded; the MILAGRO screws were more likely to be rated as intact. No significant differences were noted between the two screw types when comparing the two KOOS subscales. CONCLUSIONS CALAXO screws in the tibial tunnel were more likely to be rated as degraded or partially degraded compared with MILAGRO screws at a mean of three years after implantation for ACL reconstruction. Although these newer-generation bioabsorbable screws were designed to promote osseointegration, no tunnel narrowing was noted, and in the majority of cases the remains of the screws were present at approximately three years.