BackgroundPatients discharged to non-home facilities (NHD) after total hip arthroplasty (THA) and total knee (TKA) arthroplasty experience higher rates of adverse events and may require more aggressive venous thromboembolism (VTE) chemoprophylaxis. Our aim was to compare the rates of VTE in NHD patients and those discharged home (HD) after THA/TKA. Our secondary aim was to determine VTE rates within HD and NHD groups when stratified by chemoprophylactic regimen.MethodsA retrospective cohort of primary THA and TKA patients were stratified into HD and NHD, then allocated into groups by chemoprophylactic regimen on discharge: aspirin alone (AA), more aggressive (MA) chemoprophylaxis, and other regimens (other). The primary outcome was VTE. Rates of VTE in HD and NHD patients, as well as AA and MA regimens, were analyzed using a generalized linear regression model.ResultsSix thousand three hundred seventy-nine patients were included with 1.03% experiencing VTE. HD had lower rates of VTE compared to NHD (0.83% vs 2.17%, P < .001). AA had similar rates of VTE compared to MA (0.99% vs 1.08%, P = .82). NHD patients had a lower VTE rate with MA vs AA prophylaxis (1.47% vs 3.83%, P = .016). HD patients treated with AA vs MA had no difference in VTE rates (0.76% vs 0.96%, P = .761).ConclusionsNHD patients have higher rates of VTE than HD patients. However, NHD patients have significantly lower rates of VTE on MA chemoprophylaxis compared to those on AA. Providers should consider prescribing MA VTE chemoprophylaxis for NHD patients. Prospective, randomized studies are necessary to confirm these recommendations.

OBJECTIVE:Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality. METHODS:This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables. RESULTS:Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery. CONCLUSION:Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Existing literature is discrepant on the differences in blood loss and need for transfusion between short and long cephalomedullary nails used for extracapsular geriatric hip fractures. However, prior studies used the inaccurate estimated rather than the more accurate ‘calculated’ blood loss based on hematocrit dilution (Gibon in IO 37:735–739, 2013, Mercuriali in CMRO 13:465–478, 1996). This study sought to clarify whether use of short nails is associated with clinically meaningful reductions in calculated blood loss and resultant need for transfusion. A retrospective cohort study using bivariate and propensity score-weighted linear regression analyses was conducted examining 1442 geriatric (ages 60–105) patients undergoing cephalomedullary fixation of extracapsular hip fractures over 10 years at two trauma centers. Implant dimensions, pre and postoperative laboratory values, preoperative medications, and comorbidities were recorded. Two groups were compared based on nail length (greater or less than 235 mm). Short nails were associated with a 26

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Case: A 60-year-old woman presented with knee instability and pain that started approximately 13 years after a posterior stabilized total knee arthroplasty. Physical examination revealed significant posterior laxity. Bedside ultrasound (US) documented a free-floating, hyperechoic linear artifact within the posterior knee joint capsule. Revision with liner of increased thickness alleviated presenting symptoms. Conclusion: Tibial postfractures often present with instability and pain. Diagnosis of a tibial postfracture can be based on clinical examination; other diagnostics commonly used include arthroscopy or computed tomography/magnetic resonance imaging. US by a qualified sonographer is a potential diagnostic route that should be explored more rigorously.

Background: Obesity is associated with increased complications after total joint arthroplasty (TJA), leading some surgeons to recommend nutrition counseling and weight loss. We aim to evaluate the effect of preoperative nutritionist referral on weight loss and likelihood of surgery in obese patients seeking primary TJA.Methods: A retrospective cohort of patients seeking primary TJA who were referred to a licensed nutritionist for weight loss was matched by age, sex, and body mass index (BMI) to an unreferred control group. BMI change was compared between groups up to 1 year of follow-up. Differences were determined using 2-tailed t-tests and chi-squared tests with a significance cutoff of P < .05.Results: A total of 274 referred patients and 174 controls were included in our analysis. Patients who were referred to a nutritionist achieved significantly greater average BMI change (-1.5 kg/m(2)) than controls (-0.8 kg/m(2)) by 6 months after first contact (P = .01) although significance was lost at 1 year after first contact (P = .21). Thirty-eight percent of referred patients went on to TJA compared with 28% of controls (P < .01).Conclusions: Referral to a licensed nutritionist modestly improves early weight loss and is associated with a higher rate of surgery in obese patients seeking primary TJA.

Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720–726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically. Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices. Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths. Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

Arthritis Care & ResearchVolume 72, Issue S10 p. 219-249 Special ArticleOpen Access Measures of Adult Knee Function Michael McHugh, Michael McHugh University of Michigan, Ann ArborSearch for more papers by this authorErin Droy, Erin Droy University of Michigan, Ann ArborSearch for more papers by this authorStefano Muscatelli, Stefano Muscatelli University of Michigan, Ann ArborSearch for more papers by this authorJoel J. Gagnier, Corresponding Author Joel J. Gagnier jgagnier@med.umich.edu orcid.org/0000-0002-3162-3935 University of Michigan, Ann ArborAddress correspondence to: Joel J. Gagnier, ND, MSc, PhD, MedSport, Domino's Farms, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48105. E-mail: jgagnier@med.umich.edu.Search for more papers by this author Michael McHugh, Michael McHugh University of Michigan, Ann ArborSearch for more papers by this authorErin Droy, Erin Droy University of Michigan, Ann ArborSearch for more papers by this authorStefano Muscatelli, Stefano Muscatelli University of Michigan, Ann ArborSearch for more papers by this authorJoel J. Gagnier, Corresponding Author Joel J. Gagnier jgagnier@med.umich.edu orcid.org/0000-0002-3162-3935 University of Michigan, Ann ArborAddress correspondence to: Joel J. Gagnier, ND, MSc, PhD, MedSport, Domino's Farms, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48105. E-mail: jgagnier@med.umich.edu.Search for more papers by this author First published: 22 October 2020 https://doi.org/10.1002/acr.24235Citations: 3 No potential conflicts of interest relevant to this article were reported. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Introduction Patient-reported outcome measures (PROMs) are important to fulfill both clinical and research purposes with regard to assessing knee function in patients with a variety of knee conditions associated with injury, osteoarthritis, or rheumatological disorders. For inclusion in this review, measures of knee function were required to be pertinent to rheumatology, orthopedics, and sports medicine specialties. We identified measures published with scientific analysis and included dimensions that were most important to patients, including pain, quality of life (QOL), and activity level. A 2011 review of nine tools was published and focused on many of these issues as they related to rheumatology and orthopedic surgery. Based on the aforementioned criterion and the goals of this review, we used the same nine measures developed specifically for patient-reported knee function and perceptions: the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the KOOS Physical Function Short Form (KOOS-PS), the Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), the Lysholm Knee Scoring Scale (LKS), the Oxford Knee Score (OKS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Activity Rating Scale (ARS), and the Tegner Activity Score (TAS). This updated review was conducted by doing a thorough search of new publications for each measure between January 1, 2010, and March 1, 2020. We also included the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) measure based on its rising popularity and the amount of research dedicated for its use in a variety of knee conditions. A basic summary of the properties of the different measures is displayed in Table 1. Psychometric data pertaining to the floor and ceiling effects, validity, reliability, responsiveness, and minimum clinically important difference (MCID) of each patient-reported outcome are displayed in Table 2. Floor and ceiling effects were considered to be absent if no participants scored the bottom or top score, respectively, and to be acceptable if less than 15% of the cohort scored the bottom or top score, respectively. Validity was measured by assessing content, face, and construct validity. Content validity was present if patients were involved in development. Face validity was present if expert reviewers made a similar assessment and considered the measured items adequate. Construct validity was considered adequate if expected correlations were found with existing measures that assess similar (convergent construct validity) and dissimilar (divergent construct validity) constructs. Internal consistency was considered adequate if Cronbach's α was at least 0.7 1, and test-retest (intrarater) reliability was adequate if the intraclass correlation coefficient was at least 0.8 for groups and 0.9 for individuals. Responsiveness was determined with a measure of ability to detect change over a period of time or intervention. MCID is the amount of change in a patient-reported outcome that represents a meaningful change to the patient. Table 1. Practical applications* Measure Number of Items Content/Domains Method of Administration Recall Period Response Format Range of Scores Score Interpretation Availability of Normative Data Cross-Cultural Validation KOOS 42 Five domains: pain, symptoms, ADLs, recreation, and QOL Patient-completed questionnaire Previous week for all domains except QOL (no specification) Five-point Likert scale (0-4) 0-100 0 = worse; 100 = no problems Population-based normative data available Chinese, Greek, Icelandic, Spanish, Dutch, French, Saudi Arabic, Japanese, Persian, Portuguese, Russian, English, Thai, and Turkish KOOS-PS 7 Single domain Patient-completed questionnaire Previous week Five-point Likert scale (0-4) 0-28 28 = no problems Population-based normative data available Specific adaptations are found in French, Portuguese, and Turkish, although the KOOS has been validated as a whole in more. IKDC Subjective Knee Evaluation 18 Three domains: symptoms, sports and ADLs, and knee function Patient-completed questionnaire Not specified for some; 4 weeks for some questions; and function before and after surgery Yes/no, Likert five-point scale, and 11-point scale 0-100 100 = no limitation Available from the general US population Arabic, Portuguese, Chinese, Danish, Dutch, German, Greek, Italian, Korean, Romanian, Thai, and Turkish LKS 8 Categories of limping, support, locking, instability, pain, swelling, stair climbing, and squatting Patient-completed questionnaire Not specified Individual items are scored differently using individual scoring scales. Each item has been assigned an arbitrary score on an increasing scale. The total score is the sum of each response, of a possible score of 100. Possible score range: 0-100 (100 = no symptoms or disability) Normative data are available with and without stratification by sex. Arabic, Chinese, Dutch, Italian, German, Turkish, and Spanish TAS 11 Graduated list of ADLs, recreation, and competitive sports that describes their current level of activity Patient-completed questionnaire Current ability One item is selected from a list of 11 items. 0-10 Possible score range: 0-10 (higher scores represent participation in higher-level activities) Normative data have been presented by sex and age group. Swedish, Dutch, German, Chinese, and Iranian ARS 4 Single index pertaining to frequency of athletic activities Patient-completed questionnaire 1 year Each item is followed by five responses for the frequency of each functional component within the past year 0-4 Possible score range: 0-16 (16 represents more frequent participation) Not available Swedish and Iranian OKS 12 Single index that can be separated into pain and function subscales Patient-completed questionnaire Previous 4 weeks Five-point Likert; 1 is best and 5 is worst 12-60 Higher scores reflect poor outcomes No Arabic, Chinese, Finnish, German, Japanese, Korean, Persian, Portuguese, Spanish, Swedish, Thai, and Turkish KOS-ADL 17 Single index; two sections pertaining to symptoms and functional limitations Patient-completed questionnaire 1-2 days Descriptive response translated to a numerical ordinal scale 0-100 Higher scores reflect fewer knee-related symptoms and functional limitations No Arabic, Chinese, French, German, Portuguese, Polish, Turkish, and Greek WOMAC 24 Three subscales: pain severity during various positions or movements, severity of joint stiffness, and difficulty performing functional activities Self-administered or interview-administered questionnaire; in person, over the telephone, or electronically via computer or mobile phone 48 hours Likert version: 0-4; VAS and numerical rating scale versions: 0-100 or 11-box scale Likert format: 0-20 for pain, 0-8 for stiffness, and 0-68 for physical function; VAS format: 0-500 for pain, 0-200 for stiffness, and 0-1700 for physical function Higher scores indicate worse pain, stiffness, or physical function Yes, for Australian population stratified by age and sex Arabic, Bangladesh, Chinese, Finnish, German, Greek, Hebrew, Italian, Japanese, Korean, Moroccan, Nepali, Persian, Portuguese, Singapore, Spanish, Swedish, Thai, and Turkish PROMIS-PF 10 Five questions on limitation of activities and five questions on difficulty of ADLs Patient-completed questionnaire; paper format and computer-adaptive testing options No specific recall period Likert scoring (1-5) Raw score ranges 10-50. Scaled score 13.5 to 61.9. 50 or 61.9 representing optimal function; T-score rescales the raw score into a standardized score with a mean of 50 and an SD of 10 Yes English, Spanish, Danish, Dutch, French, German, Hungarian, Italian, Polish, Russian, Chinese, and Ukrainian * ADL = activity of daily living; ARS = Activity Rating Scale; IKDC = International Knee Documentation Committee; KOOS = Knee Injury and Osteoarthritis Outcome Score; KOOS-PS = KOOS Physical Function Short Form; KOS-ADL = Knee Outcome Survey Activities of Daily Living Scale; LKS = Lysholm Knee Scoring Scale; OKS = Oxford Knee Score; PROMIS-PF = Patient-Reported Outcomes Measurement Information System; QOL = quality of life; TAS = Tegner Activity Score; VAS = visual analog scale; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index. Table 2. Psychometrics* Measure Floor and Ceiling Effects Reliability Validity Responsiveness MCIDs Generalizability Used in RCTs KOOS Little or no floor or ceiling effects for knee injury or moderate OA; floor effects for severe OA; ceiling effects following TKA Adequate internal consistency; adequate test-retest reliability Good content and face validity; superior convergent and divergent construct validity Very responsive to change for OA; limited research for other injuries MCID and moderate improvement is 8.0 and 15.6 for QOL May be useful for a variety of conditions and populations, but its intent was OA-focused, and results may be less than optimum in other conditions. Recreational subscale may not be appropriate for some groups Yes KOOS-PS None found in one study of knee OA Adequate internal consistency; adequate test-retest reliability in mild to moderate OA; may be less adequate for severe OA Good content and face validity are assumed because items were taken from the KOOS. Has convergent and divergent construct validity; good correlation with physical domains of other measures Moderate to large effect sizes Only one study showed the MCID for nonoperated OA to be 12 Use was intended for knee OA, and studies largely focus on this without many studies on other conditions Yes IKDC Subjective Knee Evaluation None Superior reliability compared with other measurements; adequate internal consistency and adequate test-retest reliability for knee injuries and some mixed pathologies No patient contribution weakens content validity. Good face validity; high convergent and divergent construct validity Adequate response to change, particularly in injuries as well as the pediatric population Has been shown to be anywhere from 8.8 to 15.6 Generalizable to most populations, including pediatric populations; strongest psychometric properties in injury-related conditions Yes LKS Little to no floor or ceiling effects Test-retest reliability is adequate for use in groups with knee injuries but is less than adequate for groups with mixed knee pathologies. Reliability may be inadequate for use in individuals The Lysholm scale has been reported as having face validity, but content validity from the patient's perspective cannot be assumed. Two studies have reported evidence of convergent and divergent construct validity When comparing responsiveness following autologous chondrocyte implantation, the Lysholm and IKDC were the most sensitive to detecting changes when compared with MCKRS, KOOS, and SF-36 The MCID has not been calculated in any patient population Generalizability has not been reported Yes TAS Information on missing data and floor/ceiling effects is not available Adequate test-retest reliability for groups with knee injuries and knee OA, although reliability is less than adequate for use in individuals Content validity cannot be assumed, but evidence for convergent and divergent construct validity has been provided Has not been reported The MCID has not been determined The TAS was found to be reliable in both adult and pediatric population Yes ARS Studies consistently report no floor or ceiling effects in those with knee injury or OA. One study has evaluated the test-retest reliability, finding adequate reliability for use in groups and individuals. It is also reliable in patients 14-18 years old. Face, construct, and content validity have been demonstrated Has not been reported MCID has not been reported The ARS was found to be reliable in both adult and pediatric population ages 14-18. No OKS None prior to TKR; ceiling effect increases postoperatively; controversial postoperative floor effect Adequate internal consistency; adequate test-retest reliability Has content validity and internal and external validity postoperatively; correlates well with other knee-specific and general health questionnaires Good sensitivity and responsiveness to change; large ES postoperatively; predicts revision TKR and range of motion after TKR MDC90 and MIC after TKR: 4.15 and 9.22; nonoperated knee OA MIC: total 7.1, pain 17.3, and function 10.6 Useful in OA before and after TKR; likely applicable to multiple knee conditions No KOS-ADL No floor effects; ceiling effects present after TKR Adequate internal consistency and test-retest reliability Good face validity; may lack content validity; correlates well with other knee-specific scales; has convergent and divergent construct validity Good responsiveness for a variety of knee pathologies in various stages of treatment but may decrease over time MCID after PT for knee OA: 2.2 at 2 mo and 5 at 12 mo Useful for a variety of knee pathologies No WOMAC Floor and ceiling effects exist for the stiffness subscale pre- and postoperatively, and ceiling effects exist postoperatively for all subscales. Stiffness and function subscales have adequate internal consistency; may lower than adequate for pain subscale; mixed findings for test-retest reliability for all subscales. Has face and content validity; good construct validity because of strong correlations with other measures; has convergent and divergent validity High responsiveness in knee OA and chondral defects postoperatively; large ES for all subscales postoperatively, smaller ES for nonoperative management for knee OA and chondral defects MCID after TKR: pain 22.9-36, symptoms 14.4-21.4, and function 19-33 Useful in OA and TKR; likely applicable to multiple knee conditions Yes PROMIS -PF None for meniscal injuries, patellofemoral malalignment, multiligamentous injuries, and chondral disease; ceiling effects are noted in ACL injuries but below 15% cutoff. Few studies have demonstrated reliability, although one showed high reliability in RA. Unidimensional with high content and construct validity and adequate face validity PROMIS assessments collectively have been shown to be responsive. PROMIS-PF is comparable with KOOS, SF-36 in ACLs and has high responsiveness in OA. MCID has not been fully determined for knee-specific conditions. One study showed 2.45-21.55 in orthopedic patients with OA Can be used among a variety of conditions, but measure is not specific to the knee, and further psychometric analysis is necessary. Yes * ACL = anterior cruciate ligament; ARS = Activity Rating Scale; ES = effect size; IKDC = International Knee Documentation Committee; KOOS = Knee Injury and Osteoarthritis Outcome Score; KOOS-PS = KOOS Physical Function Short Form; KOS-ADL = Knee Outcome Survey Activities of Daily Living Scale; LKS = Lysholm Knee Scoring Scale; MDC90 = minimum detectable change with a 90% confidence interval; MCID = minimum clinically important difference; MIC = minimal important change; OA = osteoarthritis; OKS = Oxford Knee Score; PROMIS = Patient-Reported Outcomes Measurement Information System; PROMIS-PF = PROMIS Physical Function; PT = physical therapy; RCT = randomized controlled trial; SF-36 = Short Form 36; TAS = Tegner Activity Score; TKA = total knee arthroplasty; TKR = total knee replacement; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index. Since 2011, there have been numerous studies evaluating the psychometric properties of the above measures. There has also been ample research assessing the utility and psychometric properties of the PROMIS-PF function. Extensive work has been performed to add available translations and culturally adapted versions of the above measures. Our review summarizes the available information about how these measures perform for different patient populations in different settings. INTERNATIONAL KNEE DOCUMENTATION COMMITTEE SUBJECTIVE KNEE EVALUATION FORM Description Purpose The IKDC detects improvement or deterioration in symptoms, function, and sports activities due to knee impairment caused by a variety of knee conditions, including ligament injuries, meniscal injuries, articular cartilage lesions, and patellofemoral pain 2. Version The IKDC was formed in 1987 to develop a standardized international documentation system for knee conditions. The IKDC Standard Knee Evaluation Form, which was designed for knee ligament injuries, was subsequently published in 1993 3 and revised in 1994 4. The IKDC Subjective Knee Evaluation Form was developed as a revision of the Standard Knee Evaluation Form in 1997. It has undergone subsequent minor revisions since its publication in 2001. Content The IKDC Subjective Knee Evaluation Form contains the following three domains: 1) symptoms, including pain, stiffness, swelling, locking/catching, and giving way; 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury (not included in the total score) 2. Number of items The IKDC Subjective Knee Evaluation Form consists of 18 items (7 items for symptoms, 1 item for sport participation, 9 items for daily activities, and 1 item for current knee function). Response options/scale Response options vary for each item. Item 6 dichotomizes response into yes/no; items 1, 4, 5, 7, 8, and 9 use five-point Likert scales; and items 2, 3, and 10 use 11-point numerical rating scales. Recall period for items The recall period is not specified for items 1, 3, 5, 7, 8, and 9; it is 4 weeks for items 2, 4, and 6. Item 10a refers to function prior to knee injury, and item 10b refers to current function. Cost to use Free to use. Cost of administration and information storage was not assessed and varies for each practice. How to obtain See https://www.sport​smed.org/aossm​imis/Stagi​ng/Resea​rch/IKDC_Forms.aspx. Practical application Method of administration The IKDC Subjective Knee Evaluation Form is a patient-completed questionnaire. The form has not been validated for administration by interview, either in person or via telephone. Scoring The response to each item is scored using an ordinal method (ie, 0 for responses that represent the highest level of symptoms or lowest level of function). The most recent version has assigned scores for each possible response printed on the questionnaire. Scores for each item, excluding item 10a, are summed to give a total score. The total score is calculated as the sum of items divided by the maximum possible score multiplied by 100, to give a total score out of 100. An online scoring sheet is available (www.sport​smed.org/tabs/research/ikdc.aspx) that provides a patient's raw score and percentile score (relative to age- and sex-based norms). The item regarding knee function prior to knee injury is not included in the total score. The revised scoring method states that in cases in which patients have up to two missing values (ie, responses have been provided for at least 16 items), the total score is calculated as the sum of completed items divided by the maximum possible sum of completed items multiplied by 100. Score interpretation Possible scores range from 0 to 100, in which 100 = no limitation with daily or sporting activities and the absence of symptoms. Normative data are available from the general US population stratified for age, sex, and current/prior knee problems 5. Respondent burden The IKDC Subjective Knee Evaluation Form takes 10 minutes to complete 6. It uses simple language that is suitable for patients. Administrative burden The IKDC Subjective Knee Evaluation Form takes approximately 5 minutes to score. Training is not necessary. Manual scoring can be performed easily using the scoring instructions supplied with the questionnaire. Translations/adaptations The form is available in English, Arabic, Brazilian Portuguese, traditional Chinese (Taiwan and Hong Kong), simplified Chinese (China and Singapore), Czech, Dutch, French, German, Greek, Italian, Japanese, Korean, Norwegian, Polish, Spanish, Swedish, Thai, and Turkish. Cross-cultural adaptations have been conducted for the Arabic 7, Brazilian 8, Chinese 9-11, Danish 12, Dutch 13, German 14, Greek 15, Italian 6, Korean 16, Romanian 17, Thai 18, and Turkish 19 translations. Psychometric information Method of development The initial set of items was developed by the IKDC by considering questions from the Standard Knee Evaluation Form, the Musculoskeletal Outcomes Data Evaluation and Management Systems Lower Limb Instrument, and the Activities of Daily Living (ADLs) and Sports Activity Scales of the Knee Outcome Survey. Pilot testing of the initial version (n = 144) resulted in revision or deletion of existing items and the addition of new items. Testing of the second version (n = 222) resulted in further revisions and deletions (based on missing data), producing a final version. Item-response theory was used to create the scoring system. Patients were not involved in development; rather, the items were selected by the IKDC, a committee of international orthopedic surgeons 2. Following development, validation, and implementation of the IKDC Subjective Knee Evaluation Form, a pediatric form was developed (the Pedi-IKDC), which has been tested for psychometric properties and normative data as well as electronic use 20-22. Floor and ceiling effects Studies consistently report no floor or ceiling effects (ie, no participants scored the lowest or highest score) 2, 6, 8, 13, 15, 23, 24. Reliability Internal consistency is adequate for patients with knee injuries and mixed knee pathologies (Table 1). Test-retest reliability is adequate for groups of patients with knee injuries and mixed pathologies and individuals with knee injuries. It has also been shown to be adequate in pediatric populations 20. The test-retest reliability is slightly below adequate for individuals who fall into a broader category of knee pathologies. However, studies have shown superior reliability over other measurement forms. The Chinese IKDC has better reliability than the Chinese KOOS 25. The Dutch IKDC had better reliability than the WOMAC and KOOS for meniscal injury 26. Validity Face and content validity The domains covered by the IKDC Subjective Knee Evaluation Form appear to represent elements that are likely to be important to patients. However, the lack of patient contribution to the selection and revision of items in the IKDC Subjective Knee Evaluation Form means that content validity cannot necessarily be assumed. Construct validity There are consistent reports of high convergent and divergent construct validity, with the IKDC Subjective Knee Evaluation Form more strongly correlated with the Short Form 36 (SF-36) physical subscales and component summary than with the mental subscales and component summary 2, 8, 11, 13, 23, 24, 27. Construct validity is acceptable in the pediatric form 20 and improved over the KOOS-Child form 28. Studies have shown the IKDC Subjective Knee Evaluation Form score to be highly correlated with the Cincinnati Knee Rating System, pain visual analog scale (VAS), Oxford 12 Questionnaire, WOMAC, Lysholm score, and SF-36 physical component, physical function, and bodily pain subscales 8, 13, 29. Responsiveness The IKDC Subjective Knee Evaluation Form has been shown to be adequately responsive 24. In a study comparing responsiveness of the IKDC Subjective Knee Evaluation Form with that of the KOOS for anterior cruciate ligament (ACL) injuries, the IKDC Subjective Knee Evaluation Form was found to be adequately responsive, but the KOOS was not 30. The same finding was found in a Chinese study comparing the IKDC Subjective Knee Evaluation Form with the KOOS 25. Further testing has specifically shown its adequate responsiveness for meniscal injury 31. The Pedi-IKDC has also been shown to have acceptable responsiveness 20. When directly compared with the KOOS-Child, it has superior responsiveness 28. Minimally important differences The minimal detectable change has been reported to be between 8.8 and 15.6, and the SEM has been reported to be between 3.2 and 5.6. Few studies have shown the minimal important changes (MICs). One study shows the MIC to be 10.9 for meniscal injuries 31. Another study showed it to be 9.8 in the Chinese population 25, and another showed 12.0 for pediatric populations 12. The MCID has been reported to be 6.3 at 6 months and 16.7 at 12 months following cartilage repair 32 and 11.5 to 20.5 (range 6-28 months) in those who have undergone various surgical procedures for mixed (various) knee pathologies 33. The patient-acceptable symptom state (PASS) has not been determined. Critical appraisal of overall value to the rheumatology community Strengths At face value, the domains covered by the IKDC Subjective Knee Evaluation Form appear to represent elements that are likely to be important to patients. It shows adequate internal consistency and has no floor or ceiling effects across mixed groups of patients with knee conditions. The IKDC Subjective Knee Evaluation Form has been shown to be responsive to change following surgical interventions, highlighting its usefulness in this patient population. It has particularly been shown to be a stronger measure for ACL injuries and meniscal injuries. It has also been shown to be a strong measure in the pediatric population. Caveats and cautions Despite demonstrating face validity, the lack of patient contribution to item selection indicates that content validity cannot necessarily be assumed and has not been thoroughly investigated. The relatively long recall period associated with three of the items may be a problem for some patients. The use of one aggregate score to represent symptoms, activities, and function may mask deficits in one domain. Psychometric testing is lacking for patients with knee osteoarthritis as an isolated group, as is responsiveness following nonsurgical management, highlighting areas for future studies. Clinical usability The IKDC Subjective Knee Evaluation Form involves minimal administrative and respondent burden and can be easily scored in the clinic using the online scoring sheet. However, clinicians using the online scoring system need to keep in mind that the normative data provided are from a particular population and may not be representative of their individual patient's population. Research usability Psychometric evaluation supports the use of the IKDC Subjective Knee Evaluation Form in research for a variety of knee conditions. Because some versions of the measure published online contain subtle differences in the wording of instructions and items, researchers should ensure that they utilize the version published as a component of the 2000 IKDC Knee Forms to ensure that findings of psychometric properties still apply and that comparisons can be made with previous studies. Administrative and respondent burden would not limit research use, although researchers should be diligent in checking for missing data. KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE Description Purpose To measure the opinions of young, middle-aged, and elderly patients with posttraumatic osteoarthritis (OA) and other injuries leading to OA, regarding their knees and associated problems over short- and long-term follow-up 34. Examples of conditions include knee ligament injury (ACL, posterior cruciate ligament [PCL], or medial collateral ligament [MCL]), meniscal tears, knee cartilage lesio

BACKGROUND:We conducted a meta-analysis of randomized trials to determine the effect of the use of an orthosis (as compared with no orthosis) on clinical and radiographic outcomes in neurologically intact patients with thoracolumbar burst fractures. Optimal nonoperative treatment of thoracolumbar burst fractures in neurologically intact patients remains inconclusive. Conventional care prescribes spine precautions and a thoracolumbar orthosis. Recent studies have suggested that patients with stable burst fractures can obtain comparable outcomes with or without bracing. METHODS:We performed a comprehensive search of the literature with use of OVID MEDLINE, Embase, and the Cochrane Library. Two independent reviewers assessed the eligibility of studies and the risk of bias of included trials. We analyzed several outcomes: the Roland Morris Disability Questionnaire (RMDQ) score, Oswestry Disability Index (ODI), Short Form-36 Physical and Mental Component Summary (SF-36 PCS and MCS) scores, pain, length of stay, treatment failure, and kyphotic angle. We used weighted mean differences and standardized mean differences in a random-effects model. RESULTS:We included 3 studies with a total of 59 patients who were managed with use of a brace and 60 patients who were managed without a brace. There was no significant difference between groups treated with or without an orthosis in terms of SF-36 PCS, SF-36 MCS, RMDQ/ODI, pain, length of stay, failure rates, or kyphosis angle at baseline or 6-month follow-up. Similar outcomes were seen at long-term follow-up of ≥5 years. CONCLUSIONS:This meta-analysis suggests that neurologically intact patients with thoracolumbar burst fractures obtain similar clinical and radiographic outcomes with or without bracing at both short and long-term follow-up. Routine use of orthoses following these fractures may incur substantial costs and patient morbidity without clinical benefit. LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.