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Context Mindfulness practices are effective for injury or illness recovery, decreasing stress and anxiety, and strengthening emotional resilience. They are also beneficial for health care professionals' wellbeing and improving patient outcomes and safety. However, mindfulness has not been studied in athletic trainers. Objective To investigate athletic trainers' use of mindfulness practices and their perceptions of its importance for self-care and patient or client care. Design Cross-sectional study. Setting All athletic training practice settings. Patients and Other Participants A total of 547 athletic trainers who were currently practicing completed the survey. Main Outcome Measure(s) We developed an 18-item survey that measured use (1 = never to 6 = very frequently) and perceptions (1 = strongly disagree to 7 = strongly agree) of mindfulness practices. Mann-Whitney U or Kruskal-Wallis tests with post hoc pairwise comparisons were performed to assess differences in use (P < .05). A related-samples Wilcoxon signed rank test was calculated to assess differences in participants' perceptions between self-care and patient or client care. Results Overall, 86% (n = 471) of respondents reported involvement in some form of mindfulness practice, with females (median [interquartile range] = 4 [2–5] versus males: 3 [2–4]; P < .002), those not in a committed relationship (4 [2–5] versus those in such a relationship: 3 [2–4]; P = .048), and those without children in the home (4 [2–5] versus those with children in the home: 3 [2–4]; P = .040) describing the highest frequency of use for self-care. Females (4 [2–4] versus males: 3 [2–4]; P < .001), those without children in the home (3 [2–4] versus those with children in the home: 3 [2–4]; P = .036), and those in emerging (4 [2–4]; P = .003) or collegiate (3 [2–4]; P = .006) settings most frequently incorporated mindfulness into patient or client care. Overall frequency of use for self-care was higher than for patient or client care (4 = occasionally [2–4] versus 3 = rarely [2–4]; P < .001). Mindfulness practices were perceived as more important for self-care than for patient or client care (6 [5–7] versus 5 [5–6]; P < .001). Conclusions Athletic trainers perceived mindfulness practices as more important for personal wellbeing and used them, albeit occasionally, more for self-care than for patient or client care. Differences in gender, relationship status, children, and setting were observed. Mindfulness-based interventions for athletic trainer wellbeing and patient-centered care and implementation barriers should be explored.

Context There have been multiple education reforms aimed at incorporating patient-reported outcome measures (PROMs) into routine clinical care. However, many factors can impact PROM use, including employment setting/policies or access to literature. Objective To explore the influence of educational background and employment setting/policies on athletic trainer (AT) attitudes and practices related to PROM use in the secondary and collegiate settings. Design Cross-sectional survey. Setting Secondary schools; National Collegiate Athletic Association Division I, II, and III; National Association of Intercollegiate Athletics; and junior colleges. Patients or Other Participants Five hundred and seven ATs working in secondary and collegiate settings. Data Collection and Analysis An established scale evaluating attitudes toward PROMs was distributed to a purposeful sample of 4000 ATs. Also included were questions concerning use of PROMs, employer policies related to PROMs, access to non–National Athletic Trainers' Association (NATA) journals, and educational background. Scores on each scale were compared based on educational background, employment setting/policies, and access to non-NATA scientific journals using Kruskal-Wallis tests with a Bonferroni correction. Frequency of PROM use was evaluated using chi-square tests (α = .05). Results PROMs were viewed positively across all participants, with more positive attitudes toward PROMs observed among those with clinical doctorates (P = .029) compared to those with master's or bachelor's degrees and by those with an athletic training-–related postprofessional master's degree (P = .030) compared to a non–athletic training master's degree. There were no differences in attitudes based on timing of professional degree completion. There were no differences in the usage of PROMs based on educational background or employment setting, with only 10% of respondents reporting routine PROM use. However, access to non-NATA scientific journals (P = .016) and employer policies related to the use of PROMs were associated with increased use of PROMs (P < .001). Conclusion Educational reforms have enhanced the attitudes of practicing ATs toward PROMs; however, environmental facilitators, such as expanded access to scientific literature and policies regarding the use of PROMs, are necessary to increase the use of PROMs.

Context: Postoperative quadriceps strength weakness after knee surgery is a persistent issue patients and health care providers encounter. Objective: To investigate the effect of neuromuscular electrical stimulation (NMES) parameters on quadriceps strength after knee surgery. Data Sources: CINAHL, MEDLINE, SPORTDiscus, and PubMed were systematically searched in December 2018. Study Selection: Studies were excluded if they did not assess quadriceps strength or if they failed to report the NMES parameters or quadriceps strength values. Additionally, studies that applied NMES to numerous muscle groups or simultaneously with other modalities/treatments were excluded. Study quality was assessed with the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials. Study Design: Systematic review. Level of Evidence: Level 1. Data Extraction: Treatment parameters for each NMES treatment was extracted for comparison. Quadriceps strength means and standard deviations were extracted and utilized to calculate Hedge g effect sizes with 95% CIs. Results: Eight RCTs were included with an average Physiotherapy Evidence Database scale score of 5 ± 2. Hedge g effect sizes ranged from small (−0.37; 95% CI, −1.00 to 0.25) to large (1.13; 95% CI, 0.49 to 1.77). Based on the Strength of Recommendation Taxonomy Quality of Evidence table, the majority of the studies included were low quality RCTs categorized as level 2: limited quality patient-oriented evidence. Conclusion: Because of inconsistent evidence among studies, grade B evidence exists to support the use of NMES to aid in the recovery of quadriceps strength after knee surgery. Based on the parameters utilized by studies demonstrating optimal treatment effects, it is recommended to implement NMES treatment during the first 2 postoperative weeks at a frequency of ≥50 Hz, at maximum tolerable intensity, with a biphasic current, with large electrodes and a duty cycle ratio of 1:2 to 1:3 (2- to 3-second ramp).

Context Depressed patient-reported outcomes (PROs) are directly related to suboptimal recovery after anterior cruciate ligament reconstruction (ACLR). Various PROs commonly used after ACLR can provide a gross estimation of function but do not fully elucidate the causes of self-perceived disability. Objective To more fully characterize the factors driving responses on PROs. Design Cross-sectional study. A mixed-methods approach was used, in which qualitative interviews were conducted alongside administration of PROs to uncover the themes behind a participant's PRO responses. Setting Laboratory. Patients or Other Participants Twenty-one individuals with unilateral ACLR (age = 20.90 ± 2.86 years, height = 172.0 ± 11.03 cm; mass = 71.52 ± 13.59 kg, postsurgery = 3.66 ± 3.03 years). Main Outcome Measure(s) Patient-reported outcome measures were administered and qualitative interviews were conducted. The PROs consisted of the International Knee Documentation Committee form, Knee Injury and Osteoarthritis Outcomes Score (KOOS), ACL-Return to Sport after Injury (ACL-RSI) scale, and Tampa Scale of Kinesiophobia (TSK). A hierarchical cluster analysis was used to identify subgroups based on PRO responses. Qualitative interviews provided supplemental insight into perceived disability. Independent t tests examined cluster differences for themes. Spearman ρ correlations indicated associations between PRO responses and themes. Results Two clusters (perceived high or low disability) emerged. Individuals with low perceived disability scored better on all PROs (P < .05) except for the KOOS-Activities of Daily Living. Internal and external facilitators or barrier subthemes emerged from the interviews. A significant difference was present between clusters and themes. Lower TSK andgreater ACL-RSI and KOOS-Quality of Life scores were associated with more perceived facilitators. Conclusions Participants with greater internal motivation and confidence and a support network had improved PROs. Those with avoidance tendencies, fear, lack of clear expectations, and less social support scored worse on PROs. The TSK, ACL-RSI, and KOOS-Quality of Life scales were best able to capture the constructs associated with perceived wellness, which reinforces their utility in recovery.

Context Patient-reported outcome measures (PROMs) have been endorsed for providing patient-centered care. However, PROMs must represent their target populations. Objective To identify the primary concerns of collegiate athletes experiencing injury and compare those with the content of established PROMs. Design Cross-sectional study. Setting Collegiate athletic training facilities. Patients or Other Participants Collegiate athletes experiencing injury (N = 149). Main Outcome Measure(s) Open-ended responses to the Measure Yourself Medical Outcome Profile were used to identify primary concerns, which were linked to International Classification of Functioning, Disability and Health taxonomy codes. Items of the Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; Lower Extremity Functional Scale; Knee injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee Subjective Knee Form (IKDC); Foot and Ankle Ability Measure; Disabilities of the Arm, Shoulder, and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire were linked to International Classification of Functioning, Disability and Health codes. We calculated χ2 single-sample goodness-of-fit tests to determine if 70% of the content was shared between PROMs and participant-generated codes. Results Participant-generated concerns were primarily related to sport participation (16%) and pain (23%). Chi-square tests showed that the Lower Extremity Functional Scale and Foot and Ankle Ability Measure presented significant content differences, with common participant-generated lower extremity responses at all levels. The Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; KOOS; IKDC; Disabilities of the Arm, Shoulder and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire did not have significant content differences for level 2 codes; still, significant differences were present for level 3 analyses except for the KOOS and IKDC (P < .001). All measures except the IKDC contained significant superfluous content (P < .05). Conclusions The presence of significant content differences supports clinician-perceived barriers regarding the relevance of established PROMs. However, the IKDC was a relevant and efficient PROM for evaluating the primary concerns of collegiate athletes experiencing lower extremity injury. Clinicians should consider using patient-generated measures to support coverage of patient-specific concerns in care.

Context: Psychosocial factors arising after anterior cruciate ligament (ACL) injury may have a direct influence on an individual’s decision to return to sport after ACL reconstruction (ACLR). While there is ample evidence to suggest that deficits in quadriceps strength, neuromuscular control, and clinical functional tasks exist after ACLR, the root and contribution of psychological dysfunction to an individual’s success or return to sport after ACLR is still largely uncertain and unexplored. Given the discrepancy between successful functional outcomes and the percentage of athletes who return to sport, it is important to thoroughly address underlying factors, aside from physical function, that may be contributing to these lower return rates. Evidence Acquisition: Articles that reported on return to sport, psychological factors, and psychosocial factors after ACLR were collected from peer-reviewed sources available on Medline (1998 through August 2018). Search terms included the following: anterior cruciate ligament OR ACL AND return-to-sport OR return-to-activity, anterior cruciate ligament OR ACL AND psychological OR psychosocial OR biopsychosocial OR fear OR kinesiophobia OR self-efficacy, return-to-activity AND psychological OR psychosocial. Study Design: Clinical review. Level of Evidence: Level 5. Results: Psychosocial factors relative to injury are important components of the rehabilitation process. To fully understand how psychosocial factors potentially influence return to sport, an athlete’s emotions, experiences, and perceptions during the rehabilitation process must be acknowledged and taken into consideration. Conclusion: Acknowledgment of these psychosocial factors allows clinicians to have a better understanding of readiness to return to sport from a psychological perspective. Merging of the current ACLR rehabilitation protocols with knowledge related to psychosocial factors creates a more dynamic, comprehensive approach in creating a positive and successful rehabilitation environment, which may help improve return-to-sport rates in individuals after ACLR.

Purpose Given maladaptive neuroplasticity after musculoskeletal injury, interventions capable of restoring corticospinal excitability should be considered. We therefore aimed to determine if a 4-wk intervention of anodal transcranial direct current stimulation (aTDCS) with eccentric exercise would improve neural excitability, functional performance, and patient-reported function in individuals with chronic ankle instability (CAI). Methods Twenty-six individuals with CAI were recruited to undergo 4 wk of eccentric evertor strengthening. Subjects were randomized into aTDCS (n = 13) and sham (n = 13) groups, where the aTDCS group received 18 min of aTDCS (1.5 mA) over the primary motor cortex. Participants were assessed for cortical excitability, dynamic balance, muscle activation, functional performance, strength, and patient-reported function at baseline, week 2, week 4, and week 6. Results Twenty-two subjects completed the training and test sessions. Cortical excitability (resting motor threshold) to peroneus longus in aTDCS increased from baseline (36.92 ± 11.53) to week 6 (32.91 ± 12.33, P = 0.024), whereas sham increased excitability from baseline (36.67 ± 12.74) to week 2 (27.86 ± 14.69, P = 0.007), but decreased at week 4 (35.63 ± 13.10, P = 0.022) and week 6 (35.99 ± 13.52, P = 0.006). Dynamic balance and muscle activation also improved in the aTDCS group from baseline to week 6 (P = 0.034). Functional performance on a side-hop test increased in all participants from baseline to week 2 (P = 0.003). The aTDCS group had decreased perceived disablement from week 2 (18.09 ± 6.41) to week 4 (15.55 ± 4.82, P = 0.046), whereas the sham group reported increased disablement from baseline (17.91 ± 4.59) to week 2 (21.00 ± 8.52, P = 0.047). Conclusions Our results provide preliminary evidence that 4 wk of eccentric training with aTDCS improves cortical excitability, functional performance, and patient-reported function in individuals with CAI. These data are the first to show the efficacy of noninvasive brain stimulation therapies in patients with musculoskeletal injury, and demonstrate the link between improved neural excitability and functional outcomes.

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.

The evidence-based practice movement in health care has gained both momentum and scrutiny since its inception. Previous IJATT editorials have highlighted the dynamic interplay among evidence sources including the clinician’s internal evidence, best available external evidence, and patient evidence.1,2 In general, health care professions have applauded the integration of these three sources for making clinical decisions, as it incorporates science/knowledge (external evidence), expertise/experience (internal evidence), and the values/preferences/experiences of the individual patient (patient evidence).1,2 However, it seems that athletic training has focused predominantly on the utilization of the best available external evidence as the largest contributor to evidence-based practice (EBP); thus, our EBP education has primarily focused on the development of PICO questions (Patient or Population of interest, Intervention, Control or Comparison, Outcome of interest), searching and critically appraising external evidence. In our quest to become evidence-based practitioners, we have not given enough appreciation to the third source—patient evidence2 (e.g., the patient’s values, preferences, experiences, etc.). The integration of the patient in to decision-making in traditional athletic training settings is obscured by a lack of (a) clear clinical standards for achieving patient engagement and (b) the documentation and quanti?cation of the patient’s perspective. These challenges, combined with the nuances of patient individuality, have made a complex topic much more challenging.

Given maladaptive neuroplasticity after musculoskeletal injury, interventions capable of restoring corticospinal excitability should be considered. We therefore aimed to determine if a 4-wk intervention of anodal transcranial direct current stimulation (aTDCS) with eccentric exercise would improve neural excitability, functional performance, and patient-reported function in individuals with chronic ankle instability (CAI).Twenty-six individuals with CAI were recruited to undergo 4 wk of eccentric evertor strengthening. Subjects were randomized into aTDCS (n = 13) and sham (n = 13) groups, where the aTDCS group received 18 min of aTDCS (1.5 mA) over the primary motor cortex. Participants were assessed for cortical excitability, dynamic balance, muscle activation, functional performance, strength, and patient-reported function at baseline, week 2, week 4, and week 6.Twenty-two subjects completed the training and test sessions. Cortical excitability (resting motor threshold) to peroneus longus in aTDCS increased from baseline (36.92 ± 11.53) to week 6 (32.91 ± 12.33, P = 0.024), whereas sham increased excitability from baseline (36.67 ± 12.74) to week 2 (27.86 ± 14.69, P = 0.007), but decreased at week 4 (35.63 ± 13.10, P = 0.022) and week 6 (35.99 ± 13.52, P = 0.006). Dynamic balance and muscle activation also improved in the aTDCS group from baseline to week 6 (P = 0.034). Functional performance on a side-hop test increased in all participants from baseline to week 2 (P = 0.003). The aTDCS group had decreased perceived disablement from week 2 (18.09 ± 6.41) to week 4 (15.55 ± 4.82, P = 0.046), whereas the sham group reported increased disablement from baseline (17.91 ± 4.59) to week 2 (21.00 ± 8.52, P = 0.047).Our results provide preliminary evidence that 4 wk of eccentric training with aTDCS improves cortical excitability, functional performance, and patient-reported function in individuals with CAI. These data are the first to show the efficacy of noninvasive brain stimulation therapies in patients with musculoskeletal injury, and demonstrate the link between improved neural excitability and functional outcomes.

Context: Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments.Objective: To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR.Design: Case-control study.Setting: University research laboratory.Patients or Other Participants: Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years).Intervention(s): The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged–hop tests, isokinetic quadriceps and hamstrings strength at 60°/s and 180°/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session.Main Outcome Measure(s): The Limb Symmetry Index was calculated for all functional performance measures. Mann-Whitney U tests were used to compare measures between groups (P < .10).Results: Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67–97.70; NRTS median = 82.76, range = 63.22–96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54–100; NRTS median = 71, range = 54–100; P = .08). No differences were observed for any functional performance measures.Conclusions: The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices.

Background: Factors and details regarding return to play in elite, collegiate female soccer athletes after an anterior cruciate ligament (ACL) injury and reconstruction have not been well studied. Purpose: To evaluate return to play among collegiate female soccer players, specifically examining the effect of surgical and individual athlete characteristics on the return-to-play rate. Study Design: Descriptive epidemiology study. Methods: Sports medicine and athletic training staff at institutions from the National Collegiate Athletic Association Southeastern Conference (SEC) were contacted to request participation in the study. All institutions were sent a standardized spreadsheet with response choices and instructions regarding athlete inclusion criteria. Athlete, injury, surgical technique, and return-to-play data were requested for ACL reconstructions performed on female soccer athletes at the participating institutions over the previous 8 years. χ2 analyses were used to compare the return-to-play rate by year in school, scholarship status, position, depth chart status, procedure, graft type, graft fixation, concomitant procedures, and previous ACL injuries. Results: All 14 of the SEC institutions chose to participate and provided data. A total of 80 ACL injuries were reported, with 79 surgical reconstructions and return-to-play data for 78 collegiate soccer athletes. The overall return-to-play rate was 85%. There was a statistical significance in return-to-play rates favoring athletes in earlier years of eligibility versus later years ( P < .001). Athletes in eligibility years 4 and 5 combined had a return-to-play rate of only 40%. Scholarship status likewise showed significance ( P < .001), demonstrating a higher return-to-play rate for scholarship athletes (91%) versus nonscholarship athletes (46%). No significant differences in return-to-play rates were observed based on surgical factors, including concomitant knee procedures, graft type, and graft fixation method. Conclusion: Collegiate female soccer athletes have a high initial return-to-play rate. Undergoing ACL reconstruction earlier in the college career as well as the presence of a scholarship had a positive effect on return to play. Surgical factors including graft type, fixation method, tunnel placement technique, concomitant knee surgeries, and revision status demonstrated no significant effect on the return-to-play rate.

Background: Recent data from the Danish anterior cruciate ligament (ACL) registry demonstrated increased reoperation rates for hamstring tendon autografts when an anatomic ACL reconstruction is performed. This is consistent with reports of greater time needed for hamstring tendon autografts to mature compared with other autografts. Purpose: To review the literature comparing graft failure rate between patellar and hamstring tendon autografts placed anatomically and to determine if there are differences in return to preinjury activity levels between autografts. Study Design: Systematic review with meta-analysis and meta-regression. Methods: The PubMed, MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies published from January 1, 2000, through March 7, 2014. To compare postoperative outcomes between patellar tendon and hamstring tendon autografts, summary event rates for graft failure and return to preinjury activity level were calculated. A meta-analysis was performed to calculate a summary odds ratio (OR) for graft failure between autografts using the studies that directly compared the 2 autografts. Meta-regression analyses were performed to assess the influence of postoperative follow-up time on graft failure rate. Results: A total of 28 studies reported graft failures for patellar tendon (6 studies) and hamstring tendon (26 studies) autografts used with anatomic ACL reconstruction; 4 of the 28 were comparison studies. Graft failure rate was not significantly different between patellar tendon (7.0% [95% CI, 4.6%-10.5%]) and hamstring tendon autografts (3.9% [95% CI, 2.7%-5.6%]). The odds of graft failure were slightly higher for hamstring tendon autografts (OR, 1.21 [95% CI, 0.63-2.33]), but this difference was not significant ( P = .57). The rate of patients returning to preinjury activity levels was not significantly different between patellar (n = 1 study; 58.1% [95% CI, 40.4%-73.9%]) and hamstring tendon autografts (n = 5 studies; 75.6% [95% CI, 43.7%-92.5%]). Overall graft failure rate was positively associated with postoperative follow-up time, but this effect was only significant with hamstring tendon autografts ( P < .05). Conclusion: Differences in graft failure rate between patellar tendon and hamstring tendon autografts were not significant. Although follow-up time was only found to have a significant influence on hamstring tendon graft failure rates, this was likely due to the smaller sample of studies assessing patellar tendon graft failures. Differences in return to preinjury activity levels could not be determined due to the lack of studies assessing that outcome. Both patellar and hamstring tendon autografts demonstrate a low risk of failure and moderately high return to activity level after anatomic ACL reconstruction.

Objectives: Autologous chondrocyte implantation (ACI) is a well established treatment for articular cartilage defects of the knee. However, few studies have examined return-to-work rates among ACI patients, and even fewer have investigated the effect of mental health on postoperative outcomes. The purpose of this study was to examine the effect of preoperative mental health on return to work and patient-reported outcomes. Methods: From our IRB-approved prospective outcomes registry, we identified 109 ACI patients (mean age = 34.5 years, mean follow-up = 2.8 years) with pre- and postoperative clinical data. Patients were stratified into those with preoperative VR-12 Mental Component Scores in the bottom quartile (LOW MCS) and in the top 3 quartiles (HIGH MCS) based on normative values. Patients with patellar and/or trochlear lesions were placed in the patellofemoral (PF) group, and all other patients were placed in the tibiofemoral (TF) group. Return to work, IKDC scores, and Lysholm scores were individually compared between the LOW MCS and HIGH MCS groups that had undergone either PF or TF ACI. Fisher’s exact tests were used to compare the return to work rates and frequency of IKDC and Lysholm improvements greater than the minimal clinically important difference. One-way ANOVAs were used to examine magnitude of change of IKDC and Lysholm scores. Results: Preoperatively, 14/55 (25.5%) TF patients and 17/54 (31.5%) PF patients were included in the LOW MCS group. For PF patients, return to work rates were significantly lower for the LOW MCS group (p=.0005). Return to work rates did not differ in the TF group (p>0.99). Changes in IKDC and Lysholm scores did not differ between the LOW MCS and HIGH MCS groups in TF or PF patients (Table 1). Conclusion: Lower preoperative mental component scores were more common in PF ACI patients and were associated with decreased return to work rates in PF ACI patients. The results of this study underscore the need to preoperatively quantify mental health status for this specific patient group in order to set realistic postoperative expectations. Table 1. Comparison of postoterative outcomes between patients with either low or high preoperative VR-12 mental component scores (MCS), separated by the location of the lesion (patellofemoral or tibiofemoral). *MCID: Minimal Clinically Important Difference Patellofemoral ACI Tibiofemoral ACI LOW MCS HIGH MCS P LOW MCS HIGH MCS P Number of patients 17 37 - 14 37 - Return to Work (%) 29.4% 81.1% 0.0005 57.1% 60.9% >0.99 IKDC change > MDIC (%) 73.3% 45.7% 0.12 35% 43.9% 0.76 Mean IKDC Improvement 14.12 21.87 0.917 10.13 5.77 0.35 Lysholm Change > MDIC (%) 81.3% 62.9% 0.33 14.3% 46.2% 0.53 Mean Lysholm Improvement 16.71% 19.06 0.719 11.92 0.65 0.631

Objectives: Patient reported outcomes (PROs) are increasingly used in orthopaedics as a tool to objectively assess subjective data and provide a sense of responsiveness to treatment. Unfortunately, there are several PROs and little data as to which outcome scores are most useful. The purpose of this study was to evaluate the utilization and responsiveness of PROs reported in the literature after shoulder instability surgery. Methods: We performed a systematic review of the PubMed, SportDiscus, Cochrane, and CINHAHL databases according to PRISMA guidelines to identify studies published in the last 10 years which reported PROs after shoulder instability surgery. Articles were excluded if they were not primary research (case reports and review articles), were published only in abstract form, were not available in English, or did not report pre- and post-operative mean PRO values. The specific PROs utilized, number of patients, mean follow-up time, and preoperative and postoperative means and standard deviations were recorded for each article, For studies including preoperative and postoperative means and standard deviations of two or more PROs, and the comparative responsiveness (CR) of each PRO was assessed (CR was calculated by squaring PRO change score t-value ratio). Results: Abstracts from 112 studies were identified for full text review, and 29 studies ultimately met inclusion criteria. Sixteen different PROs were reported in various combinations in the included studies. Mean follow-up was 25.17 months (SD = 15.01) and mean sample size was 47.34 (SD = 59.06). The majority of studies (72.4%) utilized more than one PRO. The most commonly used PROs were the ASES (13 studies, 44.8%), Rowe (10, 34.5%), WOSI (8, 27.6%), VAS-pain (7, 24.1%), UCLA (7, 24.1%), and Constant (6, 20.7%). The remaining PRO tools appeared in 3 or fewer studies. Responsiveness of the different PRO tools was evaluated with a subset of 4 articles that included sample size, pre- and postoperative means, and pre- and post-operative standard deviations for PROs reported in this subset were the ASES, Rowe, WOSI, VAS-pain, and Constant scores. The Rowe score was much more responsive than both the ASES (RE = 22.8) and Constant scores (RE = 33.17). On the contrary, the VAS-pain was the least responsive, with RE = 0.57 when compared to the ASES, and RE = 0.32 when compared to the WOSI. ASES remained more responsive than the Constant (RE = 1.75), VAS-pain (RE = 1.75), and WOSI (RE = 0.97). Conclusion: Despite being less frequently utilized, the Rowe score was considerably more responsive than the ASES and Constant scores. ASES, Constant, and WOSI were similar to each other in terms of responsiveness, and the shoulder-specific scores were more responsive than the VAS-pain score. When assessing patient outcomes related to shoulder instability surgery, surgeons may want to consider employing the more sensitive, and instability-specific, Rowe score rather than other commonly used shoulder PROs.

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 (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.

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 between groups 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

Background Web-based surveys provide an efficient means to track clinical outcomes over time without the use of clinician time for additional paperwork. Our purpose was to determine the feasibility of utilizing web-based surveys to capture rehabilitation compliance and clinical outcomes among postoperative orthopedic patients. The study hypotheses were that (a) recruitment rate would be high (>90%), (b) patients receiving surveys every two weeks would demonstrate higher response rates than patients that receive surveys every four weeks, and (c) response rates would decrease over time. Methods The study deaign involved a longitudinal cohort. Surgical knee patients were recruited for study participation during their first post-operative visit ( n = 59, 34.9 ± 12.0 years of age). Patients with Internet access, an available email address and willingness to participate were counter-balanced into groups to receive surveys either every two or four weeks for 24 weeks post-surgery. The surveys included questions related to rehabilitation and questions from standard patient-reported outcome measures. Outcome measures included recruitment rate (participants consented/patients approached), eligibility (participants with email/participants consented), willingness (willing participants/participants eligible), and response rate (percentage of surveys completed by willing participants). Results Fifty-nine patients were approached regarding participation. Recruitment rate was 98% ( n = 58). Eligibility was 95% ( n = 55), and willingness was 91% ( n = 50). The average response rate was 42% across both groups. There was no difference in the median response rates between the two-week (50%, range 0–100%) and four-week groups (33%, range 0–100%; p = 0.55). Conclusions Although patients report being willing and able to participate in a web-based survey, response rates failed to exceed 50% in both the two-week and four-week groups. Furthermore, response rates began to decrease after the first three months postoperatively. Therefore, supplementary data collection procedures may be necessary to meet established research quality standards.

Background:Patellofemoral instability affects activities of daily living and hinders athletic participation. Over the past 2 decades, more attention has been paid to medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocations/subluxations. Numerous techniques have been reported; however, there is no consensus regarding optimal reconstruction.Purpose:This study sought to report on the various techniques for MPFL reconstruction described in the literature and to assess the rate of complications associated with the procedure.Study Design:Meta-analysis.Methods:A systematic review of the literature was performed in early October 2010 using keywords “medial patellofemoral ligament,” “MPFL,” “reconstruction,” “complication(s),” and “failure(s).” Articles meeting the inclusion criteria were reviewed. Graft choice, surgical technique, outcome measures, and complications were recorded and organized in a database. Descriptive statistical analysis was performed on the data collected.Results:Twenty-five articles were identified and reviewed. A total of 164 complications occurred in 629 knees (26.1%). These adverse events ranged from minor to major including patellar fracture, failures, clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain. Twenty-six patients returned to the operating room for additional procedures.Conclusion:Medial patellofemoral ligament reconstruction has a high rate of success for patients with patellofemoral instability; however, the complication rate of 26.1% associated with this procedure is not trivial. This study quantified complications and documented the variety of complications reported in outcomes-based literature.

Context: 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.Objective: 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 me-dial 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.Design: Descriptive laboratory study.Setting: Research laboratory.Patients or Other Participants: 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.Intervention(s): 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.Main Outcome Measure(s): The dependent variables were joint angles at contact and joint excursions between contact and peak knee flexion.Results: 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).Conclusions: Asymmetry of unilateral hip rotation, sex, and hip strength were associated with kinematic components of medial knee collapse.

Objective: To systematically review the literature regarding postoperative rehabilitation for articular cartilage repair: (1) does the use of continuous passive motion (CPM) enhance healing, and if so, what parameters should be applied? (2) Can active range of motion (AROM) be used in place of or with CPM? (3) When can individuals safely resume weight bearing (WB) following repair? Data Sources: A search using Medline, SportsDiscus, and CINAHL databases was performed with the following keywords: articular cartilage, AROM, CPM, microfracture, osteochondral allograft, autologous chondrocyte implantation, rehabilitation, weight bearing, and knee. Study Selection: Basic science or clinical outcomes examining the effects of CPM, AROM, or WB on knee articular cartilage healing. Data Extraction: Selected articles were rated using the Strength of Recommendation Taxonomy (SORT) to determine evidence for clinical application. Data Synthesis: Sixteen articles met selection criteria: 12 were basic science studies; 4 were clinical studies. Basic science evidence supporting CPM exists. However, few patient-oriented outcomes have been documented resulting in a SORT rating of C. Early WB and AROM received a SORT rating of B based on limited clinical research and patient-oriented outcomes. Conclusions: Basic science evidence supports CPM to maintain ROM, reduce pain, and promote healing. Patient-oriented research is needed to strengthen CPM’s recommendation. Limited evidence exists regarding early WB and AROM post cartilage repair. There is insufficient evidence to confidently address when to begin WB for maximum healing. Appropriate basic science and patient-oriented research are needed for rehabilitation protocols to maximize benefits of cartilage repair procedures.

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 TT–to–trochlear 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.

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 outcome measures (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 ± 0.69 s) 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.

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.2C.

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

Special Issue: Current Concepts in Cartilage Management and RehabilitationGuest Editors: Jennifer S. Howard, Jay R. Ebert, and Karen Hambly

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.

Objectives: We sought to determine the overall return to play (RTP) rate of female collegiate soccer athletes after anterior cruciate ligament (ACL) reconstruction in the Southeastern Conference (SEC). Additionally, we examined particular athlete related and surgical technique related variables as they correlated to RTP. We hypothesized that RTP after ACL reconstruction would be higher than previously published results and that it would be independent of graft type utilization or surgical techniques employed. Methods: Head team physicians and athletic training staff of the 14 institutions of the SEC were contacted to request participation in the study. All institutions were sent information regarding the nature of the study, a standardized spreadsheet with standardized response choices for the purpose of data collection from the participating institutions, and instructions regarding athlete inclusion criteria. The spreadsheet provided queried certain athlete and technical surgical related variables for ACL reconstructions performed at the participating institutions over the previous 8 years (2005-2013). Results: All 14 of the SEC institutions chose to participate and provided data. 79 reconstructions were reported with RTP data available for 78 women soccer athletes. Overall RTP rate was 84.6%. There was statistical significance in RTP rates favoring athletes in earlier years of eligibility versus later years (pConclusion: Of Division I collegiate women soccer athletes undergoing ACL reconstruction, overall RTP rate approaches 85%. Undergoing ACL reconstruction earlier in the college career before the 4th year of eligibility as well as the presence of a scholarship had a positive effect on RTP. Surgical factors including graft type, fixation methods, tunnel placement technique, concomitant knee surgery, and revision status played showed no significant effect on RTP rate.

Objectives: Autologous chondrocyte implantation(ACI) has become an accepted treatment for articular cartilage defects; however, selection of appropriate patients in routine clinical practice remains challenging. The purpose of this study was to evaluate the use of preoperative patient reported outcome(PRO) scores in predicting postoperative self-reported global function following ACI with the goal of defining a minimum entry score that is predictive of a successful patient outcome. Methods: A case series of patients a minimum of 1-year following ACI (n = 73, 27 female, age = 35 ± 7 yrs, BMI = 30 ± 5, mean defect = 7.4 ± 5.1 cm2, average follow-up = 2.3 ± 1.2 yrs) were evaluated. All patients were enrolled prospectively and completed PROs pre-surgery and 3, 6, and 12 months and annually post-surgery. As part of the ICRS Cartilage Injury Standard Evaluation Form, postoperatively patients were asked to rate their current function as “severely restricted in everything I do”, “restricted, many things are not possible”, “I can do nearly everything”, or “I can do everything”. Receiver operator curves (ROCs) were used to explore the discriminative accuracy of preoperative PROs (Total WOMAC Knee Score, IKDC Subjective Knee Form, and Lysholm Knee Scale) for identifying patients reporting to be able to do “nearly everything” or “everything” at the last available follow-up. From the ROCs cut-point scores for the values with the highest combined sensitivity and specificity were identified. Patients were then classified for each PRO instrument as having preoperative scores above or below the identified cut-point values. Cut-point status for preoperative WOMAC, IKDC, and Lysholm along with BMI, gender, age, defect area, and defect location (patellofemoral/tibiofemoral) were analyzed in a backwards entry logistic regression model to predict patients experiencing a positive outcome. Results: Area under the curve was significantly greater than 0.5(range 0.80(IKDC)-0.82(Lysholm), p≤0.001) for each PRO ROC, demonstrating high accuracy in using preoperative PROs to predict post-operative function. The WOMAC score demonstrated a cut-point value of 34 with a sensitivity of 0.89 and specificity of 0.60 for identifying patients who went on to a positive outcome. For IKDC the cut-point was 35 (sensitivity=0.86, specificity=0.67). For Lysholm the cut-point was 41 (sensitivity =0.89, specificity=0.61). The only variables contributing to the final logistic model were IKDC score > 35 (p=0.002), and Lysholm score > 41 (p=0.002). The model demonstrated that those individuals with a preoperative IKDC score > 35 had 7.4 (95%CI: 2.1 - 26.9) greater odds of a positive outcome compared to those with an IKDC score ≤ 35 and those with a preoperative Lysholm score > 41 had 8.5 (2.2 - 33.2) greater odds of a positive outcome compared to those with a Lysholm score ≤ 41. Overall 85.5% of patients were correctly classified by the model as having a good or poor outcome. Conclusion: Pre-operative PROs can provide patients and physicians with accurate expectations for post-operative global levels of function. These results suggest that there may exist a minimum threshold of self-reported function for which ACI procedures can result in meaningful functional outcomes. Patients with functional levels below these cut-points should undergo preoperative interventions aimed at improving their function to above cut-point values and be counseled for realistic treatment expectations or available treatment alternatives.

SummaryObjectiveTo 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?MethodsSystematic 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) classification, measured sCOMP, and reported means and standard deviations for sCOMP.ResultsFor 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 = 0.60, P