Mininder S. Kocher

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.

Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group.

Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.

Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm*†

BACKGROUND A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation. METHODS We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care childrens hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested. RESULTS Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis. CONCLUSIONS Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.

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.

Management of Osteochondritis Dissecans of the Knee Current Concepts Review

Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

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.

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.

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.

Reliability, Validity, and Responsiveness of the Lysholm Knee Scale for Various Chondral Disorders of the Knee

BACKGROUND The Lysholm knee scale is a condition-specific outcome measure that was originally designed to assess ligament injuries of the knee. The purpose of this study was to determine the psychometric properties of the Lysholm knee scale for various chondral disorders of the knee. METHODS Test-retest reliability, internal consistency, content validity, criterion validity, construct validity, and responsiveness to change were determined for the Lysholm knee scale within subsets of an overall study population of 1657 patients with chondral disorders of the knee. The study population was a heterogeneous group of patients with various types of traumatic and degenerative chondral lesions, including isolated lesions and those associated with meniscal and ligament injuries. RESULTS The overall Lysholm knee scale and six of the eight domains had acceptable test-retest reliability (intraclass correlation coefficient = 0.91) and internal consistency (Cronbach alpha = 0.65). The overall Lysholm knee scale demonstrated acceptable floor (0%) and ceiling (0.7%) effects; however, the floor effects for the domain of squatting and the ceiling effects for the domains of limp, instability, support, and locking were unacceptable (>30%). There was acceptable criterion validity with significant (p < 0.05) correlations between the overall Lysholm knee scale and the physical functioning, role-physical, and bodily pain domains of the Short Form-12 scale; the pain, stiffness, and function domains of the Western Ontario and McMaster Universities Osteoarthritis Index; and the Tegner activity scale. The overall Lysholm knee scale had acceptable construct validity, with all nine hypotheses demonstrating significance (p < 0.05), and it had acceptable responsiveness to change (effect size, 1.16; standardized response mean, 1.10), with large effects (> or = 0.80) for the domains of pain, limping, swelling, and squatting and a small effect (> or = 0.20) for the domain of instability. CONCLUSIONS The Lysholm knee scale demonstrated overall acceptable psychometric performance for outcomes assessment of various chondral disorders of the knee, although some domains demonstrated suboptimal performance. Psychometric testing of other condition-specific knee instruments in patients with chondral disorders of the knee would be helpful to allow for comparison of psychometric properties.

Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents.

To determine the diagnostic performances of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents we compared them with arthroscopic findings in a consecutive series of pediatric patients (≤16 years old). Stratification effects by patient age and magnetic resonance imaging center were examined. There were 139 lesions diagnosed clinically, 128 diagnosed by magnetic resonance imaging, and 135 diagnosed arthroscopically. There was no significant difference between clinical examination and magnetic resonance imaging with respect to agreement with arthroscopic findings (clinical examination, 70.3%; magnetic resonance imaging, 73.7%), overall sensitivity (clinical examination, 71.2%; magnetic resonance imaging, 72.0%), and overall specificity (clinical examination, 91.5%; magnetic resonance imaging, 93.5%). Stratified analysis by diagnosis revealed significant differences only for sensitivity of lateral discoid meniscus (clinical examination, 88.9%; magnetic resonance imaging, 38.9%) and specificity of medial meniscal tears (clinical examination, 80.7%; magnetic resonance imaging, 92.0%). For magnetic resonance imaging, children younger than 12 years old had significantly lower overall sensitivity (61.7% versus 78.2%) and lower specificity (90.2% versus 95.5%) compared with children 12 to 16 years old. There was no significant effect of magnetic resonance imaging center. In conclusion, selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan.