Jan Harald Røtterud

Focal Cartilage Defects in the Knee Impair Quality of Life as Much as Severe Osteoarthritis A Comparison of Knee Injury and Osteoarthritis Outcome Score in 4 Patient Categories Scheduled for Knee Surgery

Background Patients with focal cartilage defects in the knee may suffer from both pain and functional impairment. Treatment options are often insufficient. It is not known, however, to what extent their complaints affect quality of life, compared with other knee disorders. Knee Injury and Osteoarthritis Outcome Score (KOOS) is a validated global knee score suitable for comparison of patients with knee complaints attributable to different causes. Hypothesis Complaints because of localized cartilage defects in the knee reduce quality of life measured by KOOS to a different extent than those due to anterior cruciate ligament deficiency and osteoarthritis, when comparing patients within the working population scheduled for surgery. Study Design Cross-sectional study; Level of evidence, 3. Methods Previously registered KOOS baseline data on patients enrolled in different knee treatment studies were included in the present study; the patients were 18 to 67 years of age (working population) at data registration. The different patient categories were (1) patients with knee osteoarthritis enrolled for knee arthroplasty, (2) patients with knee osteoarthritis enrolled for osteotomies around the knee, (3) patients with focal cartilage lesions enrolled for cartilage repair, and (4) patients with anterior cruciate ligament—deficient knees enrolled for anterior cruciate ligament reconstruction. The KOOS subscale quality of life was the main parameter for comparison of complaints. Results At preoperative baseline, patients with focal cartilage defects in the knee scored 27.5 on the KOOS subscale quality of life, not significantly different from the 28.8 and 27.2 in the patients with osteoarthritis enrolled for knee osteotomies and arthroplasties, respectively. For all the subscales of KOOS, the cartilage patients scored significantly lower than the patients with anterior cruciate ligament deficiency. Conclusion Patients with focal cartilage lesions have major problems with pain and functional impairment. Their complaints are worse than those of patients with anterior cruciate ligament—deficient knees, and quality of life is affected to the same extent as in patients scheduled for knee replacement.

Effect of Meniscal and Focal Cartilage Lesions on Patient-Reported Outcome After Anterior Cruciate Ligament Reconstruction A Nationwide Cohort Study From Norway and Sweden of 8476 Patients With 2-Year Follow-up

Background: The effect of concomitant intra-articular injury on patient-reported outcome after anterior cruciate ligament (ACL) reconstruction is debated. Purpose: To evaluate the effect of meniscal and articular cartilage lesions on patient-reported outcome 2 years after ACL reconstruction. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: The study included all patients with primary, unilateral ACL reconstruction registered in the Norwegian and the Swedish National Knee Ligament Registry from 2005 through 2008 who had completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) Knee-Related Quality of Life subscale at a 2-year follow-up (mean ± SD, 2.1 ± 0.2 years) after surgery (n = 8476). Multiple linear regression analyses were used to evaluate the associations between each KOOS subscale (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Knee-Related Quality of Life) as the measure for patient-reported outcome and meniscal and cartilage lesions. Results: A total of 3674 (43%) patients had meniscal lesion(s), 1671 (20%) had partial-thickness (International Cartilage Repair Society [ICRS] grades 1-2) cartilage lesion(s), and 551 (7%) had full-thickness (ICRS grades 3-4) cartilage lesion(s). Multiple linear regression analyses detected no significant associations between meniscal lesions or partial-thickness cartilage lesions and the scores in any of the KOOS subscales at the 2-year follow-up. Full-thickness cartilage lesions were significantly associated with decreased scores in all of the KOOS subscales. Conclusion: Patients with concomitant full-thickness cartilage lesions reported worse outcome in all of the KOOS subscales compared with patients without cartilage lesions 2 years after ACL reconstruction. Meniscal lesions and partial-thickness cartilage lesions did not impair patient-reported outcome 2 years after ACL reconstruction.

Effect of Gender and Sports on the Risk of Full-Thickness Articular Cartilage Lesions in Anterior Cruciate Ligament–Injured Knees A Nationwide Cohort Study From Sweden and Norway of 15 783 Patients

Background: The presence of an articular cartilage lesion in anterior cruciate ligament–injured knees is considered a predictor of osteoarthritis. Purpose: This study was undertaken to evaluate risk factors for full-thickness articular cartilage lesions in anterior cruciate ligament–injured knees, in particular the role of gender and the sport causing the initial injury. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Primary unilateral anterior cruciate ligament reconstructions prospectively registered in the Swedish and the Norwegian National Knee Ligament Registry during 2005 through 2008 were included (N = 15 783). Logistic regression analyses were used to evaluate risk factors for cartilage lesions. Results: A total of 1012 patients (6.4%) had full-thickness cartilage lesions. The median time from injury to surgery was 9 months (range, 0 days-521 months). Male patients had an increased odds of full-thickness cartilage lesions compared with females (odds ratio = 1.22; 95% confidence interval, 1.04-1.42). In males, team handball had an increase in the odds of full-thickness cartilage lesions compared with soccer (odds ratio = 2.36; 95% confidence interval, 1.33-4.19). Among female patients, no sport investigated showed a significant decrease or increase in the odds of full-thickness cartilage lesions. The odds of a full-thickness cartilage lesion increased by 1.006 (95% confidence interval, 1.005-1.008) for each month elapsed from time of injury until anterior cruciate ligament reconstruction when all patients were considered, while time from injury to surgery did not affect the odds significantly in those patients reconstructed within 1 year of injury (odds ratio = 0.98; 95% confidence interval, 0.95-1.02). Previous surgery increased the odds of having a full-thickness cartilage lesion (odds ratio = 1.40; 95% confidence interval, 1.21-1.63). One year of increasing patient age also increased the odds (odds ratio = 1.05; 95% confidence interval, 1.05-1.06). Conclusion: Male gender is associated with an increased risk of full-thickness articular cartilage lesions in anterior cruciate ligament–injured knees. Male team handball players had an increased risk of full-thickness lesions. No other sports investigated were found to have significant effect on the risk in either gender. Furthermore, age, previous surgery, and time from injury to surgery exceeding 12 months are risk factors for full-thickness cartilage lesions.

The Feasibility of a 3-Month Active Rehabilitation Program for Patients With Knee Full-Thickness Articular Cartilage Lesions: The Oslo Cartilage Active Rehabilitation and Education Study

STUDY DESIGN Case series. OBJECTIVES To evaluate the feasibility of an active rehabilitation program for patients with knee full-thickness articular cartilage lesions. BACKGROUND No studies have yet evaluated the effect of active rehabilitation in patients with knee full-thickness articular cartilage lesions or compared the effects of active rehabilitation to those of surgical interventions. As an initial step, the feasibility of such a program needs to be described. METHODS Forty-eight patients with a knee full-thickness articular cartilage lesion and a Lysholm score below 75 participated in a 3-month active rehabilitation program consisting of cardiovascular training, knee and hip progressive resistance training, and neuromuscular training. Feasibility was determined by monitoring adherence to the program, clinical changes in knee function, load progression, and adverse events. Patients were tested before and after completing the rehabilitation program by using patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation Form 2000) and isokinetic muscle strength and hop tests. To monitor adherence, load progression, and adverse events, patients responded to an online survey and kept training diaries. RESULTS The average adherence rate to the rehabilitation program was 83%. Four patients (9%) showed adverse events, as they could not perform the exercises due to pain and effusion. Significant and clinically meaningful improvement was found, based on changes on the International Knee Documentation Committee Subjective Knee Evaluation Form 2000, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, isokinetic muscle strength, and hop performance (P<.05), with small to large effect sizes (standardized response mean, 0.3-1.22). CONCLUSION The combination of a high adherence rate, clinically meaningful changes, and positive load progression and the occurrence of only a few adverse events support the potential usefulness of this program for patients with knee full-thickness cartilage lesions. This study was registered with the public trial registry ClinicalTrials.gov (NCT00885729). LEVEL OF EVIDENCE Therapy, level 4.

Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years.

Background: Fractures of the clavicle are common among adolescents and have traditionally been treated nonoperatively. Recent literature has demonstrated less satisfactory results than expected after conservative management of displaced fractures in adults. The purpose of this study was to evaluate the long-term patient-reported outcome after clavicle fractures in older children and adolescents. Methods: Children aged 10 to 18 years who sustained a fracture of the clavicle between 2006 and 2008 were identified in our institution’s computerized files. The radiographs were examined and the fracture patterns, degree of dislocation, and shortening were measured. Medical records were reviewed and the patient-reported outcome was assessed using the Oxford Shoulder score and the Quick version of the Disability of Arm, Shoulder, and Hand questionnaire, and specific and general satisfaction scores. Results: A total of 185 patients (median age, 14.4 y) with 172 midshaft and 13 lateral fractures were included in the study. Sixty-five (37.8%) of the midshaft fractures were displaced, and 9 of these were operated. There was one case of nonunion and one delayed union. One hundred twenty-two (70.9%) of the patients with a midshaft fracture responded to the questionnaires on an average 4.7 years after injury. Overall results were good to excellent for the majority of nonoperatively treated patients; however, shortening of the fracture had a negative effect on the Oxford Shoulder score (P=0.02), the cosmetic satisfaction score (P=0.02), and the overall satisfaction score (P=0.01). Conclusions: The long-term patient-reported outcome after nonoperatively treated fractures of the clavicle in adolescents is good to excellent for the majority of the patients, and nonunion is rare. However, shortening of the fracture had a small negative effect on the outcome. Conservative management should remain the mainstay of management for fractures of the clavicle in this age group. Level of Evidence: Level IV—retrospective case series.

Effect on Patient-Reported Outcomes of Debridement or Microfracture of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament–Reconstructed Knees A Nationwide Cohort Study From Norway and Sweden of 357 Patients With 2-Year Follow-up

Background:The treatment of concomitant cartilage lesions in anterior cruciate ligament (ACL)–injured knees is debatable.Purpose:To evaluate the effect of debridement or microfracture (MF) compared with no treatment of concomitant full-thickness (International Cartilage Repair Society [ICRS] grades 3-4) cartilage lesions on patient-reported outcomes after ACL reconstruction.Study Design:Cohort study; Level of evidence, 2.Methods:Six hundred forty-four patients who underwent primary unilateral ACL reconstruction and had a concomitant full-thickness cartilage lesion treated simultaneously by debridement (n = 129) or MF (n = 164), or underwent no treatment (n = 351) of the cartilage lesion, registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 to 2008 were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure patient-reported outcomes. At a mean follow-up of 2.1 ± 0.2 years after surgery, 357 (55%) patients completed the KOOS. Linear regression an...

Agreement in Arthroscopic and Arthrotomy Assessment of Full-Thickness Articular Cartilage Lesions of the Knee in a Clinical Setting in 33 Consecutive Patients.

Objective To evaluate the accuracy of arthroscopic measurement of full-thickness (International Cartilage Repair Society grades 3-4) cartilage lesions of the knee. Design In 33 consecutive arthroscopically evaluated cartilage lesion knees the lesion size was routinely estimated. At the final treatment, a knee arthrotomy was performed, and the lesion was reestimated. The 2 estimates were then compared by paired t test and the area estimated by knee arthrotomy was used as the gold standard. Results. The mean area of the cartilage lesion estimated by arthroscopic surgery was 3.5 cm2 (standard deviation [SD] = 1.7) whereas in the open surgery the mean area was 3.2 cm2 (SD = 1.5). The mean difference was 0.3 cm2, indicating a tendency toward overestimation by the arthroscopic evaluation, but the difference was not significant (P = 0.09). Additional MRI assessment of the area demonstrated a mean area of 2.3 cm2 (SD = 1.6). This underestimated the size of the lesion by 1.2 cm2 (SD = 0.8; P = 0.015). Conclusion Knee arthroscopic examination estimated a cartilage full-thickness lesion with an error of less than 25 % in the majority of the patients.

A Controlled Comparison of Microfracture, Debridement, and No Treatment of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament–Reconstructed Knees: A Nationwide Prospective Cohort Study From Norway and Sweden of 368 Patients With 5-Year Follow-up

Background: The effect of microfracture (MF) or surgical debridement of concomitant full-thickness cartilage lesions in anterior cruciate ligament–reconstructed knees on patient-reported outcomes remains to be determined. Purpose: To evaluate the effect of debridement or MF compared with no surgical treatment of concomitant full-thickness cartilage lesions on patient-reported outcomes 5 years after anterior cruciate ligament reconstruction (ACLR). Study Design: Cohort study; Level of evidence, 2. Methods: Included in this study were 644 patients who were registered in the Norwegian and the Swedish National Knee Ligament Registries from 2005 to 2008 as having undergone unilateral primary ACLR and having a concomitant full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grades 3-4). Of these patients, 129 were treated with debridement, 164 were treated with MF, and 351 received no surgical treatment simultaneously with ACLR. At 5-year follow-up, 368 (57%) patients completed results on the Knee injury and Osteoarthritis Outcome Score (KOOS). Multivariable linear regression was used to estimate the effect of surgical debridement or MF of concomitant full-thickness cartilage lesions on patient-reported outcomes 5 years after ACLR. Results: Compared with no surgical treatment, there were no unadjusted or adjusted effects of debridement or MF of concomitant full-thickness cartilage lesions on KOOS scores at 5-year follow-up. Conclusion: Compared with leaving concomitant full-thickness cartilage lesions untreated at the time of ACLR, debridement and MF showed no effect on patient-reported outcomes 5 years after surgery.

Effect of Concomitant Cartilage Lesions on Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Nationwide Cohort Study From Norway and Sweden of 8470 Patients With 5-Year Follow-up

Background: The effect of concomitant focal cartilage lesions on patient-reported outcomes after anterior cruciate ligament reconstruction (ACLR) remains to be determined. Purpose: To evaluate the effect of concomitant partial-thickness (International Cartilage Repair Society [ICRS] grades 1-2) and full-thickness (ICRS grades 3-4) cartilage lesions on patient-reported outcomes 5 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: All patients who underwent unilateral primary ACLR registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 to 2008 (n = 15,783) were included in the study. At 5-year follow-up, 8470 (54%) patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS). Multivariable linear regression models were used to estimate the effect of concomitant partial-thickness and full-thickness cartilage lesions on patient-reported outcomes (KOOS) 5 years after ACLR. Results: Compared with no concomitant cartilage lesions, both partial-thickness and full-thickness cartilage lesions were indicators of statistically significant adverse effects on the KOOS in the adjusted regression analysis at 5-year follow-up after ACLR. Conclusion: ACL-injured patients with concomitant cartilage lesions reported worse outcomes and less improvement than those without cartilage lesions 5 years after ACLR.

Considerations for Treatment of Concomitant Cartilage and ACL Injury

Concomitant cartilage lesions in ACL-injured knees are common. These cartilage lesions have negative effects on patient-reported outcome after ACL reconstruction and increase the risk of later osteoarthritis (OA).