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