Outcome measurement in articular cartilage repair: exploring the patient perspective
This critical appraisal provides an overview of five published research papers that collectively make an original and significant contribution to the patients' perspective of outcome measurement after articular cartilage repair (ACR) of the knee. The work represents the evolution and development of the author's coherent research programme in this field over a period of 8 years. In 2003 the author conducted a comparative analysis of rehabilitative guidelines of 11 international ACR centres that identified large variations in practice. This work was significant as it resulted in the publication of the first evaluation of the evidence base for postoperative care after autologous chondrocyte implantation. The evidence base for postoperative care that was elucidated in this work served to uphold the biomedical model as being the dominant paradigm. Concurrently, the concept of patient-centred medicine was being actively promoted within primary care in the UK and patient-reported outcomes (PRO) were being adopted as primary endpoints in new ACR clinical trials across Europe and in the USA. This gap between PRO evidence and practice prompted this researcher to evaluate patient's and orthopaedic surgeon's perspectives of the rehabilitation process using a mixed methods approach incorporating grounded theory and content analysis. These inductive pilot works were noteworthy as they indicated that not only were ACR service users willing to allow their views to be captured for research purposes but they were prepared to do so using web-based tools. Two key research questions emerged: what are the symptoms and disabilities most important to ACR patients and are current PRO measures capturing this information? To explore these questions, two commonly used knee-specific PRO measures were evaluated for item importance to ACRpatients from an online health community (OHC) using a clinical impact methodology. The emergent pattern was one of function in sports and recreation activities being important for people who had undergone ACR, more than an anterior cruciate ligament reconstruction (ACLR) cohort from the same OHC knee population. This work led to the formulation of a further research question: what is the postoperative physical activity profile of this OHC ACR population? The Tegner activity scale (TAS) is frequently used to assess physical activity level within ACR studies but this use had not previously been evaluated. The first systematic review of the TAS for ACR raised important methodological issues relating to the use and reporting of the outcome. The key findings from this review were utilised by the researcher to inform the reporting of cross-sectional TAS data for the ACR and ACLR groups from this OHC. The postoperative physical activity profile of this ACR population was one where activity levels increased with postoperative time but remained lower than expected compared with then-current clinical and normative data. The main body of this critical appraisal reviews and evaluates the papers within this research programme and the conceptual links between them. The methodological approaches used in the studies are reflected upon and the significance of the work and future directions for research are discussed.
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