Currently, the new challenge of knee surgery appears to be the accurate assessment parallel to the development of new techniques.
The obligation of means and results becomes a daily reality.
We now seems inevitable to better understand the effectiveness of our treatment methods.
otherwise, given the wide variety of techniques described in terms, for example, graft anterior cruciate ligament (LCA), which to choose to ensure the best result ?
Certainly, it is a choice depending schools, personal experiences.
However, by observing the number of publications in the literature on this disease, we realize that there is no unity in the evaluation in France, moreover internationally.
The work of each team could not be compared objectively.
Or, the progress of surgery necessarily involves a stricter assessment.
So, was born the desire to unite the international orthopedic community and propose a common evaluation means for the sport in the field of surgery knee, la fiche International Knee Documentation Committee (IKDC).
Evaluation of knee surgery in the last century :
Throughout the century have been developed very diverse surgical techniques, as well as original postoperative care (immobilization systems, rehabilitation methods, etc).
Sixty-five ACL reconstruction methods were counted in 1983.
How to compare these methods without tools or parameter to assess ?
For a very long time, Surgeons have studied the issue and proposed evaluation systems : clinique, objective, subjective, radiographic.
These same surgeons, then become evaluators, were faced with a new problem : comparison of assessment methods.
Indeed, the diversity of schools and surgical techniques naturally leads to a variety of evaluation forms.
Fiquet analyzed 17 sheets commonly used in the world 1989 in major orthopedic services.
There are obviously many more.
Some authors have proposed to establish ways of correspondence between all these cards.
Some are imprecise, too severe, suited to one country but not generalizable ...
The correspondence evaluation scores seem a utopia.
The solution seems to be the universal plug.
MEANS OF ASSESSMENT :
This was the start of a clinical study.
We appreciate ligament laxity using repeatable manual testing.
There are a number.
We quote the test Trillat-Lachmann, the Pivotshift, test Slocum, the "jerk-test" Hughtson ...
Then, the need to quantify laxity led us to study radiographically.
Radiographic dynamic tests have been developed and validated (The drawers). in parallel, appeared clinical measurement devices laxity as KT 1000.
The evaluation criteria were consistent with preoperative objective analysis, and postoperative, for patient monitoring.
However, we reported on a dissociation between objective and functional outcome laxity.
It lacked in assessing the symptoms necessary for a comprehensive analysis of the pathology.
Thus appeared the functional evaluation of the knee involving specific criteria in the form of sheets.
In 1955, O'Donoghue was the first author to introduce the concept of ability to return to sport, encrypted percentage.
This criterion is recognized as very important.
Marshall improved by offering four items :
- return to the same sport ;
- return to the same sport with limitations ;
- return to the sport at a different level ;
- can not return to sports.
We find the same pattern in the major forms of evaluation (arpeggio 1983, Noyes 1987).
Functional assessment then required the analysis of symptoms expressed by the patient.
These various points were encrypted to obtain an overall score (40 for Lerat, 100 for Larson, for example). Among all the cards, we recall the following.
In France, Lerat offers a listing in 1972, improved in the Arpège group 1978, modified 1985 for its current version (including CLAS rating scale).
In Scandinavia, Lysholm, in 1982, modifies the original Record Larson.
In North America, very many cards have emerged. We will retain the work of Noyes offering its comprehensive sheet "knee profile".
In each Orthopedic Society, a listing refers, as in the ISPA Israel group, OAK or in Switzerland.
Fiquet, in 1989, concluded his argument stating that no evaluation system seemed perfectly satisfactory and that it was trying to achieve a compromise between the largest number of surgeons to develop a common international profile.
A working group involving surgeons of the European Society for Knee Surgery and Arthroscopy (ESSKA) et de l’American Orthopaedic Society for Sport Medicine (AOSSM) a compound 1993 a scorecard named plug IKDC, improved 1999, whose current version is described below.
Record Analysis IKDC (version 1999) :
This sheet, introduced and published in 1993, magazine 1994, has been updated in 1999.
The objectives of this update were :
- to obtain a valuable tool not only for the pathology related to the ACL tear, but also to all aspects of sports pathology (including patellofemoral, posterior cruciate ligament [LCP] and meniscal), or degenerative knee ;
- introduce a subjective evaluation with a questionnaire translated into different languages ;
- clarify cartilage damage including the criteria defined by the International Cartilage Repair Society (ICRS).
This record is the result of joint work carried out by surgeons from countries and European orthopedics companies, American and Asian (l'ESSKA 2000 and AOSSM and WPAOSM [Western Pacific and Asian Orthopaedic Sports Medicine]).
It reflects the desire to now assess the knee in the same way around the world.
Only a single international card allows a true comparison of surgical techniques and ways to support global different schools.
This sheet or rating form is presented as a small notebook containing six distinct parts.
A – FIRST PART : PATIENT IDENTIFICATION AND THE DEMOGRAPHICS COMPATIBLE MODEMS
It is optional.
This chapter includes the usually required details, pathologies and patient's general medical history, the concept of consumption alcoolotabagique, le morphotype, ethnic origin, occupation and education level, Finally, the level of activity.
About that, there are four subgroups : practice or not sports, sometimes, frequently or at a high level.
The first sporting rating scale by level does not include the type of sport, its constraints, its intensity.
B – SECOND PART : STATE HEALTH ASSESSMENT OF CURRENT
This analysis takes into account 11 items related to the patient's health status.
This is a questionnaire which provides us with a patient's subjective impression of his own fitness and mental. This must be assessed in relation to last year, in various situations of daily and professional life.
It asks the patient about the degree of discomfort felt, changes in activities related to its overall health.
C – THIRD PART : SUBJECTIVE KNEE EVALUATION
Having studied subjectively the patient's overall health status, We are particularly interested in the condition of his knee.
This is still a subjective evaluation using a questionnaire analyzing three criteria : symptoms, sports activities and functioning of the knee.
This questionnaire is completed by the patient himself.
It can even be completed without the help of the medical team.
It can be mailed (conventional or electronic).
1- sYMPTOMS :
We have seven items that assess three criteria that we find in the various pre sheets : pain, swelling, stability, and a criterion already used by Lysholm, the blocking.
* Pain :
Three items are devoted to him.
- The first item concerns the level of activity (in general, in everyday life and sports), Maximum without suffering knee.
Which of the following five levels decreasing activity, what is the most important level of activity that you can practice without suffering your knee ?
- intense activities involving jumping or pivoting as in basketball and football.
- intense activities like heavy physical work, skiing or tennis.
- Moderate activities like moderate physical work, running or jogging.
- gentle activities like walking, household or gardening.
- None of the above activities is possible for me because of my knee.
This evaluation method provides a defined symptom that holds the item as precisely not causing the symptom in question.
When the patient does not practice the maximum level (for example, if the patient has a sedentary level and does not complain of any pain), it can be evaluated as if he could perform very strenuous activities, painless.
One point must be emphasized.
The authors developed a scale of decreasing activity levels, for their intensity, giving for each level of specific examples to enlighten us.
Evaluation is thus achieved both for everyday life, but also for the professional and sporting life.
- The second item relates to the frequency of occurrence of knee pain in the last month.
We are deviating painful background, simple discomfort and turn our attention to the pain that marked the patient.
In case of permanent pain, he checks the box "constantly".
- The third item search intensity of pain on an increasing scale arbitrary assessment 0 at 10.
* Swelling :
Two items are devoted to him.
- The first item concerns the quality of swelling or assimilated knee stiffness.
Five proposals are possible.
This assessment must be representative of 4 recent weeks.
- The second item concerns the level of maximum possible without the appearance of swelling activity.
We find the same rating scale for pain and remember the same advice as to the proper understanding of the issue.
Many items using visual analogue scales that allow simple evaluation, fast and reliable (Flandry).
* blocking :
During 4 recent weeks, if not for the accident or injury, the knee is it or not blocked ?
Blocking word does not have the same diagnostic value for the physician and patient, it covers all aspects of the lock (the patellar attachment to the true patellar blocking).
This item is important.
It evokes a meniscal pathology or patellar.
* Stability :
It is studied using the same rating scale activities.
The selected symptom is stability and its corollary, the dérobement.
The authors do not distinguish here the partial or total dérobement.
It seeks the maximum level of activity without the appearance of the symptom "giving way".
2- Sporting activities :
This is the second subjective evaluation criteria.
Two items are devoted to him.
- The first item is seeking the highest level of patient activity on a scale evaluation of activities already mentioned when analyzing symptoms (five levels).
In this context, about sport in general, the patient informs us of its highest practical level it regularly.
- The second item is a questionnaire with nine specific activities including assessing the difficulties to practice.
The evaluation is done subjectively according to five definitions, of "not difficult" to "impossible".
3- Knee Operation :
This is for the patient to rate on a scale from 0 at 10, corresponding to the performance value of the knee.
Two evaluations over time are needed to express the notion of gain (improvement) or loss of function.
The first evaluation is intended reference, that is to say before the injury or accident.
The second corresponds to the current state of his knee, So the performance reached knee.
4- final expression of subjective evaluation sheet knee :
An instruction sheet for calculating subjective evaluation score is associated with the card itself.
* the final score calculation steps :
Each item of the three groups – symptoms, sports and knee function is evaluated, then encrypted.
We take the principle of giving the lowest in the lowest activity score (which equals the most pronounced symptom) and, Conversely, the highest score in the best activity (thus corresponding to the most discreet symptomatology).
Each item has a corresponding score.
Then you take the sum of scores for total gross, then apply the following formula to obtain the final score IKDC evaluated on a scale of 0 at 100.
Score final IKDC = (total brut – Lowest score) X 100 / Number of scores of possibilities
Knowing that, by definition, the lowest score is equal to 18, the number of possible scores is equal to 87 (105-18 = 87).
On the scale of 0 at 100, the score 0 corresponds to the lowest level of activity linked to a more pronounced symptomatology.
At the opposite, the score 100 corresponds to the level of peak activity without limitation and without symptoms.
It exists 18 items in this evaluation.
The score can be calculated if he misses more than two answers.
To do this, both average values of the missing items are added 16 Other scores for total gross and deduce the final score IKDC in the same way as above.
D – PART FOUR OR PATIENT HISTORY :
This sheet allows you to recognize all dated and analyzed events occurring on this knee.
It takes the coordinates of the patient.
It provides information on the date of onset of symptoms with the exact reason for the consultation..
She gives the date of the first knee exam to find out the interval ; remembering the natural history of LCA.
The state of the contralateral knee is essential to know the terrain (hyperlaxité, constitutional recurvatum…), bilateral laxity then preventing clinical or radiological comparative analysis of the knees.
The authors distinguish four types of circumstances of occurrence of an accident : during daily activities, sports, professional or in an accident on the public highway and four types of mechanisms : without trauma, progressive onset ; without trauma, secondary onset ; with no impact trauma (without shock) ; with trauma and impact (choc).
An important part of this sheet is to accurately and in detail list the history concerning the knee studied.
It is a question of finding the recognized pathology and the possible treatments proposed.
On distingue :
- meniscal history with or without suture or transplant ;
- history of ligament surgery, whether it's two ligaments, lateral ligaments, their repair, the associated external plasties as well as any peripheral gestures (repair of the posteroexternal angle point [PAPE]) ; it's about knowing the nature of the (or some) graft(s) ;
- femoropatellar history, that the authors divide into :
- alignment surgery of the extensor apparatus in case of patellar instability, whether it is an Insall type plasty, of section of the external fin or of bony gestures with type of transposition of the anterior tibial tuberosity ;
- femoropatellar bone gestures (trochoplasty, patellectomie) ;
- osteoarthritis surgery.
It's about knowing the cartilage condition of the knee, any interventions already proposed :
- Tibial ostéotomie de frontal correction ;
- cartilage surgery with all modern techniques such as cell therapy, osteochondral autografts type Mosaïcplasty, as well as Pridie type drilling, abrasions et microfractures.
Finally, this sheet provides information on the imagery data, but by so-called open or clear answers.
Nature and results of the additional assessment are the latest data from the knee history file.
E – PART FIVE OR SURGICAL DOCUMENTATION :
This is to give an objective description of the knee during the surgery.
We get the (where the) diagnostic(s) and a particularly detailed balance sheet for each compartment and element of the articulation.
This description reproduces the recommendations of the ICRS and is likely to evolve in the coming months.
The analysis focuses on three criteria.
1- Cartilaginous status :
It is a matter of plotting on diagrams representing different articular surfaces of the knee the exact affected zones observed during intraoperative.
The femoral trochlea is analyzed from the front and from the side in order to locate the affected area.
The patellar articular surface is observed on a plane, as well as the tibial surface.
Once the cartilaginous surfaces are located, it is a question of analyzing each lesion according to the size and the degree of the attack according to the Noyes cartilage scale (four degrees). We specify the size of the lesion before, then after a possible gesture (regularization type).
The diagnosis of cartilage damage and the proposed treatment are reported.
2- Status méniscal :
The sheet does not assess the type of lesion, but we deduce it from the proposed treatment and from the meniscal state at the end of the intervention.
The analysis considers the two menisci.
The quality of the menisci is established after surgery by evaluating the size of the ectomy performed in three-thirds, respect for circular peripheral fibers.
We assess the condition of the remaining meniscal tissue, especially its degenerative quality (meniscosis) and the important criterion of stability (crochet testing).
3- Ligament status :
It is a question of giving the characteristics of the surgical technique of ligament reconstruction.
The location of the tunnels is reported in profile and face for the tibia and the femur, using detailed diagrams.
We report the exact actions performed. LCA or LCP suture repair ; reconstruction of the internal lateral ligament (LINEN), lateral collateral ligament (LLE), LCA-LCP ; extra-articular plasty ; gesture on the POPE.
The nature of the transplant is specified (patellar tendon, two or four bundles of hamstring tendons, tendon quadricipital…).
We recall the nature of the graft in case of ligamentoplasty.
F – PART SIX OR KNEE CLINICAL EXAMINATION SHEET :
It comes in the form of a single front. Remember the patient's contact details.
The examination notes the existence of a ligament hyperlaxity (search for hyperextension of the metacarpophalangeal of the thumb, of the trapezometacarpal of the first column, a bilateral recurvatum as well as an elbow recurvatum).
On the contrary, we can diagnose an overall stiffness of the subject.
Other clinical criteria are necessary : le morphotype (cause of frontal imbalance and risk factor for osteoarthritis in case of laxity), the possible patellar position (centered ball joint, subluxed or luxated, which are static states, subluxable during dynamic examination).
All these criteria are not taken into account in the final evaluation of the clinical examination ; they are only useful for information.
The clinical evaluation is quantified using seven groups of physical clinical signs (exam), radiographic and testing.
Each group is analyzed separately in four levels : A, normal ; B, abnormal ; C, almost normal ; D, very abnormal.
When there are several criteria in the same group, each criterion is analyzed again separately ; the criterion with the lowest level gives the level to the whole group.
We thus obtain a separate evaluation of the different groups.
However, the final assessment is determined only by the first three groups.
The final level is given by the lowest level of the three groups raised.
The seven groups are: : outpouring, loss of passive mobility, ligament assessment, joint crackling, pathology of transplant sites, anomalies radio, functional test.
The clinical examination sheet is accompanied by an instruction sheet to fill it out correctly.
Each of the seven groups is detailed in order to specify exactly all the criteria.
The evolution and progress of knee ligament surgery now obliges us to equip ourselves with a planetary evaluation system, universal, understandable by all and yet precise.
Only an evaluation sheet common to all international orthopedic companies allows an objective comparison of techniques and results in knee surgery.
Dozens of files existed, but none was unanimous.
It took all the will of a group of mandated surgeons from continental orthopedic societies to finally reach a real consensus.
An evaluation system was born, the IKDC file, which gradually replaces all the previous ones.
This file refers to failing to achieve unanimity, thus allowing an overall analysis of the knee.
It is obviously not fixed and must evolve according to the critics collected and analyzed.
It looks like we are entering a new era of evaluation, at the International scale, which is probably essential in the years to come, for all of orthopedics.