Test-retest reliability and longitudinal validity of drop vertical jump biomechanics during rehabilitation after ACL reconstruction.

Hip and knee biomechanics measured during a drop vertical jump (DVJ) can be used to assess patients undergoing rehabilitation after anterior cruciate ligament (ACL) reconstruction. To confidently interpret such data for use as outcome measures, additional information about reliability and validity is required. Therefore, the objective of this study was to estimate the test-retest reliability and longitudinal validity of selected lower limb biomechanics assessed during a DVJ in patients undergoing rehabilitation after ACL reconstruction. Biomechanical analysis of the DVJ in primary unilateral ACL reconstruction patients (22.3 ± 5.5y) were tested twice within 1 week at 6 months post-surgery (n = 46), and again at 12 months post-surgery (n = 36). Peak and initial contact knee angles and moments, hip impulse, vertical ground reaction forces (VGRF), isokinetic knee extension and flexion strength, and global ratings of change (GRC) were assessed. Reliability was evaluated based on the 6-month post-surgery data using intraclass correlation coefficients (ICC2,1), standard errors of measurement and minimum detectable change. Longitudinal validity was evaluated by assessing change from 6 to 12 months, using standardized response means (SRM), and by assessing the correlation (Pearson's r) of change in landing biomechanics with change in strength, and GRC. ICCs ranged from 0.58 to 0.90 for peak knee abduction and flexion moments, 0.44-0.85 for knee flexion and abduction angles, 0.82-0.93 for VGRFs, and 0.42-0.65 for hip impulse. SRMs and correlations of change ranged from 0.00 to 0.50. Reliability and longitudinal validity of DVJ measures varied, ranging from poor-to-excellent; the present results assist in their interpretation when assessed during rehabilitation after ACL reconstruction.

Evaluation of Outcomes After Anterior Cruciate Ligament Reconstruction: What We Know, What We Have, and What to Consider.

Measurement of success following anterior cruciate ligament reconstruction (ACLR) hinges on the appropriate use of high quality and meaningful outcome measures. We identified and categorized over 100 outcome measures for ACLR using the International Classification of Functioning, Disability and Health (ICF) model. The ICF model is a useful framework to facilitate decisions about outcome selection and describe recovery following ACL injury. We outline key considerations when selecting outcome measures during study design (purpose, measurement properties, sample size, global assessment) or evaluating reported outcomes (measurement properties, sample size, magnitude/precision, clinical relevance, applicability), and discuss challenges in outcome measurement following ACLR.

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis.

BACKGROUND: The addition of an iliotibial band-based lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to reduce failure rates. However, there are concerns as to the potential overconstraint of tibiofemoral kinematics that may increase the risk of cartilage degradation. To date, no clinical study has investigated the effect of LET on patellofemoral joint articular cartilage health. HYPOTHESIS: It was hypothesized that at 2 years postoperatively, (1) the addition of LET at the time of ACLR would have no effect on cartilage health on magnetic resonance imaging (MRI), and (2) higher cartilage relaxation values would be associated with worse patient-reported and functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. Patients were randomized to either LET augmentation or not. Cartilage status in the patellofemoral joint between the ACLR group and ACLR+LET group was compared using 2-year postoperative quantitative MRI and the ACL osteoarthritis scores of both the surgical and the contralateral nonsurgical knees. Objective functional outcomes and patient-reported outcome measures (PROMs) were attained. RESULTS: A total of 92 patients (43 patients in the ACLR group; mean age, 18.9 ± 3.2 years; 60.5% female; and 49 patients in the ACLR+LET group; mean age, 18.7 ± 3.2 years, 63.3% female) were included. No significant differences were seen in the mean values (ms) for adjusted T1ρ/T2 relaxation times in the medial patella (47.8/42.2 vs 47.3/43.2), central patella (45.5/42.5 vs 44.1/42.7), lateral patella (48.2/43.5 vs 47.3/43.0), medial trochlea (54.7/50.9 vs 56.4/50.9), central trochlea (53.3/51.1 vs 53.1/52.0), and lateral trochlea (54.9/52.1 vs 53.9/52.6) between the ACLR and ACLR+LET groups. No difference in overall ACL osteoarthritis scores was observed (P = .99). An increase in medial patellar T2 relaxation times was associated with a decreasing International Knee Documentation Committee score (P = .046), Knee injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale score (P = .01), and total KOOS (P = .01). CONCLUSION: There was no statistical difference in patellofemoral cartilage health between knees 2 years after primary ACLR with hamstring tendon autograft with or without LET. Statistically significant correlations were found between quantitative MRI relaxation times, functional outcome scores, and PROMs; however, the correlations were weak and the clinical significance is unknown. REGISTRATION: NCT02018354 (ClinicalTrials.gov identifier).

'It's just my knee': a qualitative study investigating the process of reframing and young athletes' perceived quality of life between anterior cruciate ligament injury and surgery.

OBJECTIVES: To understand the factors influencing young athletes' perceptions of quality of life (QOL) following an anterior cruciate ligament (ACL) rupture, prior to reconstructive surgery. DESIGN: Qualitative descriptive study using semi-structured interviews and thematic analysis of data. SETTING: Tertiary sports medicine clinic with patients recruited from the practices of three specialist orthopaedic surgeons. PARTICIPANTS: Twenty athletes aged 14-25 provided consent to participate in the study and completed interviews prior to their ACL reconstruction surgery. Participants were eligible to participate if they were scheduled to undergo ACL reconstruction, were 25 years of age or younger, identified as athletes (participated in any level of organised sport), could communicate in English and agreed to be audio recorded. Participants were not eligible if they had experienced a multiligament injury or fracture. RESULTS: Young athletes shared common factors that made up their QOL; social connections and support, sport, health, and independence. However, participants' perceptions of their current QOL were quite variable (13-95/100 on a Visual Analogue Scale). Participants who were able to reframe their injury experience by shifting focus to the positive or unaffected aspects of their lives tended to have more favourable perceptions of their QOL than participants who shifted focus to the losses associated with injury. CONCLUSIONS: Young athletes who have experienced an ACL injury define their QOL based on social support, sport, health and independence. Individual processes of adaptation and cognitive reframing in response to an ACL injury may exert a greater influence on postinjury QOL than the physical ramifications of the injury itself. Understanding individual perceptions may help target potential interventions or supports to enhance athletes' adaptation to injury.

Extrusion After Meniscal Allograft Transplantation Is Lower or Equal With Bony Compared With Soft-Tissue Root Fixation: A Systematic Review.

PURPOSE: To provide an update on the incidence and extent of graft extrusion after meniscal allograft transplantation (MAT) and to systematically review the literature to identify whether the type of root fixation or additional surgical techniques may reduce the risk of graft extrusion development. METHODS: A systematic search, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, was conducted using the MEDLINE database, EMBASE database, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL) database. Patients undergoing medial meniscal allograft transplantation (MMAT) or lateral meniscal allograft transplantation (LMAT) were included. The primary outcome measure was meniscal extrusion measured on postoperative magnetic resonance imaging scans taken more than 6 weeks after MAT. The following extrusion outcomes were investigated: absolute extrusion (AE), relative percentage of extrusion (RPE), and proportion of major extrusion (PME). Additional surgical techniques that reduced the risk of graft extrusion development in the included comparative studies were identified. RESULTS: For MMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.2 mm versus 3.36 mm and RPE of 44.43% versus 33.18%. The pooled mean PME for MMAT with soft-tissue fixation was 51.62%. For LMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.72 mm versus 2.78 mm, RPE of 31.89% versus 29.47%, and PME of 64.37% versus 35.80%. Additional capsulodesis was identified as a technique to reduce LMAT extrusion. CONCLUSIONS: This study highlights that graft extrusion is a common finding after MMAT and LMAT, independent of the root fixation technique. However, MAT extrusion with bony fixation was, depending on the outcome measurement, lower than or equal to that with soft-tissue fixation. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Quantitative Magnetic Resonance Imaging of Lateral Compartment Articular Cartilage After Lateral Extra-articular Tenodesis.

BACKGROUND: Concerns have arisen that anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) may accelerate the development of posttraumatic osteoarthritis in the lateral compartment of the knee. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate whether the augmentation of ACLR with LET affects the quality of lateral compartment articular cartilage on magnetic resonance imaging (MRI) at 2 years postoperatively. We hypothesized that there would be no difference in T1rho and T2 relaxation times when comparing ACLR alone with ACLR + LET. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive subgroup of patients at the Fowler Kennedy Sport Medicine Clinic participating in the STABILITY 1 Study underwent bilateral 3-T MRI at 2 years after surgery. The primary outcome was T1rho and T2 relaxation times. Articular cartilage in the lateral compartment was manually segmented into 3 regions of the tibia (lateral tibia [LT]-1 to LT-3) and 5 regions of the femur (lateral femoral condyle [LFC]-1 to LFC-5). Analysis of covariance was used to compare relaxation times between groups, adjusted for lateral meniscal tears and treatment, cartilage and bone marrow lesions, contralateral relaxation times, and time since surgery. Semiquantitative MRI scores according to the Anterior Cruciate Ligament OsteoArthritis Score were compared between groups. Correlations were used to determine the association between secondary outcomes (including results of the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Lower Extremity Functional Scale, 4-Item Pain Intensity Measure, hop tests, and isokinetic quadriceps and hamstring strength tests) and cartilage relaxation. RESULTS: A total of 95 participants (44 ACLR alone, 51 ACLR + LET) with a mean age of 18.8 years (61.1% female [58/95]) underwent 2-year MRI (range, 20-36 months). T1rho relaxation times were significantly elevated for the ACLR + LET group in LT-1 (37.3 ± 0.7 ms vs 34.1 ± 0.8 ms, respectively; P = .005) and LFC-2 (43.9 ± 0.9 ms vs 40.2 ± 1.0 ms, respectively; P = .008) compared with the ACLR alone group. T2 relaxation times were significantly elevated for the ACLR + LET group in LFC-1 (51.2 ± 0.7 ms vs 49.1 ± 0.7 ms, respectively; P = .03) and LFC-4 (45.9 ± 0.5 ms vs 44.2 ± 0.6 ms, respectively; P = .04) compared with the ACLR alone group. All effect sizes were small to medium. There was no difference in Anterior Cruciate Ligament OsteoArthritis Scores between groups (P = .99). Weak negative associations (rs = -0.27 to -0.22; P < .05) were found between relaxation times and quadriceps and hamstring strength in the anterolateral knee, while all other correlations were nonsignificant (P > .05). CONCLUSION: Increased relaxation times demonstrating small to medium effect sizes suggested early biochemical changes in articular cartilage of the anterolateral compartment in the ACLR + LET group compared with the ACLR alone group. Further evidence and long-term follow-up are needed to better understand the association between these results and the potential risk of the development of osteoarthritis in our patient cohort.

Detection and Characterization of Endplate Structural Defects on CT: A Diagnostic Accuracy Study.

STUDY DESIGN: Diagnostic test study. OBJECTIVE: To determine the reliability and validity or diagnostic accuracy of two previously described endplate structural defect (EPSD) assessment methods. SUMMARY OF BACKGROUND DATA: Studies of EPSD may further the understanding of pathoanatomical mechanisms underlying back pain. However, clinical imaging methods used to document EPSD have not been validated, leaving uncertainty about what the observations represent. METHODS: Using an evaluation manual, 418 endplates on CT sagittal slices obtained from 19 embalmed cadavers (9 men and 10 women, aged 62-91 y) were independently assessed by two experienced radiologists and a novice for EPSD using the two methods. The corresponding micro-CT (µCT) from the harvested T7-S1 spines were assessed by another independent rater with excellent intra-rater reliability (Kappa=0.96). RESULTS: Inter-rater reliability was good for presence (Kappa=0.60-0.69) and fair for specific phenotypes (Kappa=0.43-0.58) of EPSD. Erosion, for which the Brayda-Bruno classification lacked a category, was mainly (82.8%) classified as wavy/irregular, while many notched defects (n=15, 46.9%) and Schmorl's nodes (n=45, 79%) were recorded as focal defects using Feng's classification. When compared to µCT, endplate fractures (n=53) and corner defects (n=28) were routinely missed on CT. Endplates classified as wavy/irregular on CT corresponded to erosion (n=29, 21.2%), jagged defects (n=21, 15.3%), calcification (n=19, 13.9%), and other phenotypes on µCT. Some focal defects on CT represented endplate fractures (n=21, 27.6%) on µCT. Overall, with respect to the presence of an EPSD, there was a sensitivity of 70.9% and specificity of 79.1% using Feng's method, and 79.5% and 57.5% using Brayda-Bruno's. Poor to fair inter-rater reliability (k=0.26-0.47) was observed for defect dimensions. CONCLUSION: There was good inter-rater reliability and evidence of criterion validity supporting assessments of EPSD presence using both methods. However, neither method contained all needed EPSD phenotypes for optimal sensitivity, and specific phenotypes were often misclassified.

External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial.

PURPOSE: A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS: The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS: In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION: When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE: Level 3, cohort study.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate.

PURPOSE: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. METHODS: This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. RESULTS: We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001). CONCLUSIONS: At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction.

CONTEXT: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. METHODS: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. RESULTS: There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval,  1.3 to 10.4; P = .01). CONCLUSION: A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

A bifactor model supports unidimensionality of the International Knee Documentation Committee Subjective Knee Form in young active patients with anterior cruciate ligament tears: a retrospective analysis of a randomized controlled trial.

BACKGROUND: The International Knee Documentation Committee Subjective Knee Form (IKDC) is the most highly recommended patient reported outcome measure for assessing patients with anterior cruciate ligament (ACL) injuries and those undergoing ACL reconstruction (ACLR) surgery. The IKDC was developed as a unidimensional instrument for a variety of knee conditions. Structural validity, which determines how an instrument is scored, has not been definitively confirmed for the IKDC in respondents with ACL injuries, and in fact an alternative two-factor/subscale structure has been proposed in this population. The purpose of this study was to determine the most appropriate structure and scoring system for the IKDC in young active patients following ACL injury. METHODS: In total, 618 young patients deemed at high risk of graft rupture were randomized into the Stability 1 trial. Of the trial participants, 606 patients (98%) completed a baseline IKDC questionnaire used for this analysis. A cross sectional retrospective secondary data analysis of the Stability 1 baseline IKDC data was completed to assess the structural validity of the IKDC using exploratory and confirmatory factor analyses. Factor analyses were used to test model fit of the intended one-factor structure, a two-factor structure, and alternative four-factor and bifactor structures (i.e., a combination of a unidimensional factor with additional specific factors) of the IKDC, in a dataset of young active ACL patients. RESULTS: The simple one-factor and two-factor structures of the IKDC displayed inadequate fit in our dataset of young ACL patients. A bifactor model provided the best fit. This model contains one general factor that is substantially associated with all items, plus four secondary, more specific content factors (symptoms, activity level, activities of daily living, and sport) with generally weaker associations to subsets of items. Although the single-factor model did not provide unambiguous support to unidimensionality of the IKDC based on fit indices, the bifactor model supports unidimensionality of the IKDC when covariance between items with similar linguistic structure, response options, or content are acknowledged. CONCLUSIONS: Overall, findings of a bifactor model with evidence of a reliable general factor well defined by all items lends support to continue interpreting and scoring this instrument as unidimensional. This should be confirmed in other samples. Clinically, based on these findings, the IKDC can be represented by a single score for young active patients with ACL tears. A more nuanced interpretation would also consider secondary factors such as sport and activity level. TRIAL REGISTRATION: The Stability 1 trial for which these data were collected was registered on ClinicalTrial.gov (NCT02018354).

A History of Musculoskeletal Medicine and Its Place and Progress in Undergraduate Medical Education.

Musculoskeletal diseases are responsible for some of the most prevalent conditions affecting population health in the world. Despite the prevalence of these conditions, musculoskeletal medicine has a fraught history within the world of undergraduate medical education. We review the origins of musculoskeletal medicine, its evolution in undergraduate medical education, and progress that has been made over the last decade as a result of global initiatives such as the Bone and Joint Decade. Understanding the history of musculoskeletal medicine is essential to contextualizing the problems that exist today and creating comprehensive solutions to fill the gaps that persist in musculoskeletal curricula.

Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy.

PURPOSE: To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy. METHODS: From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5 mg/325 mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500 mg twice daily × 3 weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5 mg nightly × 7 days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600 mg orally, 1 h preoperatively; 600 mg postoperatively, 8 h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400 mg orally, 1 h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6 weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay. RESULTS: Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.). CONCLUSION: The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy. LEVEL OF EVIDENCE: l.

External Validation of the KOOS-ACL in the MOON Group Cohort of Young Athletes Followed for 10 Postoperative Years.

BACKGROUND: The Knee injury and Osteoarthritis Outcome Score-Anterior Cruciate Ligament (KOOS-ACL) is a short form version of the KOOS, developed to target populations of young active patients with ACL tears. The KOOS-ACL consists of 2 subscales: Function (8 items) and Sport (4 items). The KOOS-ACL was developed and validated using data from the Stability 1 study from baseline to postoperative 2 years. PURPOSE: To validate the KOOS-ACL in an external sample of patients matching the outcome's target population. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: The Multicenter Orthopaedic Outcomes Network group cohort of 839 patients aged 14 to 22 years who tore their ACLs while playing sports was used to assess internal consistency reliability, structural validity, convergent validity, responsiveness to change, and floor/ceiling effects of the KOOS-ACL at 4 time points: baseline and postoperative 2, 6, and 10 years. Detection of treatment effects between graft type (hamstring tendon vs bone-patellar tendon-bone) were also compared between the full-length KOOS and KOOS-ACL. RESULTS: The KOOS-ACL demonstrated acceptable internal consistency reliability (α = .82-.89), structural validity (Tucker-Lewis index and comparative fit index = 0.98-0.99; standardized root mean square residual and root mean square error of approximation = 0.04-0.07), convergent validity (Spearman correlation with International Knee Documentation Committee subjective knee form = 0.66-0.85; Western Ontario and McMaster Universities Osteoarthritis Index function = 0.84-0.95), and responsiveness to change across time (large effect sizes from baseline to postoperative 2 years; d = 0.94 [Function] and d = 1.54 [Sport]). Stable scores and significant ceiling effects were seen from 2 to 10 years. No significant differences in KOOS or KOOS-ACL scores were detected between patients with different graft types. CONCLUSION: The KOOS-ACL shows improved structural validity when compared with the full-length KOOS and adequate psychometric properties in a large external sample of high school and college athletes. This strengthens the argument to use the KOOS-ACL to assess young active patients with ACL tears in clinical research and practice.

Development and Preliminary Validation of the KOOS-ACL: A Short Form Version of the KOOS for Young Active Patients With ACL Tears.

BACKGROUND: The Knee injury and Osteoarthritis Outcomes Score (KOOS) is a widely used region-specific outcome measure for assessing patients of all ages with a variety of knee conditions. Use of the KOOS for young active patients with anterior cruciate ligament (ACL) tear has been called into question regarding its relevance and interpretability for this specific population. Furthermore, the KOOS does not have adequate structural validity for use in high-functioning patients with ACL deficiency. PURPOSE: To develop a condition-specific short form version of the KOOS that is appropriate for the young active population with ACL deficiency: the KOOS-ACL. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A baseline data set of 618 young patients (≤25 years old) with ACL tears was divided into development and validation samples. Exploratory factor analyses were conducted in the development sample to identify the underlying factor structure and to reduce the number of items based on statistical and conceptual indicators. Confirmatory factor analyses were conducted to check fit indices of the proposed KOOS-ACL model in both samples. Psychometric properties of the KOOS-ACL were assessed using the same data set, expanded to include patient data from 5 time points (baseline and postoperative 3, 6, 12, and 24 months). Internal consistency reliability, structural validity, convergent validity, responsiveness to change, floor/ceiling effects, and detection of treatment effects between surgical interventions (ACL reconstruction alone vs ACL reconstruction + lateral extra-articular tenodesis) were assessed. RESULTS: A 2-factor structure was deemed most appropriate for the KOOS-ACL. Of 42 items, 30 were removed from the full-length KOOS. The final KOOS-ACL model showed acceptable internal consistency reliability (α = .79-.90), structural validity (comparative fit index and Tucker-Lewis index = 0.98-0.99; root mean square error of approximation and standardized root mean square residual = 0.04-0.07), convergent validity (Spearman correlation with International Knee Documentation Committee subjective knee form = 0.61-0.83), and responsiveness across time (significant small to large effects; P < .05). CONCLUSION: The new KOOS-ACL questionnaire contains 12 items and 2 subscales-Function (8 items) and Sport (4 items)-relevant to young active patients with an ACL tear. Use of this short form would reduce patient burden by more than two-thirds; it provides improved structural validity as compared with the full-length KOOS for our population of interest; and it demonstrates adequate psychometric properties in our sample of young active patients undergoing ACL reconstruction.

Cross-sectional reliability and concurrent validity of a quantitative 2-dimensional ultrasound image analysis of effusion and synovial hypertrophy in knee osteoarthritis.

Objective: Effusion-synovitis is related to pain and progression in knee osteoarthritis (OA), but current gold standard ultrasound (US) measures are limited to semi-quantitative grading of joint distension or 1-dimensional thickness measures. A novel quantitative 2-dimensional image analysis methodology is applied to US images of effusion-synovitis; reliability and concurrent validity was assessed in patients with knee OA. Methods: Cross sectional analysis of US images collected from 51 patients with symptomatic knee OA were processed in ImageJ and segmented in 3DSlicer to produce a binary mask of the supra-patellar synovitis region of interest (ROI). Area measures (mm2) of total synovitis, effusion and hypertrophy components were exported. Intra-rater reliability and test-retest reliability (1-14 days washout) were estimated with intra-class correlation coefficients (ICCs). Concurrent validity was measured by Spearman correlations between quantitative measures and gold standard OMERACT and caliper measurements of synovitis. Results: Intra-rater reliability for hypertrophy area was estimated at 0.98, 0.99 for effusion area, and 0.99 for total synovitis area. The test-retest reliability for total synovitis area was 0.63 (SEM 87.8 â€‹mm2), 0.59 for hypertrophy area (SEM 21.0 â€‹mm2), and 0.64 for effusion area (SEM 73.8 â€‹mm2). Correlation between total synovitis area and OMERACT grade was 0.84, 0.81 between total synovitis area and effusion-synovitis calipers, and 0.81 between total effusion area and effusion calipers. Conclusion: This new research tool for image analysis demonstrated excellent intra-rater reliability, good concurrent validity, and moderate test-retest reliability. Quantitative 2D US measures of effusion-synovitis and its individual components may enhance the study and management of knee OA.

Balancing clinician and patient priorities for total shoulder replacement preoperative education programs.

OBJECTIVE: To investigate patient and clinician preferences regarding a preoperative educational program for patients undergoing shoulder replacement surgery. METHODS: This study used a cross-sectional survey of patients awaiting shoulder replacement surgery and clinicians. The survey was comprised of 41 questions for patients and clinicians, regarding preferences for receiving information, content preferences and device preferences. Descriptive statistics were reported for survey questions. RESULTS: 180 patients and 175 clinicians completed the survey. Patients and clinicians' top choices for ways to receive information were: in-person, website and booklets, with use of CD/DVD being extremely unlikely. Patients and clinicians had different preferences regarding content choices. Patients rated the following content topics as important to include in a program: including other patient's previous experiences with this surgery (83 % patients; 40 % clinicians), information for caregivers (84 % patients; 65 % clinicians), expectations for hospital stay (89 % patients; 57 % clinicians), process of anesthesia (87 % patients; 51 % clinicians), and how the surgery is performed (94 % patients; 60 % clinicians). CONCLUSIONS: Clinicians and patients have differing priorities and perspectives on the content and delivery of preoperative education programs, however, therapeutic goals and accessibility should be considered when designing programs. PRACTICE IMPLICATIONS: Creating education programs should include the lens of both clinicians and patients.

Dissatisfaction With Total Knee Arthroplasty at 1 Year Post Surgery Can be Predicted Using a Short Questionnaire Early in the Recovery Process.

BACKGROUND: Approximately 20% of patients are dissatisfied with their total knee arthroplasty (TKA). Identifying patients likely to be dissatisfied early in the recovery process could help reduce the number of dissatisfied patients. The purpose of this study was to create an easily administered short questionnaire to identify patients likely to be dissatisfied at 1 year post surgery early in the recovery process. METHODS: The study included 275 patients who underwent primary TKA for osteoarthritis. Individual 3-month postsurgery questionnaire items from the Knee Injury and Osteoarthritis Outcome Score and Knee Society Knee Scoring System were pooled together and used as candidate items to create 3 different short questionnaires. Items included in each questionnaire were selected using least absolute shrinkage and selection operator logistic regressions, a backward elimination method, and theory-based approaches. The area under the curve for each short questionnaire was calculated to evaluate predictive performances. RESULTS: All 3 questionnaires contained a small number of items and appeared to successfully predict 1-year postsurgery dissatisfaction early in the recovery process. The least absolute shrinkage and selection operator logistic regression, backward elimination, and theory-based questionnaires were comprised of 4, 7, and 5 items and had the area under the curve scores of 0.893, 0.902, and 0.890, respectively. A question evaluating rising from sitting and activities of daily living appeared in all of the created questionnaires. CONCLUSION: A short questionnaire that is easy to administer and interpret can effectively predict TKA patient dissatisfaction at 1 year post surgery early in the recovery process.

Test-Retest Reliability and Sensitivity to Change of Ultrasound-Based Methods of Measuring Synovial Inflammation in Knee Osteoarthritis.

OBJECTIVES: To assess test-retest reliability of musculoskeletal ultrasound (US) measures of inflammation in patients with knee osteoarthritis (OA) and to assess the sensitivity to change of US measures of inflammation in patients with knee OA. METHODS: To mimic a common clinical scenario, 36 patients (n = 70 knees) with symptomatic knee OA who were in stable condition underwent 2 assessments within 14 days by different operators and different US machines, graded by a single rater. Test-retest reliability was measured using Cohen's kappa coefficient, intraclass correlation coefficient (ICC), and absolute agreement parameters. A total of 51 patients (n = 72 knees) were tested immediately before and 21-28 days after intraarticular glucocorticoid injection to investigate sensitivity to change and longitudinal construct validity. Paired t-tests and standardized response mean (SRM) were used to assess sensitivity to change. Multivariate linear regression was used to investigate longitudinal construct validity of US with Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scores, while adjusting for covariates. RESULTS: US measures of inflammation demonstrated moderate (κ = 0.41, 0.60) to substantial (κ = 0.61, 0.80) agreement. Quantitative measures of synovitis and effusion demonstrated good test-retest reliability (ICC2,1 0.71, 0.92). US measures of synovitis and effusion demonstrated low-to-moderate sensitivity to change (SRM -0.29, -0.50). The associations between changes in US measures and KOOS pain scores over time were low, and 95% confidence intervals included zero. CONCLUSION: In a clinical setting, US measures of inflammatory features of knee OA have substantial reliability and low-to-moderate sensitivity to change, whereas measures of structural OA features are less reliable. Longitudinal construct validity of US measures of synovitis and effusion to KOOS pain scores is not strongly supported.

A scoping review of postoperative return to sport criteria and protocols for patients with femoroacetabular impingement syndrome.

PURPOSE: To identify the objective criteria and guidelines utilized to determine if patients diagnosed with FAIS can safely return to sport following hip arthroscopy. METHODS: The electronic databases MEDLINE Ovid, EMBASE Ovid, and CINAHL were searched to identify eligible studies. Details of study design, sample size, primary diagnosis, and return to sport protocol, duration, and rate were collected by two reviewers, independently. RESULTS: Sixty-two studies were selected for full text review of which 14 were included in the final analysis. Of these, nine were clinical commentaries and five were retrospective cohort studies. Three types of rehabilitation guidelines are currently utilized postoperatively: 4-phase, 5-phase, and 6-phase protocols. Although all 14 studies recommend using various types of outcome measures to evaluate a patient's ability to return to sport, only eleven outlined the specific outcome criteria they must achieve to do so. The most utilized outcome measures are the hip outcome score, active and passive range of motion tests, gait analysis, single- and double-leg squat tests, and the Vail hip sports test. Criteria across all three types of protocols was variable, but they all evaluated the same international classification of disability and function constructs described by the World Health Organization: body function, body structure limitations, and activity capacity limitations. CONCLUSIONS: There is no consensus on the optimal methods of evaluating a patient's readiness to return to sport after undergoing hip arthroscopy, with most criteria focused on expert opinion. Performance-based return to sport outcome criteria is not clearly defined, and validated outcome measures are not being used for FAIS patients post hip arthroscopy. Lastly, well-conducted prospective cohort studies using validated outcome measures and objective definitions of return to sport are needed to consistently identify signs that are prognostic of safe return to sport.