Mininder S. Kocher

PURPOSE: In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee. TYPE OF STUDY: A case series of patients with 7 to 17 years' follow-up. METHODS: Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively. RESULTS: The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement. CONCLUSIONS: Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.

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.

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 children's 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.

BACKGROUND: An anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only. METHODS: A cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained. RESULTS: In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation. CONCLUSIONS: ACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

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 with outcome. 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.