Elsevier

The Knee

Volume 8, Issue 1, March 2001, Pages 51-57
The Knee

Outcome measurement in the ACL deficient knee — what's the score?

https://doi.org/10.1016/S0968-0160(01)00068-0Get rights and content

Abstract

There is increasing pressure within the United Kingdom for transparent assessment of the performance of every doctor along with the procedures they perform. Unfortunately, the validation of the outcome measures used to assess such procedures has been questioned. This has been well illustrated in the anterior cruciate ligament (ACL) deficient knee. Over 54 different outcome measures used to assess the ACL deficient knee have been identified, few of which were formally assessed at their initial publication. For those most frequently used the Lysholm (I and II) knee scoring scale and Tegner activity score are the only ones to have been adequately validated prior to use. The Cincinnati rating system and International Knee Documentation Committee (IKDC) form were not assessed and the reliability of both measures has since been questioned. Appropriately tested newer measures include the IKDC subjective knee evaluation form, Mohtadi's ACL quality of life outcome measure and the Knee injury and osteoarthritis outcome score (KOOS). We recommend use of the Lysholm II knee scoring scale and Tegner activity score for clinical follow-up of patients and for use as a gold standard to which future measures can be compared. These have their deficiencies and will ultimately require replacement. In view of the international standing of its authors, the IKDC subjective knee evaluation form is likely to be used in preference to the KOOS despite its attractions. For long-term clinical trials the SF-36 should also be used. Further research is required to produce suitable measures for assessing the ACL deficient knee and this work should be appropriately funded.

Introduction

Recent events in the United Kingdom have brought the medical profession under the spotlight. Although the front pages of the media have picked on high profile cases there is increasing pressure for transparent assessment of the performance of every doctor in addition to the procedures they perform [1]. Although self-assessment has been ingrained into the philosophy of medical practice for thousands of years [2], the Department of Health has introduced a more formalised framework of assessment within the NHS [3], [4] with the mantle of re-validation being taken up by the GMC and the specialist medical bodies [5].

In the light of these changes it is appreciated that the assessment of outcome will become increasingly important. Mortality figures have often been used to determine outcome; however, within orthopaedics this information although important, is unlikely to be adequate. Many measures have been designed for use in orthopaedic research to assess the outcome of all forms of intervention. Increasingly, the reliability and validity of these have been called into question. It is imperative, therefore, that careful consideration of each measure is made prior to their use for research or re-validation.

These problems are well illustrated in the assessment of the anterior cruciate ligament (ACL) deficient knee. Although several articles have already reviewed this subject [6], [7], [8], [9], [10], [11] none has been complete. This article will review the available outcome measures and highlight some problems associated with their design and use.

Section snippets

Use of ACL outcome measures

A review of 197 articles reporting the clinical outcome of the ACL deficient knee in four journals [The Journal of Bone and Joint Surgery (American and British volumes), Clinical Orthopaedics and Related Research, and The American Journal of Sports Medicine] over the period 1984–1997 was made. This review identified 39 distinctly different outcome measures designed for use in the ACL deficient knee. The frequency of use of each family of measure is presented in Table 1. A literature search

Assessment of outcome measures

Prior to the commencement of any study or process of re-validation a method of assessment must be chosen. It is easy to select a measure that has been used frequently in the past, but this approach may perpetuate the use of an inappropriate measure. Unfortunately, this problem has not been helped by the editorial committee of journals exerting pressure to use individual measures for their publication.

An adequate measure must be designed, and tested for reliability/validity prior to use. The

A review of the ACL outcome measures

The first measure was produced in 1955 when O'Donoghue devised a questionnaire to assess the outcome of repair for an acutely torn ACL [18]. No formal attempt was made to validate it, as with many of the measures described below. Since then, many individual measures have been created (Table 3). The final scores are usually generated as a sum of the individual question items. Alternatively, the scores are grouped into categories (e.g. symptoms, function and examination findings) or are presented

Which ACL outcome measures to use?

Reliability and validity testing is the most important factor in deciding which of these measures to use; the second is the use for which it is intended. We feel the Lysholm knee scoring scale [20] and Tegner activity score [20] have been adequately tested. They are easy to use for both research and clinical follow-up of patients. An additional advantage is their extensive use in the past, making them ideal as gold standards for comparison to future measures.

Reliability problems preclude the

Summary

The available outcome measures for use in the ACL deficient knee have been reviewed. It is clear that a small group of the 54 available measures have been in use for research. A similar pattern is found in everyday orthopaedic practice although the majority of surgeons at present do not use an outcome measure for clinical follow-up of patients. Clearly, the assessment of the majority of measures to date has been poor, leaving few adequate measures to chose from. However, recommendation of a

Acknowledgements

Funding to print and mail the questionnaire described was sponsored by Intavent Orthofix

References (73)

  • J. Gillquist et al.

    Reconstruction for old rupture of the anterior cruciate ligament. A follow-up study

    Injury

    (1971)
  • S.T. Hanley et al.

    Arthroscopic meniscectomy in the anterior cruciate ligament deficient knee

    Arthroscopy

    (1987)
  • Laurance J. Do we need league tables for doctors? Independent 2000 July 6; Thursday Review:...
  • R. Rosser

    A history of the development of health indicators

  • Department of Health. The New NHS. London: HMSO,...
  • Department of Health. The NHS Plan. London: HMSO,...
  • General Medical Council. Revalidating doctors. London: GMC,...
  • F.R. Noyes et al.

    Functional disability in the anterior cruciate insufficient knee syndrome. Review of knee rating systems and projected risk factors in determining treatment

    Sports Med

    (1984)
  • F. Hefti et al.

    Evaluation of knee ligament injuries with the IKDC form

    Knee Surg Sports Traumatol Arthrosc

    (1993)
  • J.J. Irrgang et al.

    Use of the international knee documentation committee guidelines to assess outcome following anterior cruciate ligament reconstruction

    Knee Surg Sports Traumatol Arthrosc

    (1998)
  • F. Flandry et al.

    Analysis of subjective knee complaints using visual analogue scales

    Am J Sports Med

    (1991)
  • N. Mohtadi

    Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency

    Am J Sports Med

    (1998)
  • C.T. Vangsness et al.

    Review of outcome instruments for evaluation of anterior cruciate ligament reconstruction

    Bull Hosp Jt Dis

    (1995)
  • D.S. Johnson et al.

    Database of outcome measures by the clinical effectiveness unit (CEU) of the Royal College of Surgeons of England

    Ann R Coll Surg Engl

    (2000)
  • C.B. Frank et al.

    The science of reconstruction of the anterior cruciate ligament

    J Bone Joint Surg (Am)

    (1997)
  • E. Eriksson

    Validation of ACL scoring methods

    Knee Surg Sports Traumatol Arthrosc

    (1996)
  • M.E. Blazina

    Ligament replacements-clinical evaluation

    Clin Orthop

    (1985)
  • J. Browne

    Response to David Johnson and Roger Smith

    Ann R Coll Surg Engl

    (2000)
  • D.L. Streiner et al.

    Health measurement scales: a practical guide to their development and use

    (1995)
  • D.H. O'Donoghue

    An analysis of end results of surgical treatment of major injuries to the ligaments of the knee

    J Bone Joint Surg (Am)

    (1955)
  • J. Lysholm et al.

    Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale

    Am J Sports Med

    (1982)
  • Y. Tegner et al.

    Rating systems in the evaluation of knee ligament injuries

    Clin Orthop

    (1985)
  • Johnson DS. An assessment of the outcome measures used in the anterior cruciate ligament deficient knee. Thesis for...
  • F.R. Noyes et al.

    The symptomatic anterior cruciate deficient knee. Part I: the long-term functional disability in athletically active individuals

    J Bone Joint Surg (Am)

    (1983)
  • F.R. Noyes et al.

    The symptomatic anterior cruciate deficient knee. Part II: the results of rehabilitation, activity modification and counselling on functional disability

    J Bone Joint Surg (Am)

    (1983)
  • J.L. Seto et al.

    Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction

    Am J Sports Med

    (1988)
  • R.A. Harter et al.

    Long-term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency

    Am J Sports Med

    (1988)
  • F.R. Noyes et al.

    Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency

    J Bone Joint Surg (Br)

    (1989)
  • F.R. Noyes et al.

    A rationale for assessing sports activity levels and limitations in knee disorders

    Clin Orthop

    (1989)
  • F.R. Noyes et al.

    Bone-patellar ligament-bone and fascia lata allografts for reconstruction of the anterior cruciate ligament

    J Bone Joint Surg (Am)

    (1990)
  • M.A. Olsen et al.

    Clinical use of fresh, frozen soft tissue allografts

    Orthopaedics

    (1992)
  • F.R. Noyes et al.

    High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. A two to seven-year follow-up study

    Am J Sports Med

    (1993)
  • K.D. Shelbourne et al.

    Anterior cruciate ligament injury: evaluation of intraarticular reconstruction of acute tears without repair. Two to seven-year follow-up of 155 athletes

    Am J Sports Med

    (1990)
  • International Knee Documentation Committee. IKDC form. International Knee Society Meeting, Toronto, Canada 15th May...
  • P.M. Aichroth et al.

    Documentation and evaluation in disorders of the knee: an overview

  • D.S. Johnson et al.

    Evaluation of the IKDC form: what's the score?

    J Bone Jt Surg (Br) Suppl II

    (2000)
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