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 TTetoetrochlear 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

Structure, Sex, And Strength And Knee And Hip Kinematics During Landing

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. 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. 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. 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. 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 R2 = 0.47, P < .001). Asymmetry of unilateral hip rotation and sex were predictive of knee external rotation excursion (adjusted R2 = 0.23, P = .001). The RAD was correlated with hip adduction at contact (R2 = 0.10, R = 0.32, P = .04) and knee flexion excursion (R2 = 0.11, R = –0.34, P = .03). Asymmetry of unilateral hip rotation, sex, and hip strength were associated with kinematic components of medial knee collapse

Comparing Responsiveness Of Six Common Patient-Reported Outcomes To Changes FollowingAutologous 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

The Role Of Rehabilitation Following Autologous Chondrocyte Implantation: A Retrospective Chart Review

Clinical outcomes following autologous chondrocyte implantation (ACI) are influenced by multiple factors, including patient demographics, lesion characteristics, quality of the surgical repair, and post-operative rehabilitation. However, it is currently unknown what specific characteristics of rehabilitation have the greatest influence on clinical outcomes following ACI. The purpose of this study was to conduct a retrospective chart review of patients undergoing ACI with the intent to describe this patient population’s demographics, clinical outcomes, and rehabilitation practices. This study aimed to assess the consistency of the documentation process relative to post-operative rehabilitation in order to provide information and guide initiatives for improving the quality of rehabilitation practices following ACI. The medical records of patients treated for chondral defect(s) of the knee who subsequently underwent the ACI procedure were retrospectively reviewed. A systematic review of medical, surgical, and rehabilitation records was performed. In addition, patient-reported outcome measures (IKDC, WOMAC, Lysholm, SF-36) recorded pre-operatively, and 3, 6, and 12 months post-operatively were extracted from an existing database. 20 medical charts (35.9 ± 6.8 years; 9 male, 11 female) were systematically reviewed. The average IKDC, WOMAC, Lysholm, and SF-36 scores all improved from baseline to 3, 6 and 12 months post-operatively, with the greatest changes occurring at 6 and 12 months. There was inconsistent documentation relative to post-operative rehabilitation, including CPM use, weight-bearing progression, home-exercise compliance, and strength progressions. Due to variations in the documentation process, the authors were unable to determine what specific components of rehabilitation influence the recovery process. In order to further understand how rehabilitation practices influence outcomes following ACI, specific components of the rehabilitation process must be consistently and systematically documented over time

Serum Cartilage Oligomeric Matrix Protein (Scomp) Is Elevated In Patients With Knee Osteoarthritis: A Systematic Review And Meta-Analysis

Objective: To be used in diagnostic studies, it must be demonstrated that biomarkers can differentiate between diseased and non-diseased patients. Therefore, the purpose of this study was to answer the following questions: (1) Is serum cartilage oligomeric matrix protein (sCOMP) elevated in patients with radiographically diagnosed knee osteoarthritis (OA) compared to controls? (2) Are there differences in sCOMP levels when comparing differing radiographic OA severities to controls? Methods: Systematic review and meta-analysis. Data Sources: A systematic search of CINAHL, PEDro, Medline, and SportsDiscus was completed in March 2010. Keywords: knee, osteoarthritis, sCOMP, radiography. Study inclusion criteria: Studies were written in English, compared healthy adults with knee OA patients, used the Kellgren Lawrence (K/L) classi?cation, measured sCOMP, and reported means and standard deviations for sCOMP. Results: For question 1, seven studies were included resulting in seven comparisons. A moderate overall effect size (ES) indicated sCOMP was consistently elevated in those with radiographically diagnosed knee OA when compared to controls (ES ¼ 0.60, P < 0.001). For question 2, four studies were included resulting in 13 comparisons between radiographic OA severity levels and controls. Strong ESs were calculated for K/L-1 (ES ¼ 1.43, P ¼ 0.28), K/L-3 (ES ¼ 1.05, P ¼ 0.04), and K/L-4 (ES ¼ 1.40, P ¼ 0.003). A moderate ES was calculated for K/L-2 (ES ¼ 0.60, P ¼ 0.01). Conclusions: These results indicate sCOMP is elevated in patients with knee OA and is sensitive to OA disease progression. Future research studies with a higher level of evidence should be conducted to investigate the use of this biomarker as an indicator for OA development and progression

Decision To Return To Sport After Anterior Cruciate Ligament Reconstruction, Part I: A Qualitative Investigation Of Psychosocial Factors

Context: Return-to-sport criteria after anterior cruciate ligament (ACL) injury are often based on “satisfactory” functional and patient-reported outcomes. However, an individual's decision to return to sport is likely multifactorial; psychological and physical readiness to return may not be synonymous. Objective: To determine the psychosocial factors that influence the decision to return to sport in athletes 1 year post–ACL reconstruction (ACLR). Design: Qualitative study. Setting: Academic medical center. Patients or Other Participants: Twelve participants (6 males, 6 females) were purposefully chosen from a large cohort. Participants were a minimum of 1-year postsurgery and had been active in competitive athletics preinjury. Data Collection and Analysis: Data were collected via semistructured interviews. Qualitative analysis using a descriptive phenomenologic process, horizontalization, was used to derive categories and themes that represented the data. The dynamic-biopsychosocial model was used as a theoretical framework to guide this study. Results: Six predominant themes emerged that described the participants' experiences after ACLR: (1) hesitation and lack of confidence led to self- limiting tendencies, (2) awareness was heightened after ACLR, (3) expectations and assumptions about the recovery process influenced the decision to return to sport after ACLR, (4) coming to terms with ACL injury led to a reprioritization, (5) athletic participation helped reinforce intrinsic personal characteristics, and (6) having a strong support system both in and out of rehabilitation was a key factor in building a patient's confidence. We placed themes into components of the dynamic- biopsychosocial model to better understand how they influenced the return to sport. Conclusions: After ACLR, the decision to return to sport was largely influenced by psychosocial factors. Factors including hesitancy, lack of confidence, and fear of reinjury are directly related to knee function and have the potential to be addressed in the rehabilitation setting. Other factors, such as changes in priorities or expectations, may be independent of physical function but remain relevant to the patient-clinician relationship and should be considered during postoperative rehabilitation

Patient-Oriented And Performance-Based Outcomes After Knee Autologous Chondrocyte Implantation: A Timeline For The First Year Of Recovery

Context: It is well established that autologous chondrocyte implantation (ACI) can require extended recovery postoperatively; however, little information exists to provide clinicians and patients with a timeline for anticipated function during the first year after ACI. Objective: To document the recovery of functional performance of activities of daily living after ACI. Patients: ACI patients (n = 48, 29 male; 35.1 ± 8.0 y). Intervention: All patients completed functional tests (weight-bearing squat, walk-across, sit-to-stand, step- up/over, and forward lunge) using the NeuroCom long force plate (Clackamas, OR) and completed patient-reported outcomemeasures (International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm, Western Ontario and McMaster Osteoarthritis Index [WOMAC], and 36-Item Short-Form Health Survey) preoperatively and 3, 6, and 12 mo postoperatively. Main Outcome Measures: A covariance pattern model was used to compare performance and self-reported outcome across time and provide a timeline for functional recovery after ACI. Results: Participants demonstrated significant improvement in walk-across stride length from baseline (42.0% ± 8.9% height) at 6 (46.8% ± 8.1%) and 12 mo (46.6% ± 7.6%). Weight bearing on the involved limb during squatting at 30°, 60°, and 90° was significantly less at 3 mo than presurgery. Step-up/over time was significantly slower at 3 mo (1.67 ±1.69s) than at baseline (1.49 ± 0.33 s), 6 mo (1.51 ± 0.36 s), and 12 mo (1.40 ± 0.26 s). Step-up/over lift-up index was increased from baseline (41.0% ± 11.3% body weight [BW]) at 3 (45.0% ± 11.7% BW), 6 (47.0% ± 11.3% BW), and 12 mo (47.3% ± 11.6% BW). Forward-lunge time was decreased at 3 mo (1.51 ± 0.44 s) compared with baseline (1.39 ± 0.43 s), 6 mo (1.32 ± 0.05 s), and 12 mo (1.27± 0.06). Similarly, forward-lunge impact force was decreased at 3 mo (22.2% ± 1.4% BW) compared with baseline (25.4% ± 1.5% BW). The WOMAC demonstrated significant improvements at 3 mo. All patient-reported outcomes were improved from baseline at 6 and 12 mo postsurgery. Conclusions: Patients’ perceptions of improvements may outpace physical changes in function. Decreased function for at least the first 3 mo after ACI should be anticipated, and improvement in performance of tasks requiring weight-bearing knee flexion, such as squatting, going down stairs, or lunging, may not occur for a year or more after surgery

Influence Of Response Shift On Early Patient-Reported Outcomes Following Autologous Chondrocyte Implantation

Response shift is the phenomenon by which an individual’s standards for evaluation change over time. The purpose of this study was to determine whether patients undergoing autologous chondrocyte implantation (ACI) experience response shift. Forty-eight patients undergoing ACI participated. The ‘‘then-test’’ method was used to evaluate response shift in commonly used patient-reported outcome measures (PROMs)—the SF-36 Physical Component Scale (SF-36 PCS), WOMAC, IKDC, and Lysholm. Each PROM was completed pre- and 6 and 12 months post-surgery. At 6 and 12 months, an additional ‘‘then’’ version of each form was also completed. The ‘‘then’’ version was identical to the original except that patients were instructed to assess how they were prior to ACI. Traditional change, response shift adjusted change, and response shift magnitude were calculated at 6 and 12 months. T tests (p \ 0.05) were used to compare traditional change to response-shift-adjusted change, and response shift magnitude values to previously established minimal detectable change.There were no differences between traditional change and response-shift-adjusted change for any of the PROMs. The mean response shift magnitude value of the WOMAC at 6 months (15 ± 14, p = 0.047) was greater than the previously established minimal detectable change (10.9). The mean response shift magnitude value for the SF-36 PCS at 12 months (9.4 ± 6.8, p = 0.017) also exceeded the previously established minimal detectable change (6.6). There was no evidence of a group-level effect for response shift. These results support the validity of pre-test/post-test research designs in evaluating treatment effects. However, there is evidence that response shifts may occur on a patient-by-patient basis, and scores on the WOMAC and SF-36 in particular may be influenced by response shift

Response Shift Theory: An Application For Health-Related Quality Of Life In Rehabilitation Research And Practice

Evaluating change in patients over time can be challenging to any health care provider. Response shift theory is based on the change typology of alpha, beta, and gamma change and proposes that residual changes in self-response measures occur over time. These changes are the result of recalibration, reconceptualization, and reprioritization of internal standards and references utilized for self-appraisal. Failing to account for response shift may result in over- or under-reporting of true physiologic change. The purpose of this paper is to review the components of response shift, identify research designs used to detect it, and present a model for its practical application to rehabilitation of both acute and chronic disabilities. Awareness of response shifts throughout the rehabilitation process may be beneficial in guiding patient goal-setting, treatment, and education. Of particular emphasis is the role that the rehabilitation specialist can have in using the response shift process to result in the highest possible perceived quality of life for each individual patient

Comparison Of Muscle Activation Levels Between Healthy Individuals And Persons Who Have Undergone Anterior Cruciate Ligament Reconstruction During Different Phases Of Weight-Bearing Exercises

STUDY DESIGN: Cross-sectional, controlled laboratory study. BACKGROUND: Quantification of muscular activation during different phases of functional activities is important to understand activation deficits in individuals who have undergone anterior cruciate ligament reconstruction (ACLR). OBJECTIVES: To compare activation levels of the vastus medialis (VM), medial hamstrings (MH), and gluteus medius (GMed) muscles during the different phases of weight- bearing tasks between individuals who had undergone ACLR and healthy controls. METHODS: Surface electromyography was used to measure the activation levels of the VM, MH, and GMed muscles in 16 participants who had undergone ACLR (average time since surgery, 4 years) and 15 healthy participants during the reach and return phases of the Star Excursion Balance Test (SEBT) and the ascending and descending phases of a step-down task (SDT). Repeated- measures analyses of variance were performed to determine whether muscle activation levels differed betweengroups during different phases of the tasks. RESULTS: There were significant group-by-phase interactions for the GMed during both the SEBT and SDT. Gluteus medius activation was lower for the ACLR group during the return phase of the posteromedial direction of the SEBT compared to the control group (P = .03). During the SDT, GMed activation was higher for the ACLR group during the ascending phase than during the descending phase (P<.001), while the control group showed no difference between phases (P = .71). CONCLUSION: Individuals who had undergone ACLR have similar VM and MH activation compared to healthy individuals during different phases of the SDT and SEBT. However, phase differences for GMed activity and decreased GMed activity relative to healthy individuals were observed among ACLR participants