IKDC DEMOGRAPHIC FORM

Transcription

1 IKDC DEMOGRAPHIC FORM Your Full Name Your Date of Birth / / Your Social Security Number - - Your Gender: Male Female Occupation Today s Date / / The following is a list of common health problems. Please indicate Yes or No in the first column, and then skip to the next item. If you do have the problem, please indicate in the second column if you receive medications or some other type of treatment for the problem. In the last column, indicate if the problem limits any of your activities. Do you have Do you receive Does it limit the problem? treatment for it? your activities? Yes No Yes No Yes No Heart disease High blood pressure Asthma or pulmonary disease Diabetes Ulcer or stomach disease Bowel disease Kidney disease Liver disease Anemia or other blood disease Overweight Cancer Depression Osteoarthritis, degenerative arthritis Rheumatoid arthritis Back pain Lyme disease Other medical problem Alcoholism

2 Page 2 - IKDC DEMOGRAPHIC FORM 1. Do you smoke cigarettes? Yes No, I quit in the last six months. No, I quit more than six months ago. No, I have never smoked. 2. Your height centimeters inches 3. Your weight kilograms pounds 4. Your race (indicate all that apply) White Black or African-American Hispanic Asian or Pacific Islander Native American Indian Other 5. How much school have you completed? Less than high school Graduated from high school Some college Graduated from college Postgraduate school or degree 6. Activity level Are you a high competitive sports person? Are you well-trained and frequently sporting? Sporting sometimes Non-sporting

3 2000 IKDC SUBJECTIVE KNEE EVALUATION FORM Your Full Name Today s Date: / / Date of Injury: / / SYMPTOMS*: *Grade symptoms at the highest activity level at which you think you could function without significant symptoms, even if you are not actually performing activities at this level. 1. What is the highest level of activity that you can perform without significant knee pain? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework or yard work Unable to perform any of the above activities due to knee pain 2. During the past 4 weeks, or since your injury, how often have you had pain? Never Constant 3. If you have pain, how severe is it? No pain Worst pain imaginable 4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee? Not at all Mildly Moderately Very Extremely 5. What is the highest level of activity you can perform without significant swelling in your knee? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework, or yard work Unable to perform any of the above activities due to knee swelling 6. During the past 4 weeks, or since your injury, did your knee lock or catch? Yes No 7. What is the highest level of activity you can perform without significant giving way in your knee? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework or yard work Unable to perform any of the above activities due to giving way of the knee

4 Page IKDC SUBJECTIVE KNEE EVALUATION FORM SPORTS ACTIVITIES: 8. What is the highest level of activity you can participate in on a regular basis? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework or yard work Unable to perform any of the above activities due to knee 9. How does your knee affect your ability to: 10. Not difficult at all Minimally difficult Moderately Difficult Extremely difficult Unable to do a. Go up stairs b. Go down stairs c. Kneel on the front of your knee d. Squat e. Sit with your knee bent f. Rise from a chair g. Run straight ahead h. Jump and land on your involved leg i. Stop and start quickly FUNCTION: 11. How would you rate the function of your knee on a scale of 0 to 10 with 10 being normal, excellent function and 0 being the inability to perform any of your usual daily activities which may include sports? FUNCTION PRIOR TO YOUR KNEE INJURY: Cannot perform No limitation daily activities in daily activities CURRENT FUNCTION OF YOUR KNEE: Cannot perform No limitation daily activities in daily activities

5 Scoring Instructions for the 2000 IKDC Subjective Knee Evaluation Form Several methods of scoring the IKDC Subjective Knee Evaluation Form were investigated. The results indicated that summing the scores for each item performed as well as more sophisticated scoring methods. The responses to each item are scored using an ordinal method such that a score of 1 is given to responses that represent the lowest level of function or highest level of symptoms. For example, item 1, which is related to the highest level of activity without significant pain is scored by assigning a score of 1 to the response Unable to Perform Any of the Above Activities Due to Knee and a score of 5 to the response Very strenuous activities like jumping or pivoting as in basketball or soccer. For item 2, which is related to the frequency of pain over the past 4 weeks, the response Constant is assigned a score of 1 and Never is assigned a score of 11. The IKDC Subjective Knee Evaluation Form is scored by summing the scores for the individual items and then transforming the score to a scale that ranges from 0 to 100. Note: The response to item 10 Function Prior to Knee Injury is not included in the overall score. The steps to score the IKDC Subjective Knee Evaluation Form are as follows: 1. Assign a score to the individual s response for each item, such that lowest score represents the lowest level of function or highest level of symptoms. 2. Calculate the raw score by summing the responses to all items with the exception of the response to item 10 Function Prior to Your Knee Injury 3. Transform the raw score to a 0 to 100 scale as follows: IKDC Raw Score - Lowest Possible Score Score = x100 Range of Scores Where the lowest possible score is 18 and the range of possible scores is 87. Thus, if the sum of scores for the 18 items is 60, the IKDC Score would be calculated as follows: IKDC Score = x IKDC Score = The transformed score is interpreted as a measure of function such that higher scores represent higher levels of function and lower levels of symptoms. A score of 100 is interpreted to mean no limitation with activities of daily living or sports activities and the absence of symptoms. The IKDC Subjective Knee Score can still be calculated if there are missing data, as long as there are responses to at least 90% of the items (i.e. responses have been provided for at least 16 items). To calculate the raw IKDC score when there are missing data, substitute the average score of the items that have been answered for the missing item score(s). Once the raw IKDC score has been calculated, it is transformed to the IKDC Subjective Knee Score as described above. 48.3

6 2000 IKDC KNEE HISTORY FORM Patient Name Birthdate / / Date of Injury / / Date of Initial Exam / / Today s Date / / Involved Knee: Right Left Contralateral: Normal Nearly Normal Abnormal Severely abnormal Onset of Symptoms: (date) / / Chief Complaint: Activity at Injury: ADL Sports Traffic Work Mechanism of Injury: Non-traumatic gradual onset Non-traumatic sudden onset Traumatic non-contact onset Traumatic contact onset Previous Surgery: Type of Surgery: (check all that apply) Meniscal Surgery Medial meniscectomy Medial meniscal repair Medial meniscal transplant Lateral meniscectomy Lateral meniscal repair Lateral meniscal transplant Ligament Surgery Type of Graft ACL Repair Intraarticular ACL reconstruction Extraarticular ACL reconstruction PCL Repair Intraarticular PCL reconstruction Posterolateral corner reconstruction Medial collateral ligament repair/reconstruction Lateral collateral ligament repair/reconstruction Patella tendon graft Ipsilateral Contralateral Single hamstring graft 2 Bundle hamstring graft 4 Bundle hamstring graft Quadriceps tendon graft Allograft Other

7 Page IKDC KNEE HISTORY FORM Extensor Mechanism Surgery Patella tendon repair Quadriceps tendon repair Patellofemoral Surgery Osteoarthritis Surgery Extensor Mechanism Realignment Soft Tissue Realignment Medial imbrication Lateral release Bone Realignment Movement of the tibial tubercle Proximal Distal Medial Lateral Anterior Trochleoplasty Patellectomy Osteotomy Articular Surface Surgery Shaving Abrasion Drilling Microfracture Cell therapy Osteochondral autograft transfer/mosaic-plasty Other Total number of previous surgeries Imaging Studies: Structural MRI CT Arthrogram Metabolic (Bone Scan) Findings: Ligament Meniscus Articular Cartilage Bone

8 2000 IKDC SURGICAL DOCUMENTATION FORM Patient s Name: Date of Index Procedure: / / Postoperative Diagnosis: Status After Procedure: ARTICULAR CARTILAGE STATUS: Document the size and location of articular cartilage defects on these figures according to the ICRS mapping system c.

9 ICRS Grade 0 - Normal Page IKDC SURGICAL DOCUMENTATION FORM Record size, location and grade of articular cartilage lesions. Femur Side Right Left Condyle Medial Lateral Sagittal plane Trochlear Anterior Middle Posterior Frontal plane Lateral Central Medial First lesion Second Lesion ICRS Grade 1 Nearly Normal Superficial lesions, Soft indentation (A) and/or superficial fissures and cracks (B) Cartilage lesion (Grade) (*) Defect size pre-debridement Defect size post-debridement Tibia mm mm A B ICRS Grade 2 Abnormal Lesions extending down to <50% of cartilage depth Side Right Left Plateau Medial Lateral Sagittal Plane Anterior Middle Posterior Frontal Plane Lateral Central Medial Cartilage lesion (Grade) (*) Defect size pre-debridement Defect size post-debridement mm mm ICRS Grade 3 - Severely Abnormal Cartilage defects extending down >50% of cartilage depth (A) as well as down to calcified layer (B) and down to Blisters are included in this Grade (D) Patella Side Right Left Sagittal plane Distal Middle Proximal Frontal plane Lateral Central Medial A B Cartilage lesion (Grade) (*) Defect size pre-debridement Defect size post-debridement mm mm Diagnosis: Traumatic cartilage lesi OD OA AVN Others Biopsy/Osteochondral Plugs: Location Diameter of Plugs: mm Number of Plugs: Treatment: Shaving Abrasion Drilling Microfracture Osteochondral autograft transfer/mosaic-plasty Cell therapy Other C D ICRS Grade 4 Severely Abnormal Osteochondral injuries, lesions extending just through the subchondral boneplate (A) or deeper defects down into trabecular bone (B). Defects that have been drilled are regarded as osteochondral defects and classified as ICRS-C. Notes: A B

10 Page IKDC SURGICAL DOCUMENTATION FORM MENISCUS STATUS: Procedure: medial meniscectomy lateral meniscectomy medial meniscal repair lateral meniscus repair medial meniscal transplant lateral meniscal transplant medial abrade & trephine lateral abrade & trephine Right Knee Left Knee Document tears of the menisci or meniscectomy on these figures Medial: Normal 1/3 Removed 2/3 Removed 3/3 Removed Circumferential Hoop Fibers: Intact Disrupted Lateral: Remaining Meniscal Tissue: Normal Degenerative changes Stable tear Unstable tear Tear left in situ Normal 1/3 Removed 2/3 Removed 3/3 Removed Circumferential Hoop Fibers: Intact Disrupted Remaining Meniscal Tissue: Normal Degenerative changes Stable tear Unstable tear Tear left in situ

11 LIGAMENT STATUS: Page IKDC SURGICAL DOCUMENTATION FORM Procedure: ACL repair Intraarticular ACL reconstruction Extraarticular ACL reconstruction PCL repair Intraarticular PCL reconstruction Posterolateral corner repair/reconstruction Medial collateral ligament repair/reconstruction Lateral collateral ligament repair/reconstruction Graft: Autologous patella tendon Hamstring tendons Quadriceps tendon Other Previous Graft Harvest: Autologous patella tendon Hamstring tendons Quadriceps tendon Document drill hole placement for ligament reconstruction on these figures.

12 2000 IKDC KNEE EXAMINATION FORM Patient Name: Date of Birth: / / Gender: F M Age: Date of Examination: / / Generalized Laxity: tight normal lax Alignment: obvious varus normal obvious valgus Patella Position: obvious baja normal obvious alta Patella Subluxation/Dislocation: centered subluxable subluxed dislocated Range of Motion (Ext/Flex): Index Side: passive / / active / / Opposite Side: passive / / active / / SEVEN GROUPS FOUR GRADES *Group A B C D Grade Normal Nearly Abnormal Severely Normal Abnormal A B C D 1. Effusion None Mild Moderate Severe 2. Passive Motion Deficit Lack of extension <3 3 to 5 6 to 10 >10 Lack of flexion 0 to 5 6 to to 25 >25 3. Ligament Examination (manual, instrumented, x-ray) Lachman (25 flex) (134N) -1 to 2mm 3 to 5mm(1 + ) 6 to 10mm(2 + ) >10mm(3 + ) <-1 to 3 <-3 stiff Lachman (25 flex) manual max -1 to 2mm 3 to 5mm 6 to 10mm >10mm Anterior endpoint: firm soft Total AP Translation (25 flex) 0 to 2mm 3 to 5mm 6 to 10mm >10mm Total AP Translation (70 flex) 0 to 2mm 3 to 5mm 6 to 10mm >10mm Posterior Drawer Test (70 flex) 0 to 2mm 3 to 5mm 6 to 10mm >10mm Med Joint Opening (20 flex/valgus rot) 0 to 2mm 3 to 5mm 6 to 10mm >10mm Lat Joint Opening (20 flex/varus rot) 0 to 2mm 3 to 5mm 6 to 10mm >10mm External Rotation Test (30 flex prone) <5 6 to to 19 >20 External Rotation Test (90 flex prone) <5 6 to to 19 >20 Pivot Shift equal +glide ++(clunk) +++(gross) Reverse Pivot Shift equal glide gross marked 4. Compartment Findings crepitation with Crepitus Ant. Compartment none moderate mild pain >mild pain Crepitus Med. Compartment none moderate mild pain >mild pain Crepitus Lat. Compartment none moderate mild pain >mild pain 5. Harvest Site Pathology none mild moderate severe 6. X-ray Findings Med. Joint Space none mild moderate severe Lat. Joint Space none mild moderate severe Patellofemoral none mild moderate severe Ant. Joint Space (sagittal) none mild moderate severe Post. Joint Space (sagittal) none mild moderate severe 7. Functional Test One Leg Hop (% of opposite side) 90% 89 to 76% 75 to 50% <50% **Final Evaluation * Group grade: The lowest grade within a group determines the group grade ** Final evaluation: the worst group grade determines the final evaluation for acute and subacute patients. For chronic patients compare preoperative and postoperative evaluations. In a final evaluation only the first 3 groups are evaluated but all groups must be documented. Difference in involved knee compared to normal or what is assumed to be normal. IKDC COMMITTEE AOSSM: Anderson, A., Bergfeld, J., Boland, A. Dye, S., Feagin, J., Harner, C. Mohtadi, N. Richmond, J. Shelbourne, D., Terry, G. ESSKA: Staubli, H., Hefti, F., Hoher, J., Jacob, R., Mueller, W., Neyret, P. APOSSM: Chan, K., Kurosaka, M.

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