Jennifer S. Howard

A Systematic Review of Complications and Failures Associated With Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation

Background: Patellofemoral instability affects activities of daily living and hinders athletic participation. Over the past 2 decades, more attention has been paid to medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocations/subluxations. Numerous techniques have been reported; however, there is no consensus regarding optimal reconstruction. Purpose: This study sought to report on the various techniques for MPFL reconstruction described in the literature and to assess the rate of complications associated with the procedure. Study Design: Meta-analysis. Methods: A systematic review of the literature was performed in early October 2010 using keywords “medial patellofemoral ligament,” “MPFL,” “reconstruction,” “complication(s),” and “failure(s).” Articles meeting the inclusion criteria were reviewed. Graft choice, surgical technique, outcome measures, and complications were recorded and organized in a database. Descriptive statistical analysis was performed on the data collected. Results: Twenty-five articles were identified and reviewed. A total of 164 complications occurred in 629 knees (26.1%). These adverse events ranged from minor to major including patellar fracture, failures, clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain. Twenty-six patients returned to the operating room for additional procedures. Conclusion: Medial patellofemoral ligament reconstruction has a high rate of success for patients with patellofemoral instability; however, the complication rate of 26.1% associated with this procedure is not trivial. This study quantified complications and documented the variety of complications reported in outcomes-based literature.

Comparison of Graft Failure Rate Between Autografts Placed via an Anatomic Anterior Cruciate Ligament Reconstruction Technique A Systematic Review, Meta-analysis, and Meta-regression

Background: Recent data from the Danish anterior cruciate ligament (ACL) registry demonstrated increased reoperation rates for hamstring tendon autografts when an anatomic ACL reconstruction is performed. This is consistent with reports of greater time needed for hamstring tendon autografts to mature compared with other autografts. Purpose: To review the literature comparing graft failure rate between patellar and hamstring tendon autografts placed anatomically and to determine if there are differences in return to preinjury activity levels between autografts. Study Design: Systematic review with meta-analysis and meta-regression. Methods: The PubMed, MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies published from January 1, 2000, through March 7, 2014. To compare postoperative outcomes between patellar tendon and hamstring tendon autografts, summary event rates for graft failure and return to preinjury activity level were calculated. A meta-analysis was performed to calculate a summary odds ratio (OR) for graft failure between autografts using the studies that directly compared the 2 autografts. Meta-regression analyses were performed to assess the influence of postoperative follow-up time on graft failure rate. Results: A total of 28 studies reported graft failures for patellar tendon (6 studies) and hamstring tendon (26 studies) autografts used with anatomic ACL reconstruction; 4 of the 28 were comparison studies. Graft failure rate was not significantly different between patellar tendon (7.0% [95% CI, 4.6%-10.5%]) and hamstring tendon autografts (3.9% [95% CI, 2.7%-5.6%]). The odds of graft failure were slightly higher for hamstring tendon autografts (OR, 1.21 [95% CI, 0.63-2.33]), but this difference was not significant (P = .57). The rate of patients returning to preinjury activity levels was not significantly different between patellar (n = 1 study; 58.1% [95% CI, 40.4%-73.9%]) and hamstring tendon autografts (n = 5 studies; 75.6% [95% CI, 43.7%-92.5%]). Overall graft failure rate was positively associated with postoperative follow-up time, but this effect was only significant with hamstring tendon autografts (P < .05). Conclusion: Differences in graft failure rate between patellar tendon and hamstring tendon autografts were not significant. Although follow-up time was only found to have a significant influence on hamstring tendon graft failure rates, this was likely due to the smaller sample of studies assessing patellar tendon graft failures. Differences in return to preinjury activity levels could not be determined due to the lack of studies assessing that outcome. Both patellar and hamstring tendon autografts demonstrate a low risk of failure and moderately high return to activity level after anatomic ACL reconstruction.

Structure, sex, and strength and knee and hip kinematics during landing.

CONTEXT Researchers have observed that medial knee collapse is a mechanism of knee injury. Lower extremity alignment, sex, and strength have been cited as contributing to landing mechanics. OBJECTIVE To determine the relationship among measurements of asymmetry of unilateral hip rotation (AUHR); mobility of the foot, which we described as relative arch deformity (RAD); hip abduction-external rotation strength; sex; and medial collapse of the knee during a single-leg jump landing. We hypothesized that AUHR and RAD would be positively correlated with movements often associated with medial collapse of the knee, including hip adduction and internal rotation excursions and knee abduction and rotation excursions. DESIGN Descriptive laboratory study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty women and 15 men (age = 21 ± 2 years, height = 171.7 ± 9.5 cm, mass = 68.4 ± 9.5 kg) who had no history of surgery or recent injury and who participated in regular physical activity volunteered. INTERVENTION(S) Participants performed 3 double-leg forward jumps with a single-leg landing. Three-dimensional kinematic data were sampled at 100 Hz using an electromagnetic tracking system. We evaluated AUHR and RAD on the preferred leg and evaluated isometric peak hip abductor-external rotation torque. We assessed AUHR by calculating the difference between internal and external hip rotation in the prone position (AUHR = internal rotation - external rotation). We evaluated RAD using the Arch Height Index Measurement System. Correlations and linear regression analyses were used to assess relationships among AUHR, RAD, sex, peak hip abduction-external rotation torque, and kinematic variables for 3-dimensional motion of the hip and knee. MAIN OUTCOME MEASURE(S) The dependent variables were joint angles at contact and joint excursions between contact and peak knee flexion. RESULTS We found that AUHR was correlated with hip adduction excursion (R = 0.36, P = .02). Asymmetry of unilateral hip rotation, sex, and peak hip abduction-external rotation torque were predictive of knee abduction excursion (adjusted R(2) = 0.47, P < .001). Asymmetry of unilateral hip rotation and sex were predictive of knee external rotation excursion (adjusted R(2) = 0.23, P = .001). The RAD was correlated with hip adduction at contact (R(2) = 0.10, R = 0.32, P = .04) and knee flexion excursion (R(2) = 0.11, R = -0.34, P = .03). CONCLUSIONS Asymmetry of unilateral hip rotation, sex, and hip strength were associated with kinematic components of medial knee collapse.

Continuous Passive Motion, Early Weight Bearing, and Active Motion following Knee Articular Cartilage Repair: Evidence for Clinical Practice

Objective: To systematically review the literature regarding postoperative rehabilitation for articular cartilage repair: (1) does the use of continuous passive motion (CPM) enhance healing, and if so, what parameters should be applied? (2) Can active range of motion (AROM) be used in place of or with CPM? (3) When can individuals safely resume weight bearing (WB) following repair? Data Sources: A search using Medline, SportsDiscus, and CINAHL databases was performed with the following keywords: articular cartilage, AROM, CPM, microfracture, osteochondral allograft, autologous chondrocyte implantation, rehabilitation, weight bearing, and knee. Study Selection: Basic science or clinical outcomes examining the effects of CPM, AROM, or WB on knee articular cartilage healing. Data Extraction: Selected articles were rated using the Strength of Recommendation Taxonomy (SORT) to determine evidence for clinical application. Data Synthesis: Sixteen articles met selection criteria: 12 were basic science studies; 4 were clinical studies. Basic science evidence supporting CPM exists. However, few patient-oriented outcomes have been documented resulting in a SORT rating of C. Early WB and AROM received a SORT rating of B based on limited clinical research and patient-oriented outcomes. Conclusions: Basic science evidence supports CPM to maintain ROM, reduce pain, and promote healing. Patient-oriented research is needed to strengthen CPM’s recommendation. Limited evidence exists regarding early WB and AROM post cartilage repair. There is insufficient evidence to confidently address when to begin WB for maximum healing. Appropriate basic science and patient-oriented research are needed for rehabilitation protocols to maximize benefits of cartilage repair procedures.

Rates and Determinants of Return to Play After Anterior Cruciate Ligament Reconstruction in National Collegiate Athletic Association Division I Soccer Athletes A Study of the Southeastern Conference

Background: Factors and details regarding return to play in elite, collegiate female soccer athletes after an anterior cruciate ligament (ACL) injury and reconstruction have not been well studied. Purpose: To evaluate return to play among collegiate female soccer players, specifically examining the effect of surgical and individual athlete characteristics on the return-to-play rate. Study Design: Descriptive epidemiology study. Methods: Sports medicine and athletic training staff at institutions from the National Collegiate Athletic Association Southeastern Conference (SEC) were contacted to request participation in the study. All institutions were sent a standardized spreadsheet with response choices and instructions regarding athlete inclusion criteria. Athlete, injury, surgical technique, and return-to-play data were requested for ACL reconstructions performed on female soccer athletes at the participating institutions over the previous 8 years. χ2 analyses were used to compare the return-to-play rate by year in school, scholarship status, position, depth chart status, procedure, graft type, graft fixation, concomitant procedures, and previous ACL injuries. Results: All 14 of the SEC institutions chose to participate and provided data. A total of 80 ACL injuries were reported, with 79 surgical reconstructions and return-to-play data for 78 collegiate soccer athletes. The overall return-to-play rate was 85%. There was a statistical significance in return-to-play rates favoring athletes in earlier years of eligibility versus later years (P < .001). Athletes in eligibility years 4 and 5 combined had a return-to-play rate of only 40%. Scholarship status likewise showed significance (P < .001), demonstrating a higher return-to-play rate for scholarship athletes (91%) versus nonscholarship athletes (46%). No significant differences in return-to-play rates were observed based on surgical factors, including concomitant knee procedures, graft type, and graft fixation method. Conclusion: Collegiate female soccer athletes have a high initial return-to-play rate. Undergoing ACL reconstruction earlier in the college career as well as the presence of a scholarship had a positive effect on return to play. Surgical factors including graft type, fixation method, tunnel placement technique, concomitant knee surgeries, and revision status demonstrated no significant effect on the return-to-play rate.

Medial Patellofemoral Ligament Reconstruction With Concomitant Tibial Tubercle Transfer: A Systematic Review of Outcomes and Complications

PURPOSE To examine the outcomes and complications of medial patellofemoral ligament (MPFL) reconstruction and concomitant tibial tubercle (TT) transfer. METHODS A systematic review of published literature on MPFL reconstruction and TT transfer was performed using the following databases: PubMed/Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and Cochrane. To be included, studies were required to present outcomes and/or complication data for MPFL reconstruction performed in combination with TT transfer. Each study was assessed for quality and level of evidence. RESULTS Five studies consisting of 92 knees met the inclusion criteria. Between 57% and 77% of the patients were female patients, and the mean age at surgery was 20.6 years (range, 19 to 31 years). The mean follow-up period was 38 months (range, 23 to 53 months). Postoperative outcome measures including the Lysholm score, Kujala score, International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, and visual analog scale score were similar to those previously reported for isolated MPFL reconstruction. Reported complication rates were lower than 15% and included wound infection, hardware irritation, and stiffness. Four studies were graded as Level IV evidence, and 1 study was graded as Level II evidence. Only 1 study scored greater than 50% in the quality analysis. CONCLUSIONS Results from the analyzed studies indicate that MPFL reconstruction combined with TT transfer is a safe and effective procedure, with a low to moderate risk of complications but overall favorable results. TT transfer is most often performed in conjunction with MPFL reconstruction in the setting of malalignment such as an increased TT-to-trochlear groove distance, and although the surgical indications may differ, the outcomes and risk profiles are similar to those of isolated MPFL reconstruction. With the recognition that these patients are difficult to standardize, additional well-designed studies are needed to further investigate the ideal surgical candidates for MPFL reconstruction with concomitant TT transfer. LEVEL OF EVIDENCE Level IV, systematic review of Level II and IV studies.

Comparing Responsiveness of Six Common Patient-Reported Outcomes to Changes Following Autologous Chondrocyte Implantation: A Systematic Review and Meta-Analysis of Prospective Studies.

Objective: To compare the responsiveness of six common patient-reported outcomes (PROs) following autologous chondrocyte implantation (ACI). Design: A systematic search was conducted to identify reports of PROs following ACI. Study quality was evaluated using the modified Coleman Methodology Score (mCMS). For each outcome score, pre- to postoperative paired Hedge’s g effect sizes were calculated with 95% confidence intervals (CIs). Random effects meta-analyses were performed to provide a summary response for each PRO at time points (TP) I (<1 year), II (1 year to <2 years), III (2 years to <4 years), IV (≥4 years), and overall. Results: The mean mCMS for the 42 articles included was 50.9 ± 9.2. For all evaluated instruments, none of the mean effect size CIs encompassed zero. The International Knee Documentation Committee Subjective Knee Form (IKDC) had increasing responsiveness over time with TP-IV, demonstrating greater mean effect size [confidence interval] (1.78 [1.33, 2.24]) than TP-I (0.88 [0.69, 1.07]). The Knee Injury and Osteoarthritis Outcome Score–Sports and recreation subscale (KOOS-Sports) was more responsive at TP-III (1.76 [0.87, 2.64]) and TP-IV (0.98 [0.81, 1.15]) than TP-I (0.61 [0.44, 0.78]). Overall, the Medical Outcomes Study 36-Item Short Form Health Survey Physical Component Scale (0.60 [0.46, 0.74]) was least responsive. Both the Lysholm Scale (1.42 [1.14, 1.72]) and the IKDC (1.37 [1.13, 1.62]) appear more responsive than the KOOS-Sports (0.90 [0.73, 1.07]). All other KOOS subscales had overall effect sizes ranging from 0.90 (0.74, 1.22) (Symptoms) to 1.15 (0.76, 1.54) (Quality of Life). Conclusions: All instruments were responsive to improvements in function following ACI. The Lysholm and IKDC were the most responsive instruments across time. IKDC and KOOS-Sports may be more responsive to long-term outcomes, especially among active individuals.

Use of Preoperative Patient Reported Outcome Scores to Predict Outcome Following Autologous Chondrocyte Implantation

Objectives: Autologous chondrocyte implantation(ACI) has become an accepted treatment for articular cartilage defects; however, selection of appropriate patients in routine clinical practice remains challenging. The purpose of this study was to evaluate the use of preoperative patient reported outcome(PRO) scores in predicting postoperative self-reported global function following ACI with the goal of defining a minimum entry score that is predictive of a successful patient outcome. Methods: A case series of patients a minimum of 1-year following ACI (n = 73, 27 female, age = 35 ± 7 yrs, BMI = 30 ± 5, mean defect = 7.4 ± 5.1 cm2, average follow-up = 2.3 ± 1.2 yrs) were evaluated. All patients were enrolled prospectively and completed PROs pre-surgery and 3, 6, and 12 months and annually post-surgery. As part of the ICRS Cartilage Injury Standard Evaluation Form, postoperatively patients were asked to rate their current function as “severely restricted in everything I do”, “restricted, many things are not possible”, “I can do nearly everything”, or “I can do everything”. Receiver operator curves (ROCs) were used to explore the discriminative accuracy of preoperative PROs (Total WOMAC Knee Score, IKDC Subjective Knee Form, and Lysholm Knee Scale) for identifying patients reporting to be able to do “nearly everything” or “everything” at the last available follow-up. From the ROCs cut-point scores for the values with the highest combined sensitivity and specificity were identified. Patients were then classified for each PRO instrument as having preoperative scores above or below the identified cut-point values. Cut-point status for preoperative WOMAC, IKDC, and Lysholm along with BMI, gender, age, defect area, and defect location (patellofemoral/tibiofemoral) were analyzed in a backwards entry logistic regression model to predict patients experiencing a positive outcome. Results: Area under the curve was significantly greater than 0.5(range 0.80(IKDC)-0.82(Lysholm), p≤0.001) for each PRO ROC, demonstrating high accuracy in using preoperative PROs to predict post-operative function. The WOMAC score demonstrated a cut-point value of 34 with a sensitivity of 0.89 and specificity of 0.60 for identifying patients who went on to a positive outcome. For IKDC the cut-point was 35 (sensitivity=0.86, specificity=0.67). For Lysholm the cut-point was 41 (sensitivity =0.89, specificity=0.61). The only variables contributing to the final logistic model were IKDC score > 35 (p=0.002), and Lysholm score > 41 (p=0.002). The model demonstrated that those individuals with a preoperative IKDC score > 35 had 7.4 (95%CI: 2.1 - 26.9) greater odds of a positive outcome compared to those with an IKDC score ≤ 35 and those with a preoperative Lysholm score > 41 had 8.5 (2.2 - 33.2) greater odds of a positive outcome compared to those with a Lysholm score ≤ 41. Overall 85.5% of patients were correctly classified by the model as having a good or poor outcome. Conclusion: Pre-operative PROs can provide patients and physicians with accurate expectations for post-operative global levels of function. These results suggest that there may exist a minimum threshold of self-reported function for which ACI procedures can result in meaningful functional outcomes. Patients with functional levels below these cut-points should undergo preoperative interventions aimed at improving their function to above cut-point values and be counseled for realistic treatment expectations or available treatment alternatives.

Feasibility of conducting a web-based survey of patient-reported outcomes and rehabilitation progress

Background Web-based surveys provide an efficient means to track clinical outcomes over time without the use of clinician time for additional paperwork. Our purpose was to determine the feasibility of utilizing web-based surveys to capture rehabilitation compliance and clinical outcomes among postoperative orthopedic patients. The study hypotheses were that (a) recruitment rate would be high (>90%), (b) patients receiving surveys every two weeks would demonstrate higher response rates than patients that receive surveys every four weeks, and (c) response rates would decrease over time. Methods The study deaign involved a longitudinal cohort. Surgical knee patients were recruited for study participation during their first post-operative visit (n = 59, 34.9 ± 12.0 years of age). Patients with Internet access, an available email address and willingness to participate were counter-balanced into groups to receive surveys either every two or four weeks for 24 weeks post-surgery. The surveys included questions related to rehabilitation and questions from standard patient-reported outcome measures. Outcome measures included recruitment rate (participants consented/patients approached), eligibility (participants with email/participants consented), willingness (willing participants/participants eligible), and response rate (percentage of surveys completed by willing participants). Results Fifty-nine patients were approached regarding participation. Recruitment rate was 98% (n = 58). Eligibility was 95% (n = 55), and willingness was 91% (n = 50). The average response rate was 42% across both groups. There was no difference in the median response rates between the two-week (50%, range 0–100%) and four-week groups (33%, range 0–100%; p = 0.55). Conclusions Although patients report being willing and able to participate in a web-based survey, response rates failed to exceed 50% in both the two-week and four-week groups. Furthermore, response rates began to decrease after the first three months postoperatively. Therefore, supplementary data collection procedures may be necessary to meet established research quality standards.

Current Concepts in Cartilage Management and Rehabilitation

Special Issue: Current Concepts in Cartilage Management and RehabilitationGuest Editors: Jennifer S. Howard, Jay R. Ebert, and Karen Hambly