Karen K. Briggs

Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: MINIMUM TWO-YEAR FOLLOW-UP

Over an eight-month period we prospectively enrolled 122 patients who underwent arthroscopic surgery of the hip for femoroacetabular impingement and met the inclusion criteria for this study. Patients with bilateral hip arthroscopy, avascular necrosis and previous hip surgery were excluded. Ten patients refused to participate leaving 112 in the study. There were 62 women and 50 men. The mean age of the patients was 40.6 yrs (95% confidence interval (CI) 37.7 to 43.5). At arthroscopy, 23 patients underwent osteoplasty only for cam impingement, three underwent rim trimming only for pincer impingement, and 86 underwent both procedures for mixed-type impingement. The mean follow-up was 2.3 years (2.0 to 2.9). The mean modified Harris hip score (HHS) improved from 58 to 84 (mean difference = 24 (95% CI 19 to 28)) and the median patient satisfaction was 9 (1 to 10). Ten patients underwent total hip replacement at a mean of 16 months (8 to 26) after arthroscopy. The predictors of a better outcome were the pre-operative modified HHS (p = 0.018), joint space narrowing >or= 2 mm (p = 0.005), and repair of labral pathology instead of debridement (p = 0.032). Hip arthroscopy for femoroacetabular impingement, accompanied by suitable rehabilitation, gives a good short-term outcome and high patient satisfaction.

Relationships Between Objective Assessment of Ligament Stability and Subjective Assessment of Symptoms and Function After Anterior Cruciate Ligament Reconstruction

Background Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction have not been established. Hypothesis Relationships exist between objective and subjective assessments after anterior cruciate ligament reconstruction. Study Design Case series. Methods Patients (N = 202) undergoing anterior cruciate ligament reconstruction with 2-year minimum follow-up were studied. Objective variables of ligament stability at follow-up included instrumented laxity, Lachman examination, and pivot-shift examination. Subjective variables of symptoms at follow-up included pain, swelling, giving way, locking, crepitus, stiffness, and limping. Subjective function at follow-up included walking, squatting, stair climbing, running, cutting, jumping, twisting, activity limitation, sports level, activities of daily living level, work level, knee function, sports participation, Lysholm score, and satisfaction withoutcome. Results Instrumented knee laxity and Lachman examination had no significant (P> .05) relationships with any subjective variables of symptoms and function. Pivot-shift examination had significant associations with satisfaction (P= .03), partial giving way (P= .01), full giving way (P= .01), difficulty cutting (P= .01), difficulty twisting (P= .01), activity limitation (P= .01), overall knee function (P= .03), sports participation (P= .02), and Lysholm score (P= .01). Conclusions The pivot-shift examination may be a better measure of “functional instability” than instrumented knee laxity or Lachman examination after anterior cruciate ligament reconstruction.

Revision Hip Arthroscopy

Background Hip arthroscopy has become increasingly popular; however, little is known about revision hip arthroscopy. Hypothesis Revision hip arthroscopy is associated with unaddressed femoroacetabular impingement. The purpose of this study was to describe reasons for revision hip arthroscopy. Study Design Case series; Level of evidence, 4. Methods Between March 2005 and March 2006, 37 revision hip arthroscopies were performed by the senior author. Data were collected through retrospective review of clinical and operative notes. Results All patients required revision surgery because of persistent hip pain. There were 25 women and 12 men with an average age of 33 years (range, 16-53 years). The average time from prior surgery to revision was 20.5 months (range, 2.9-84 months). Common findings among patients needing revision were hip pain, decreased range of motion, and functional disability. The average modified Harris Hip Score was 53 (range, 22-99). Thirty-six patients had radiographic evidence of femoroacetabular impingement at the time of revision. Revision procedures included 34 (95%) for femoroacetabular impingement, 32 (87%) for labral lesions, 26 (70%) for a chondral defect, 23 (62%) for lysis of adhesions, and 13 (35%) for previously unaddressed instability. Two patients had total hip arthroplasty after revision, and 3 patients required further revision. Of the remaining 32 patients, early follow-up was obtained on 27 (84%) at an average of 12.7 months postoperatively (range, 6-19 months). Outcomes showed patients regained some of their lost function within the first year. Conclusion Patients commonly required revision hip arthroscopy because of persistent impingement.

The Reliability, Validity, and Responsiveness of the Lysholm Score and Tegner Activity Scale for Anterior Cruciate Ligament Injuries of the Knee 25 Years Later

Background In 1982, the Lysholm score was first published as a physician-administered score in the American Journal of Sports Medicine. The Tegner activity scale was published in 1985. Hypothesis The Lysholm and Tegner scores are valid as patient-administered scores and responsive at early time points after treatment of anterior cruciate ligament tears. Study Design Cohort study (Diagnosis); Level of evidence, 1. Methods All patients were treated for an anterior cruciate ligament tear. For responsiveness, the Lysholm score (n = 1075) and Tegner activity level (n = 505) were measured preoperatively and 6, 9, 12, and 24 months postoperatively. For test-retest (n = 50), scores were measured at 2 years postoperatively and again within 4 weeks by questionnaire. For criterion validity (n = 170), patients completed the Short Form-12 and the International Knee Documentation Committee score in addition to Lysholm and Tegner instruments. For all other analyses, preoperative Lysholm score (n = 1783) or Tegner activity levels (n = 687) were collected. Results There was acceptable test-retest reliability for both the Lysholm (intraclass correlation coefficient = 0.9) and Tegner (intraclass correlation coefficient = 0.8) scores. The minimum detectable change for Lysholm was 8.9 and for Tegner was 1. The Lysholm demonstrated acceptable internal consistency. The Lysholm correlated with the International Knee Documentation Committee (r = .8) and the Short Form-12 (r = .4), and Tegner correlated with the Short Form-12 (r = .2). Both scores had acceptable floor and ceiling effects and all hypotheses were significant. The Lysholm and Tegner were responsive to change at each of the time points. Conclusion After 25 years of changes in treatment of anterior cruciate ligament injuries, the Lysholm knee score and the Tegner activity scale demonstrated acceptable psychometric parameters as patient-administered scores and showed acceptable responsiveness to be used in early return to function after anterior cruciate ligament treatment.

Determinants of Patient Satisfaction with Outcome After Anterior Cruciate Ligament Reconstruction

Background: The purpose of this study was to identify the determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament.Methods: A cohort of 201 patients undergoing primary reconstruction of the anterior cruciate ligament was studied prospectively. All patients were followed for a minimum of two years (mean, 35.9 months). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Nonparametric univariate analysis and multivariable modeling were performed to identify determinants of satisfaction.Results: The demographic variables were not found to have a significant association (p > 0.05) with patient satisfaction. The variables at surgery demonstrated a significant association (p < 0.05) with patient satisfaction only with respect to the status of the lateral meniscus, the presence of osteophytes, and concurrent plica excision. The objective variables at follow-up revealed that patients were significantly less satisfied (p < 0.05) if they had a flexion contracture, increased laxity of the involved leg on the manual maximum test as measured on a KT-1000 device, an abnormal result on the pivot-shift examination, effusion, or tenderness at the medial joint line or patella. With regard to the subjective symptoms at follow-up, patients were found to be significantly (p < 0.05) less satisfied with the outcome if they had symptoms of pain, swelling, partial giving-way, full giving-way, locking, noise, stiffness, or a limp. Analysis of the subjective function at follow-up demonstrated that patients were significantly less satisfied (p < 0.05) with the outcome if they had a lower level of activity, sports activity, strenuous work, activities of daily living, overall knee function, sports participation, or symptom-free activity; if they were unemployed; or if they had difficulty with walking, squatting, ascending or descending stairs, running, jumping, cutting, or twisting. Patient satisfaction was significantly associated (p < 0.05) with the Lysholm knee score, overall International Knee Documentation Committee (IKDC) knee score, IKDC subjective subscore, IKDC symptoms subscore, and IKDC range-of-motion subscore. The seven independent multivariate determinants (adjusted R 2 = 0.83, p < 0.001) of patient satisfaction included the Lysholm score, overall subjective knee function, IKDC range-of-motion subscale, patellar tenderness, full giving-way, flexion contracture, and swelling.Conclusions: Univariate and multivariate determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament were established. Although some specific surgical and objective variables were important, subjective variables of symptoms and function had the most robust associations with patient satisfaction. In assessing the outcome of reconstruction from the perspective of patient satisfaction with the outcome, we should emphasize patient-derived subjective assessment of symptoms and function, particularly those involving issues of stiffness, giving-way, swelling, and patellofemoral symptoms.

Clinical presentation of femoroacetabular impingement.

The purpose of this study was to identify subjective complaints and objective findings in patients treated for femoroacetabular impingement (FAI). Three hundred and one arthroscopic hip surgeries were performed to treat FAI. The most frequent presenting complaint was pain, with 85% of patients reporting moderate or marked pain. The most common location of pain was the groin (81%). The average modified Harris Hip score was 58.5(range 14–100). The average sports hip outcome score was 44.0 (range 0–100). The anterior impingement test was positive in 99% of the patients. Range of motion was reduced in the injured hip. Patients who had degenerative changes in the hip had a greater reduction in range of motion. The most common symptom reported in patients with FAI was groin pain. Patient showed decreased ability to perform activities of daily living and sports. Significant decreases in hip motion were observed in operative hips compared to non-operative hips.

Arthroscopic Labral Repair and Treatment of Femoroacetabular Impingement in Professional Hockey Players

Background Hip injuries are common among professional hockey players in the National Hockey League (NHL). Hypothesis Professional hockey players will return to a high level of function and ice hockey after arthroscopic labral repair and treatment of femoroacetabular impingement. Study Design Case series; Level of evidence, 4. Methods Twenty-eight professional hockey players (NHL) were unable to perform at the professional level due to unremitting and debilitating hip pain. Players underwent arthroscopic labral repair and were treated for femoroacetabular impingement from March 2005 to December 2007. Players who had bilateral hip symptoms were excluded. Athletes completed the Modified Harris Hip Score preoperatively and postoperatively and also completed a patient satisfaction questionnaire postoperatively. Return to sport was defined as the player resuming skating for training or participation in the sport of ice hockey. Results The average age at the time of surgery was 27 years (range, 18-37). There were 11 left hips and 17 right hips. Player positions included 9 defensemen, 12 offensive players, and 7 goaltenders. All players had labral lesions that required repair. In addition, all patients had evidence of femoroacetabular impingement at the time of surgery. The average time to return to skating/hockey drills was 3.4 months. The average time to follow-up was 24 months (range, 12-42). The Modified Harris Hip Score improved from 70 (range, 57-100) preoperatively to an average of 95 (range, 74-100) at follow-up. The median patient satisfaction was 10 (range, 5-10). Two players had reinjury and required additional hip arthroscopy. Conclusion Treatment of femoroacetabular impingement and labral lesions in professional hockey players resulted in successful outcomes, with high patient satisfaction and prompt return to sport.

Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement.

PURPOSE The purpose of this study was to examine the relationship between the size of cam lesions and the presence of cartilage damage, labral damage, or changes in range of motion in the hips with signs and symptoms of femoroacetabular impingement (FAI). METHODS Cross-table lateral radiographs were available for 102 consecutive patients presenting with signs and symptoms of FAI. Radiographs with excessive external rotation, dysplasia, severe arthritis, avascular necrosis, or Legg-Calvé-Perthes syndrome were excluded, leaving 82 patients available for analysis (47 men, 35 women; average age, 25 yr [range, 12 to 55 yr]). Offset angle alpha was measured from the films with a digital goniometer. Patients subsequently underwent hip arthroscopy and the surgical findings and hip range of motion were prospectively recorded. RESULTS Higher offset angle alpha was associated with the presence of acetabular rim chondral defects (P = .044) and full-thickness delamination of the acetabular cartilage (P = .034). Patients with detachment of the base of the labrum had a higher offset angle alpha (P = .016). Higher offset angle alpha was related to male sex (P = .001) and decreased range of motion (P < .05), but not to age. CONCLUSIONS Cam-type FAI, as measured by an increased offset angle alpha, was correlated with increased chondral damage, labral injury, and decreased range of motion.

Reproducibility and Reliability of the Outerbridge Classification for Grading Chondral Lesions of the Knee Arthroscopically

Background Few studies have investigated the accuracy and reproducibility of the Outerbridge classification system for classification of chondral damage in the knee. Hypothesis Arthroscopically assigned Outerbridge grades are accurate, reliable, and reproducible. Study Design Cadaver study. Methods Six cadaveric knees underwent diagnostic arthroscopy, which was videotaped. An arthrotomy was then performed and the arthroscopically identified lesions were measured with calipers. Nine orthopaedic surgeons reviewed each video and graded each chondral lesion two separate times. Accuracy of observations was calculated based on the percentage of agreement between the grades determined during arthroscopy and arthrotomy. Results The overall accuracy was 68% but varied by location. The kappa coefficient between the two scores was 0.602; the arthroscopy grade was higher than the arthrotomy grade 63% of the time. The intraobserver and interobserver kappa coefficients were 0.80 and 0.52, respectively. The mean interobserver kappa between the two physicians in practice 5 years or more was 0.72, compared with 0.50 for physicians in practice less than 5 years. Conclusions The Outerbridge classification was moderately accurate when used to grade chondral lesions arthroscopically. Clinical Relevance Orthopaedic surgeons can accurately grade chondral lesions of the knee with the Outerbridge classification, regardless of their level of experience.

Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee.

BACKGROUND A torn meniscus is one of the most common indications for knee surgery. The purpose of this study was to determine the psychometric properties of the Lysholm knee score and the Tegner activity scale when used for patients with a meniscal injury of the knee. METHODS Test-retest reliability, content validity, criterion validity, construct validity, and responsiveness to change were determined for the Lysholm score and the Tegner activity scale. Test-retest reliability was measured in a group of 122 patients at least two years after they had undergone surgery for a meniscal lesion. This group completed a follow-up form and then completed it again within four weeks. The other tests were performed in a group of 191 patients who had only a meniscal lesion at the time of the surgery and a group of 477 patients who had a meniscal lesion and other intra-articular lesions. RESULTS The overall Lysholm score showed acceptable test-retest reliability, floor and ceiling effects, criterion validity, construct validity, and responsiveness to change. There were unacceptable ceiling effects (>30%) for the Lysholm domains of limp, instability, support, and locking. The Tegner activity scale showed acceptable test-retest reliability, floor and ceiling effects, criterion validity, construct validity, and responsiveness to change. CONCLUSIONS Overall, the Lysholm knee score and the Tegner activity scale demonstrated acceptable psychometric performances as outcome measures for patients with a meniscal injury of the knee. Some domains of the Lysholm score showed suboptimal performance, and the Tegner scale had only a moderate effect size. Psychometric testing of other condition-specific knee instruments for patients with a meniscal lesion of the knee would be helpful to allow comparison of the properties of the various knee instruments.