Introduction of a classification system for patients with patellofemoral instability (WARPS and STAID).

PURPOSE: The primary purpose of this paper is to introduce the WARPS/STAID classification system for patellofemoral instability. The secondary purpose is to establish the validity and reliability of the WARPS/STAID classification system. METHODS: Patients (n = 31) with a confirmed diagnosis of patellofemoral instability underwent a thorough knee history and physical examination with 3 raters. The raters graded each component of the WARPS/STAID classification system on a visual analogue scale (VAS). A single Global VAS WARPS/STAID score was graded after all other components of the classification system were completed. Intraclass correlation coefficient (ICC 2, 3) was calculated for each metric of the classification scale and for the Global score. Concurrent validity was assessed by correlating the WARPS/STAID score with the Kujala score. Subjects were assigned to one of three categories (WARPS, STAID, or mixed characteristics) according to the Total WARPS/STAID score to determine the level of agreement between the three raters. RESULTS: Intraclass correlation coefficient (ICC 2, 3) of the WARPS/STAID classification continuum ranged between 0.73 and 0.91 for the individual metrics of the classification. The ICC (2, 3) for the Global WARPS/STAID score was 0.75. The mean Kujala score (m = 61, SD 18) was significantly correlated with the total WARPS/STAID score (r = 0.387, p < 0.05). The majority of subjects were assigned to either the WARPS or STAID categories. CONCLUSION: This study introduced the WARPS/STAID classification system and established both validity and reliability in subjects with patellofemoral instability. LEVEL OF EVIDENCE: II.

Remnant-Sparing Anterior Cruciate Ligament Reconstruction Results in Similar Clinical, Functional, and Quality-of-Life Outcomes to Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction.

Purpose: To compare a large cohort of patients who underwent remnant-sparing anterior cruciate ligament reconstruction (rACLR) with a matched group of patients who underwent anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) with respect to clinical laxity, patient-reported outcomes, and functional testing. Methods: Patients who underwent rACLR between January 2010 and December 2015 were matched according to age, sex, body mass index, and graft type to patients who underwent ACLR. The primary outcome measure was the ACL Quality of Life (ACL-QOL) score at final follow-up of 24 months. Secondary outcomes included functional tests and clinical laxity measurements at 6, 12, and 24 months postoperatively. Concurrent intra-articular pathology at the time of surgery and postoperative complications were also recorded. Statistical analyses included the dependent t test and the Wilcoxon signed rank test. Results: A total of 210 rACLR patients were successfully matched to a corresponding cohort of 210 ACLR patients. There were no statistically significant differences in ACL Quality of Life (ACL-QOL) or functional testing results between the groups; however, scores in both groups showed a steady and statistically significant improvement over time. A statistically significant difference was noted with respect to the Lachman test findings, favoring the rACLR cohort (Z = -2.79, P = .005); no between-group difference was seen for the pivot-shift test (Z = -0.36, P = .72). The rACLR group had a significantly lower rate of concurrent meniscal and chondral injury. There was no difference in complications between the groups (Z = -0.49, P = .63). Conclusions: There was no difference in patient-reported or functional testing outcomes in patients undergoing remnant-sparing compared with anatomic single-bundle ACLR. There was, however, a significantly lower rate of positive Lachman test findings after rACLR. Furthermore, the rate of concurrent meniscal and chondral pathology was lower in the rACLR group. Level of Evidence: Level III, retrospective cohort study.

Evolution of a Novel Tissue Preservation Protocol to Optimize Osteochondral Transplantation Outcomes.

OBJECTIVE: Osteochondral allograft transplantation is a procedure to treat focal osteochondral lesions (OCLs), but is limited by tissue availability, the quality of transplanted tissue, and inconsistent storage protocols. The objective of this study was to assess the clinical outcomes of a novel tissue procurement, storage, and quality control protocol in treating OCLs. DESIGN: Prospective case series. Donor cadaveric tissue was processed, stored, and the tissue quality analyzed using the unique tissue preservation protocol developed at our institution. Advanced cross-sectional imaging was used to size match donor tissue with recipient patients. Osteochondral allografts were transplanted using the Arthrex Allograft OATS. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), and 36-Item Short Form Survey (SF-36) preoperatively and at 1 year and 2 years postoperatively. RESULTS: Twenty patients (17 knees, 3 shoulders) were included in the study. There was a significant improvement in the following scores: overall WOMAC score, WOMAC function and pain subcategories; KOOS pain, knee-related symptoms, activities of daily living, sports and recreation, and quality of life; SF-36 physical functioning, physical role, pain, and social functioning subcategories; and VAS at all time points postoperatively. There was a significant improvement in WOMAC stiffness at 2 years postoperatively. There were 2 failures, defined by graft subsidence and persistent pain requiring reoperation. CONCLUSION: The protocol developed at our institution for OAT resulted in significant clinical improvement in patients with OCLs and is an improvement on existing tissue storage techniques.

Initial validity and reliability of the Banff Patella Instability Instrument.

BACKGROUND: Patellofemoral instability is a well-recognized problem, but there are currently no published patient-reported quality of life outcome measures that are disease specific for the treatment of this population. PURPOSE: To establish the content validity, initial construct validity, and initial reliability of the Banff Patella Instability Instrument (BPII). STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The content of the BPII was validated using a modified 3-stage Ebel procedure and analysis of floor and ceiling effects. As a measure of internal consistency, the Cronbach α was utilized to assess how reliably the 32 items of the questionnaire measured a similar construct. Test-retest reliability of the BPII was calculated using an intraclass correlation coefficient (ICC). Construct validity was evaluated on 150 questionnaires completed by patients with a confirmed diagnosis of patellofemoral instability. A one-way between-group analysis of variance was employed to determine if the BPII was able to differentiate between patients presenting at the initial orthopaedic consultation relative to patients presenting at 6 months and 12 months postoperatively. RESULTS: Content validity was clearly established as each item in the BPII achieved a minimum of 83.3% agreement (range, 83.3%-100%) for relevance among the expert panelists. The average agreement was 96.9%; 24 items achieved 100% agreement. There was no evidence of floor or ceiling effects. Reliability (internal consistency) of the BPII was established at the initial orthopaedic consultation (α = .91), 6 months postoperatively (α = .97), and 12 months postoperatively (α = .97). Test-retest analysis resulted in an ICC of 0.98 between tests. Construct validity was established as there was a statistically significant difference in BPII scores at the initial orthopaedic consultation and 6-month and 12-month postoperative appointments (F2,146 = 75.62; P < .001). CONCLUSION: The BPII demonstrates content validity, strong initial reliability, and a statistically significant level of construct validity in patients with patellofemoral instability. This population includes patients with recurrent patellofemoral instability as well as surgically stabilized patients.

Knee immobilization for pain control after a hamstring tendon anterior cruciate ligament reconstruction: a randomized clinical trial.

BACKGROUND: This study will attempt to evaluate the efficacy of knee immobilization on patient pain levels after an anterior cruciate ligament reconstruction. HYPOTHESIS: There is no difference in visual analog scale pain scores 2 days after anterior cruciate ligament reconstruction between patients who wear a knee immobilizer and those who do not wear a knee immobilizer. STUDY DESIGN: Randomized clinical trial; Level of evidence, 1. METHODS: Patients aged 18 to 40 years who met study inclusion criteria were eligible. Patients meeting intraoperative inclusion criteria were randomized (immobilizer or no immobilizer) after wound closure. The immobilizer used was a soft, unhinged brace with Velcro straps. Preoperative, intraoperative, and postoperative protocols were standardized. The primary outcome was patient self-assessed pain using a 0-to-100-mm visual analog scale at day 2 after surgery. Secondary outcomes included pain and analgesic use in the first 14 days after surgery, complications, and range of motion (approximately 3 weeks postoperatively). A sample size estimate was calculated and resulted in the need for 44 patients per group. RESULTS: A total of 102 patients were enrolled; 88 patients were randomized, and 14 were excluded intraoperatively. There was no difference in mean visual analog scale pain scores at 2 days after surgery between immobilized and nonimmobilized patients (32.6 and 35.2, respectively; P = .59; difference, -2.6; 95% confidence interval, -12.2 to 6.9). There were no differences between groups in medication consumed, range of motion, or complications. Pain and analgesic use were the same for both groups at 7 and 14 days postoperatively. CONCLUSION: No differences in pain or any of the secondary outcomes were detected between immobilized and nonimmobilized patients at any point during the first 14 days after anterior cruciate ligament reconstruction.