Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain,symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement

Purpose

There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the Danish version of the Copenhagen Hip and Groin Outcome Score (HAGOS) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist.

Methods

Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pretesting. The final version was evaluated for reliability, validity and responsiveness. Five hundred and two patients (337 men and 167 women, mean age 37, range 15–75) were included in the study.

Results

Cronbach’s alpha for the six HAGOS-S subscales ranged from 0.77 to 0.89. Significant correlations were obtained with the international Hip Outcome Tool average score (r _s = 0.37–0.68; p < 0.01) and a standardised instrument, the EuroQol, EQ-5D total score (r _s = 0.40–0.60, p = 0.01), for use as a measurement of health outcome. Test–retest reliability (intraclass correlation coefficient) ranged from 0.81 to 0.87 for the six HAGOS-S subscales. The smallest detectable change ranged from 7.8 to 16.1 at individual level and 1.6–3.2 at group level. Factor analysis revealed that the six HAGOS-S subscales had one strong factor per subscale. Effect sizes were generally medium or large.

Conclusion

The Swedish version of the HAGOS is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting at individual and group level.

Level of evidence

Diagnostic study, Level I.     

Complications following hip arthroscopy: a systematic review and meta-analysis

Purpose

The use of hip arthroscopy to address injuries and conditions about the hip is becoming more widespread. There are several narrative reviews regarding complications of hip arthroscopy but a systematic review is currently lacking. The primary goal of this study is to determine the complication rate associated with hip arthroscopy in the literature.

Methods

A search of the EMBASE and Ovid Medline databases was performed to identify articles published between 1 January 2000 and 25 November 2011 that reported a complication rate after hip arthroscopy. Appropriate inclusion and exclusion criteria were applied to identify articles, and a meta-analysis was performed to determine an overall complication rate. Complications were divided into major and minor.

Results

A total of 66 papers (n = 6,962 hip arthroscopies) were identified and deemed appropriate for analysis. The overall complication rate was found to be 4.0 % (95 % CI 2.9–5.2 %). Of the 287 complications identified in the literature, 20 were deemed major constituting a rate of 0.3 %.

Conclusions

Hip arthroscopy appears to be safe. The vast majority of complications are minor in nature. Prospective trials looking at the complications of hip arthroscopy would aid in identifying prognostic factors.

Level of evidence

Systematic review and meta-analysis, Level III.     

Learning curve of basic hip arthroscopy technique: CUSUM analysis

Purpose

Hip arthroscopy is known to have a steep learning curve by measuring operation times or complication rates. However, these measures are arbitrary and are based on the number of procedures performed rather than clinical outcomes. Recently, Cumulative sum (CUSUM) analysis has been used to monitor the performance of a single surgeon by evaluating clinical outcomes. Our purpose was to determine the learning curve for basic hip arthroscopy technique using CUSUM technique.

Methods

Forty consecutive patients who underwent hip arthroscopy were evaluated. Modified Harris Hip Score less than 80 at 6 months postoperatively was considered as treatment failure. Patients were chronologically stratified in two groups (the early group—cases 1–20, and the late group—cases 21–40), and age, gender, body mass index, and operation time were compared in both group. CUSUM analysis was then used to plot the learning curve.

Results

Eight patients (20 %) experienced treatment failure. Although there was no significant difference of treatment failure rate between the early and late groups (30 vs. 10 %, n.s.), the operation time was shorter in the late group (p = 0.014). In addition, CUSUM analysis showed that failure rates diminished rapidly after 21 cases and reached an acceptable rate after 30 cases.

Conclusions

Surgeon’s experience is an important predictor of failure after hip arthroscopy, and CUSUM analysis revealed that a learning period is required to become proficient at this procedure, and that experience of approximately 20 cases is required to achieve satisfactory outcomes in terms of clinical outcomes. Surgeon can use the present learning curve for self-monitoring and continuous quality improvement in hip arthroscopy.

Level of evidence

Retrospective case series, Level IV.     

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears

Purpose

Currently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2-year follow-up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).

Methods

The records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2-year follow-up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.

Results

Fifty-nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow-up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.

Conclusions

Isolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.

Level of evidence

Retrospective case series, Level IV.     

Intra-articular adhesions following hip arthroscopy: a risk factor analysis

Purpose

The purpose of this study was to evaluate possible risk factors for symptomatic adhesions after hip arthroscopy.

Methods

Data were analysed from hip arthroscopies performed between 2005 and 2009. Only primary hip arthroscopies were included. Data collected included demographics, primary treatment, rehabilitation, revision surgery, and presence of adhesions at revision.

Results

One thousand two hundred and sixty-four hips in patients 18 years or older underwent primary hip arthroscopy during the defined period. Eight underwent revision hip arthroscopy by a different surgeon. Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not [95 % CI 1.1–8.2]. Patients who did not receive circumduction therapy were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises [95 % CI 1.25–11.0].

Conclusion

Risk factors for adhesions following hip arthroscopy identified were age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction.

Level of evidence

IV.     

Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement

Purpose

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management.

Methods

A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated.

Results

Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15–24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery.

Conclusion

In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery.

Level of evidence

Level II.     

Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up

Purpose

To compare long-term functional and radiological outcome following microfracture technique (MF) versus osteochondral autologous transplantation (OAT) mosaicplasty for treating focal chondral lesions of the knee.

Methods

Twenty-five patients (mean age 32.3 years, SD 7.7) with a full-thickness (International Cartilage Repair Society grade 3 or 4) chondral lesion of the articulating surface of the femur were randomized to either MF (n = 11) or OAT mosaicplasty (n = 14). At a median follow-up of 9.8 years (range 4.9–11.4), the patients were evaluated using Lysholm score (n = 25), Knee Injury and Osteoarthritis Outcome Score (KOOS, n = 25), isokinetic quadriceps measurement and hamstring strength measurement (n = 22) and standing radiographs (n = 23).

Results

There were no significant differences in Lysholm score, KOOS, isokinetic muscle strength or radiographic osteoarthritis between MF-treated patients and OAT mosaicplasty-treated patients at follow-up. Mean Lysholm score at follow-up was 69.7 [95 % confidence interval (CI), 55.1–84.4] for the MF group and 62.6 (95 % CI, 52.6–72.6) for the OAT mosaicplasty group.

Conclusion

At long-term follow-up, there were no significant differences between patients treated with MF and patients treated with OAT mosaicplasty in patient-reported outcomes, muscle strength or radiological outcome.

Level of evidence

Therapeutic study, Level II.     

Modular augmentation in revision total knee arthroplasty

Purpose

Controversy exists about the real effectiveness of modular augmentation to manage bone defects in revision total knee arthroplasty. The purpose of this study was to determine whether use of modular augmentation to reconstruct severe defects (1) significantly increased overall outcomes, (2) caused radiolucency or osteolysis and (3) affected mid-term survivorship of knee revisions. The hypothesis was that modular augmentation provides a good survivorship of knee revisions.

Methods

Thirty-eight consecutive revision knee arthroplasties were followed for a median follow-up period of 7 (4.5–9) years. Type 2 and 3 defects were treated with metal augments, tantalum cones and modular cementless stems. Patients were assessed using the IKS knee and function scores and the HSS score.

Results

The median IKS knee and function scores and HSS score were 34 (15–58), 19.5 (13–39) and 30 (24–60) points before the operation, respectively, and 78 (49–97), 76 (58–90) and 80.5 (64–98) points (p < 0.001) at the latest follow-up. The median knee flexion increased from 82° (31°–110°) to 116° (100°–129°) (p < 0.01). Tibial radiolucencies were observed in 2 (5.2 %) cases. Re-revision was necessary in three (7.9 %) patients.

Conclusions

Modular augmentation may reduce the need for allografting to treat severe bone defects, providing a well-functioning and durable knee joint reconstruction.

Level of evidence

Case-series study, Level IV.     

Arguments for an increasing differentiation towards fibrocartilaginous components in midportion Achilles tendinopathy

Purpose

The objective of this study was to investigate the fibrocartilaginous differentiation occurring in midportion Achilles tendinopathy.

Methods

Tendon samples were retrospectively collected from 23 patients, who had undergone surgery for midportion Achilles tendinopathy resistant to conservative treatment. Based on histological scores, the biopts were subdivided into three categories: a light, moderate and severe histopathological stage. Throughout these stages, immunohistochemical staining was performed against biglycan, aggrecan and collagen type II, components characteristic for fibrocartilage. Staining of these components was evaluated using a semi-quantitative scoring method.

Results

The immunohistochemical scores of biglycan and aggrecan were statistically significant between the histopathological stages (P < 0.001). The immunohistochemical scores were positively correlated with the increasing histopathological stages [Spearman’s correlation coefficient = 0.93 for biglycan and 0.78 for aggrecan (P < 0.001)]. Staining for collagen type II remained negative throughout these stages.

Conclusion

Immunohistochemical staining of the fibrocartilaginous components biglycan and aggrecan showed a progressive increase, correlated with a further evolved histopathological stage. This observation gave arguments for an increased differentiation towards fibrocartilaginous components at protein level in midportion Achilles tendinopathy.

Level of evidence

III.     

Sagittal and coronal plane location of the popliteal artery in the open-wedge high tibial osteotomy

Purpose

The objectives of this study were (1) to evaluate the sagittal and coronal plane location of the popliteal artery during the advancement of open-wedge high tibial osteotomy and (2) to confirm the effect of osteoarthritis if it changes the relationship between the popliteal artery and posterior cortex.

Methods

Two hundred consecutive patients were enrolled, and we divided patients into two subgroups according to age and cartilage status in the radiologic report of magnetic resonance imaging (group I: 100 non-arthritic knees; group II: 100 arthritic knees). For prediction of the location of the popliteal artery during the operation, sagittal and coronal plane location along the osteotomy plane was evaluated.

Results

The distance between the posterior cortex of the osteotomy and popliteal artery was 13–14 mm on the sagittal plane, and the popliteal artery was located at an approximately 35 ± 5.5 mm portion from the starting point of the osteotomy on the coronal plane. The distance at the starting point of osteotomy was larger than at the end portion and prominent area. In comparison between groups I and II, group II showed a larger distance on the sagittal planes [osteotomy–vascular: 13.6 vs 14.4 (p = 0.01), fibula–vascular: 4.88 vs 6.5 (p < 0.01), and prominence–vascular: 4.3 vs 5.3 (p < 0.01)] compared to the group I.

Conclusions

Special caution and some protection should be given until the approximately 35 mm portion from the starting point of the posteromedial cortex with consideration for the approximity on the sagittal plane. In comparison between the non-arthritic and arthritic knee, differences were observed on the sagittal plane. However, the value was minimal, and the clinical relevance was questionable.

Level of evidence

Case series, Level IV.     

Translation and validation of ‘The Knee Society Clinical Rating System’ into Spanish

Purpose

The Knee Society Clinical Rating System (KSS) is a questionnaire evaluating knee function itself and the patient’s ability to walk and climb stairs. The aim of our study is to present the validated translation of KSS into Spanish.

Methods

The validated method of translation–retrotranslation was used to translate KSS into Spanish. Three hundred and sixteen patients undergoing primary knee arthroplasty, before surgery and 6 months postoperative, completed the questionnaire (with an orthopedist’s help). Psychometric properties of feasibility (percentage of no answers), validity and sensitivity to change (test’s ability to detect change in patients’ functional status over time) were assessed. In the second part of the study, the translated version of KSS was compared with two already validated questionnaires (SF-36 and WOMAC).

Results

During the translation process, item 3 (ROM) presented low appropriateness and null comprehensibility. The alternative writing proposed was ‘for every 5°, we sum up 1 point, as if 8° were 1 point, to obtain the maximum scoring of 25 points you should bend more than 200°’. Feasibility: the item ‘malalignment’ obtained 15 % of missing item at visit 1. The percentage of invalid items was high in both visits (60 and 47 %). Validity: the coefficients of convergent correlation with WOMAC and SF-36 scales confirm the questionnaire’s validity. Sensitivity to change: significant differences were found in all cases between the mean scores comparing both visits.

Conclusion

The translated version 1.1 of KSS (final version) has shown to be feasible, valid and sensible to changes within the clinical practice of patients undergoing primary knees arthroplasty.

Level of evidence

Prognostic study, Level I.     

Anatomical factors influencing patellar tracking in the unstable patellofemoral joint

Purpose

The current study was performed to relate anatomical parameters to in vivo patellar tracking for pediatric patients with recurrent patellar instability.

Methods

Seven pediatric patients with recurrent patellar instability that failed conservative treatment were evaluated using computational reconstruction of in vivo patellofemoral function. Computational models were created from high-resolution MRI scans of the unloaded knee and lower-resolution scans during isometric knee extension at multiple flexion angles. Shape matching techniques were applied to replace the low-resolution models of the loaded knee with the high-resolution models. Patellar tracking was characterized by the bisect offset index (lateral shift) and lateral tilt. Anatomical parameters were characterized by the inclination of the lateral ridge of the trochlear groove, the tibial tuberosity–trochlear groove distance, the Insall–Salvati index and the Caton–Deschamps index. Stepwise multivariable linear regression analysis was used to relate patellar tracking to the anatomical parameters.

Results

The bisect offset index and lateral tilt were significantly correlated with the lateral trochlear inclination (p ≤ 0.002) and TT–TG distance (p < 0.05), but not the Insall–Salvati index or the Caton–Deschamps index. For both the bisect offset index and lateral tilt, the standardized beta coefficient, used to identify the best anatomical predictors of tracking, was larger for the lateral trochlear inclination than the TT–TG distance.

Conclusion

For this population, the strongest predictor of lateral maltracking that could lead to patellar instability was lateral trochlear inclination.

Level of evidence

Diagnostic study, Level II.     

Treatment and evolution of grade III acromioclavicular dislocations in soccer players

Purpose

To evaluate postoperative functional results in soccer players diagnosed with acute grade III acromioclavicular dislocation, stabilized with clavicular hook plate.

Methods

Between 2006 and 2010, 11 soccer players were diagnosed with acute acromioclavicular dislocation. Mean age was 22.9 years. The clavicular hook plate was used for stabilization. The follow-up was 4 years (2–6 years).

Results

Constant score showed 82 % excellent results and 18 % good functional results. Average pain measured with VAS was 1.8 (±0.59) mm out of 10. We did not report any complication within the process.

Conclusions

Use of the clavicular hook plate is considered adequate for the treatment of acute acromioclavicular dislocation in soccer players, allowing a quick return to sports.

Level of evidence

Retrospective case series, Level IV.     

Validity of GNRB® arthrometer compared to Telos™ in the assessment of partial anterior cruciate ligament tears

Purpose

The main goal of this study was to compare the results of the GNRB^® arthrometer to those of Telos? in the diagnosis of partial thickness tears of the anterior cruciate ligament (ACL).

Methods

A prospective study performed January–December 2011 included all patients presenting with a partial or full-thickness ACL tears without ACL reconstruction and with a healthy contralateral knee. Anterior laxity was measured in all patients by the Telos? and GNRB^® devices. This series included 139 patients, mean age 30.7 ± 9.3 years. Arthroscopic reconstruction was performed in 109 patients, 97 for complete tears and 12 single bundle reconstructions for partial thickness tears. Conservative treatment was proposed in 30 patients with a partial thickness tear. The correlation between the two devices was evaluated by the Spearman coefficient. The optimal laxity thresholds were determined with ROC curves, and the diagnostic value of the tests was assessed by the area under the curve (AUC).

Results

The differential laxities of full and partial thickness tears were significantly different with the two tests. The correlation between the results of laxity measurement with the two devices was fair, with the strongest correlation between Telos? 250 N and GNRB^® 250 N (r = 0.46, p = 0.00001). Evaluation of the AUC showed that the informative value of all tests was fair with the best results with the GNRB^® 250 N: AUC = 0.89 [95 % CI 0.83–0.94]. The optimal differential laxity threshold with the GNRB^® 250 N was 2.5 mm (Se = 84 %, Sp = 81 %).

Conclusion

The diagnostic value of GNRB^® was better than Telos? for ACL partial thickness tears.

Level of evidence

Diagnostic study, Level II.     

Knee morphology and risk factors for developing an anterior cruciate ligament rupture: an MRI comparison between ACL-ruptured and non-injured knees

Purpose

The objective of this study was to evaluate multiple morphological features on MR images in patients with and without ACL rupture to evaluate whether there are certain variables that confer a higher risk for an ACL rupture.

Methods

MRI measurements were taken from 45 subjects with ACL injury and 43 subjects without ACL injury, by two independent observers. The morphometrics were compared between ACL-injured and non-injured subjects, between men and women and for male and female subjects separately. A factor analysis was performed to determine whether any variables were related in the injured, non-injured, male or female groups.

Results

There were no significant differences in the overall population between the ACL-injured and non-injured group. Significant differences were found in bicondylar (P ≤ 0.001), medial condyle (P ≤ 0.001) and lateral condyle widths (P = 0.001) between men and women. In the male group, there were no significant differences between ACL-injured and non-injured subjects. In the female group, there was a significant difference in bicondylar (P = 0.002) and lateral condyle width (P = 0.002) between ACL-injured and non-injured subjects.

Conclusions

There were gender-related differences in bony morphology between ACL-injured and non-injured subjects. The morphological features that were different between ACL-injured and non-injured subjects varied between male and female subjects.

Level of evidence

Case–Control study, Level III.     

The effect of infraspinatus hypotrophy and weakness on the arthroscopic treatment of spinoglenoid notch cyst associated with superior labrum anterior-to-posterior lesions

Purpose

Patients with spinoglenoid notch cyst associated with superior labrum anterior-to-posterior (SLAP) lesions were evaluated. The patients were all treated by arthroscopic cyst decompression combined with SLAP repair. The hypothesis of the study was that the patients who underwent prolonged conservative treatment period prior to surgery would exhibit significant infraspinatus hypotrophy and weakness, and their postoperative clinical and functional outcomes would be less satisfactory.

Methods

Sixteen patients exhibited positive MRI and EMG findings with clinical signs of weakness and pain. The median age was 40.5 years (range 32–52), and the study group consisted of 11 males and 5 females with a median follow-up period of 26 months (12–48). The median duration of symptoms and conservative treatment prior to the surgical intervention was 3.5 months (1–14). Seven patients in group A exhibited infraspinatus hypotrophy. Group B comprised 9 patients without infraspinatus hypotrophy.

Results

The results of the pre- and postoperative Constant scores, visual analogue scale (VAS) scores, and external rotation strength test rates were compared between groups. They all improved in terms of pain, strength, and function (P < 0.05). Significant differences were observed between the pre- and postoperative external rotation strengths and Constant scores (P < 0.05). However, no significant difference was observed between the pre- and postoperative VAS scores (n.s.). A significant correlation was observed in group A between surgical timing, the preoperative external rotation strength ratio (P = 0.04) and the postoperative VAS scores (P = 0.013).

Conclusion

The arthroscopic treatment was satisfactory with good clinical outcomes. Infraspinatus hypotrophy occurred in cases of prolonged surgical duration and significantly affected external rotation strength and functional outcomes.

Level of evidence

Retrospective comparative study, Level III.     

Validation and reliability of the Dutch language version of the Modifiable Activity Questionnaire in healthy subjects

Background

The Modifiable Activity Questionnaire (MAQ) is a physical activity questionnaire shown to be both valid and reliable in French. After translation and adaptation to Dutch, the objective of the study was to see whether this questionnaire was valid and reliable in the Dutch language and thus could be used as a tool for the detection of exercise levels in a Dutch native-speaking population.

Methods

After translating and back translating the valid French version of the MAQ into Dutch, the final product of the Dutch version was tested twice in the same population (n = 101) interrupted by 1 week for the assessment of the test–retest reliability. To measure concurrent validity, the valid Dutch version of the IPAQ was filled in at the same time as the MAQ. To measure the construct validity of this assessment tool, a smaller sample size (n = 28) of the total population carried an accelerometer for 1 week.

Results

The intraclass correlation coefficient for the test–retest reliability was 0.78 (p < 0.01), suggesting a good test–retest reliability. Pearson’s rho correlation coefficient between the IPAQ and the MAQ was 0.41 (p < 0.01), suggesting a medium concurrent validity. Pearson correlation statistics showed a low, non-significant correlation coefficient (r = 0.243, p = 0.213) when measuring construct validity.

Conclusion

The present study shows that the Dutch language of the MAQ is reliable and has a medium concurrent validity. Although the construct validity is low, these results are in line with previous validation studies of physical activity questionnaires.     

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies

Purpose

To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting.

Methods

Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure.

Results

All patients were available for the follow-up; the median follow-up period was 33 months (range 22–61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p < 0.001). Sixteen patients (84.2 %) returned to their previous activity levels.

Conclusions

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity.

Level of evidence

Case series, Level IV.     

Dutch translation of the Kujala Anterior Knee Pain Scale and validation in patients after knee arthroplasty

Purpose

To translate and validate the Kujala Anterior Knee Pain Scale (AKPS) in patients who have undergone total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) and evaluate the internal consistency, construct validity and ceiling or floor effect.

Methods

After standard forward and backward translation was performed, 302 patients who have received a TKA or UKA filled out the AKPS together with Hospital for Special Surgery (HSS) patella score, visual analogue score (VAS) for pain, the Oxford 12-item questionnaire and the SF-36 at follow-up. The internal consistency was tested using Cronbach’s α coefficient. The construct validity was assessed using Spearman’s rank correlation (R) to test for correlations between the AKPS and VAS HSS, HSS patella score, VAS month, Oxford 12-item questionnaire and SF-36 subscales. Ceiling or floor effects are given in percentage of patients giving a maximum or minimum score.

Results

The internal reliability of the AKPS is acceptable with a Cronbach’s α of 0.81 in patients after TKA or UKA. A high correlation was found between the AKPS and the Oxford 12-item questionnaire (R = 0.81). Moderate correlations were found with the VAS month (R = 0.63), HSS patella score (R = 0.51) and SF-36 subscales physical functioning (R = 0.59), role-physical (R = 0.59), bodily pain (R = 0.57). Other correlations were poor, therefore indicating a good convergent and divergent validity. Ceiling effects were observed for the HSS patella score (31 %), VAS HSS (51 %), VAS pain (19 %), SF36-RP (46 %), SF36-RE (80 %) and SF36-BP (24 %). No ceiling or floor effect was found for the AKPS, Oxford 12-item and the other SF36 domains.

Conclusions

The AKPS appears to be reliable and valid in patients after knee arthroplasty, with no ceiling and floor effects, and can be used to assess anterior knee pain in patient who underwent joint replacement surgery.

Level of evidence

Diagnostic study, Level I.     

Patellofemoral osteoarthritis after Insall’s proximal realignment for recurrent patellar dislocation

Purpose

The aim of the present study was to retrospectively investigate the development of patellofemoral osteoarthritis after the historical Insall’s proximal realignment for patellar stabilisation in patients with recurrent patellar dislocation. Furthermore, risk factors for recurrent patellar dislocation and for patellofemoral osteoarthritis development were evaluated.

Methods

Forty-two patients underwent patellofemoral stabilising surgery by the historic Insall’s proximal realignment; they were evaluated with a mean follow-up period of 52 months. Plain radiography was used to document osteoarthritic changes by using the Iwano classification. MRIs obtained at the latest follow-up were evaluated for patellofemoral cartilage lesions. Univariate and multivariate logistic regression analyses were performed to evaluate the influence of trochlear dysplasia, tibial tubercle–trochlear groove distance and patellar height on redislocation. Pearson’s χ ² and the Spearman’s correlation tests were used to assess a possible correlation between trochlear dysplasia and patellar dislocation, as well as between instability and development of patellofemoral osteoarthritis.

Results

At the latest follow-up, plain radiographs showed a significant increase in patellofemoral osteoarthritis (grades II–IV according to the Iwano classification) in 18 patients (43 %) compared with 4 patients (10 %) at the time of surgery (P = 0.001). Patellofemoral cartilage lesions (grades II–IV) were detected in 18 patients (43 %) on MRI. Nine patients (21 %) had at least one incidence of redislocation at follow-up. Estimated redislocation-associated risk factors could not be determined. Trochlear dysplasia had a significant impact on patellofemoral osteoarthritis development (P = 0.001), whereas recurrent patellar instability had none (n.s.).

Conclusion

Insall’s proximal realignment technique leads to a significant progression of patellofemoral osteoarthritis. No risk factors for redislocation could be found; however, the presence of trochlear dysplasia did correlate with patellofemoral osteoarthritis.

Level of evidence

IV.