CLINICAL EVALUATION OF PATIENTS AFTER ARTHROSCOPIC KNEE

SURGERY WITH TEGNER LYSHOLM SCORE

Sutan Agung Tobing*; Andreas Siagian**

*General Practitioner, Ulin General Hospital, Banjarmasin

**Consultant of Hip, Knee, and Adult Reconstruction,
Department of Orthopaedic and Traumatology, Ulin General Hospital, Banjarmasin
Medical Faculty Lambung Mangkurat University

Corresponding email: sutanagungtobing@gmail.com

Introduction: Since its first case of true surgery under arthroscopic control was perform in 1955, this
kind of procedure have become one of preferred method to treat knee ligament injury in recent year.
This kind of surgery has just recently been performed in Ulin General Hospital since January 2016.
The aim of this study is to evaluate the outcome of patients who underwent arthroscopic knee surgery
in Orthopaedic and traumatology Department, Ulin General Hospital.

Method: This was a descriptive retrospective study conducted on patiets who underwent Arthroscopic
Knee Surgery in Ulin General Hospital Banjarmasin from January 2016 to December 2017 with data
collecting methods in the form of history and interview of 25 patients. History and interview
conducted on the basis of Tegner Lysholm Knee Score.

Result and Discussion: The result of Tegner Lysholm Knee Score from 25 Patients are 10 patient
with excellent criteria, 12 patients with good criteria, 2 patients with fair criteria, 1 patients with poor
criteria. The Tegner Lysholm knee score used to evaluate outcomes of knee ligament surgery and how
the knee pain affected patient ability to manage in everyday life.

Conclusion: In this study, we found that patients who were underwent Arthroscopic Knee Surgery
procedure in Ulin General Hospital has satisfactory result refer to Tegner Lysholm knee scoring index.

Keyword: Arthroscopic knee surgery, Tegner Lysholm Knee Score

 1. INTRODUCTION
Lysholm score was introduced in 1980s as a patient-oriented subjective assessment
tool to evaluate patients with knee ligament injury.1 Its reliability and validly has been
studied and established by the past literature. 2,3 Briggs et al studied the reliability and validity
of Lysholm score and reported that it was a reliable and valid patient-administered tool to
assess patients with anterior cruciate ligament (ACL) tear. They also suggested that Lysholm
score showed acceptable responsiveness to be used in return to function after ACL injury.2
Even though Lysholm score was developed to assess patients with knee ligament injury, it
has been used to assess other patients including total knee arthroplasty (TKA).3
The follow-up evaluation in this case consisted of Tegner Activity Score and Lysholm
Knee Scoring Scale. The Lysholm Score consists of 8 different items on a 100-point scale
with 25 points each attributed to instability and pain. The single-item Tegner Activity Scale
measures the highest activity level achieved during work/sport activities and use 0-10 point
scale. Different activities put different demands on the knee, and different patients strive to
carry out different activities. Thus, it was considered necessary to grade activities in a
standardized way. The main advantage of the activity scale is not to compare different
patients, but to note changes in activity level in the same person at different times. With this
scale, the pre-injury level and the present and desired activity levels can be defined.4,5
The score should be regarded in relation to the activity level. Patients who have
reached the desired high activity level and have a high score may have better function than
patients with a high score but a low activity level, for example patientswho are not fully
rehabilitated or those who have adapted to their disability. The Lysholm-Tegner rating
system is well documented according to all the analyzed properties.5
The aim of this study is to evaluation of patients after arthroscopic knee surgery with
tegner lysholm in General Hospital of Ulin Banjarmasin.

2. METHODS
The design of this study was a descriptive rertrospective type of study. The data was
obtained from of history and interview conducted on the basis of Tegner Lysholm Knee
Score. The sample of this research is patients who underwent Arthroscopic knee surgery in
Ulin General Hospital South Kalimantan during January 2016 until December 2017, with
total of 25 patients.Inclusion criteria of this research is patient who underwent arthroscopic
knee surgery and the exclusion criteria of this research was as follow : 1)Patient who
underwent arthroscopic knee surgery for diagnostic purpose. 2) Incomplete medical record.
3. RESULT AND DISCUSSION
There was a total of 25 patients who underwent arthroscopic knee surgery in this
study, and the characteristic was showed as follow:

Gender Distribution
In this study male patientswere accounted for 22 patients (88%) and female were 3
patients (12%) .

Sex Total (patients) Percentage (%)

Male 22 88
Female 3 12

100
80
60
Male
40
Female
20
0
Sex

Figure 1. Gender Distribution

Many studies shows that the incidence of knee injury is higher in male than in female,
which correlated with sport activity that is more common in males.

Age Distribution
This study showed that arthroscopic knee surgery was mostly done in young adult
patients. The age of the patient ranged from 15 to 35 years old with the average age 24 years
old.
Age Total (patients) Percentage (%)
11 – 15 1 4
16 – 20 4 16
21 – 25 14 56
26- 30 5 20
31 -35 1 4
 60
50
40
30
20
10
0
11-15 16-20 21-25 26-30 31-35

Figure 2. Age Distribution

Knee arthroscopic surgery is usually performed on young or middle-aged patients
with meniscal tears. Young or middle-aged men and women with meniscal tears constitute a
significant amount of patients who present knee pain, swelling of the knee, and loss of
function, to which partial arthroscopic meniscectomy is a common surgical procedure.6,7

Index Side Distribution

The index side that injured was primarily at left knee 16 patients (64%) followed by
right knee 9 patients (36 %).

Index side Total (patients) Percentage (%)

Right 9 36
Left 16 64

40

30

20 right
left
10

0
Index Side

Figure 3. Index Side Distribution

Distribution of Activities that Leads to Injury

In this study the most common activity which leads to injury was soccer 10 patients
(40%), followed by traffic injury 5 patients (20%) ,basketball 4 patients (16%), Martial Art 3
patients (12%), Volleyball 2 patients (8%) and Racket sport 1 patient (4%).
Activity that leads to injury Total ( patient) Percentage (%)
Volleyball 2 8
Basketball 4 16
Martial arts 3 12
Racket sport 1 4
Traffic injury 5 20
Soccer 1 40

60 Volleybal
40 Basketball

20 Martial arts
Racket sport
0
Activity that lead to injury Traffic injury

Figure 4. Distribution of Activites that Lead to Injury

In many studies, anterior cruciate ligament is frequently injured in sports such as

snow skiing, basketball, football, and volleyball. It is also injured in falls and automobile
accidents.

Actual Injury Distribution

The actual injury was mostly ACL injury 15 patients (60%) followed by ACL and
meniscus injury 7 patients (28%),PCL injury 2 patients (8%), PCL and meniscus injury 1
patients (4%) and Meniscus injury 1 patient (4%).

Actual injury Total (patients) Percentage (%)

ACL 15 60
PCL 2 8
ACL + Meniscus 6 24
PCL + Meniscus 1 4
Meniscus 1 4

80 ACL
60
PCL
40
ACL + Meniscus
20
PCL + Meniscus
0
Actual Injury Meniscus

Figure 5. Actual Injury Distribution

 Anterior cruciate ligament (ACL) rupture is one of the major knee injuries throughout
the world. The incidence of ACL tears has increased in the general population with the rise of
participation in sports. The annual incidence of the ACL injury ranges between 100,000–
200,000 in USA. Due to the unsatisfactory outcomes of conservative treatment for ACL
injuries, reconstruction surgery remains the treatment of choice in most young patients who
want to maintain an active lifestyle.8
In this study, the reconstruction of cruciate ligament was performed in all patients
(100%) using semitendinosus gracilis graft and meniscus resection was done in 8 patients
with meniscial lesion (33%).

Tegner Activity Score Distribution

The activity level according to Tegner is presented in Figure 6. From 25 patients, 16
patient (75%) had returned to their previous activity at follow-up. 9 patients (23%) reported
that they had not returned to their previous activity at follow-up.
No of patients Score
1 9
2 6
3 7
4 4
5 6
6 6
7 7
8 7
9 5
10 3
11 4
12 7
13 8
14 6
15 6
16 7
17 6
18 5
19 3
20 8
21 5
22 2
23 4
24 2
25 7
 tegner activity score
20

15

10

0
returned not returned

Figure 6. Tegner Activity Score Distribution

The most common reasons why subjects had not returned to their previous activities
were reduced function of the knee or knees (38%), a sense of not trusting the knee or knees
(23%), fear of re-injury (19%), a family situation (8%), a work situation (8%), team/training
had changed (for example not the same coach or team mates) (2%), or others (2%). At
follow-up, 20 patients (92%) had changed their training habits because of their knee injuries.9

Tegner activity score provide a standardized method of grading work and sporting
activities. Developed to complement the Lysholm scale, based on observations that
limitations in function scores (Lysholm) may be masked by a decrease in activity level .
Tegner activity score containing about graduated list of activities of daily living, recreation,
and competitive sports. The patient selects the level of participation that best describes their
current level of activity. A score of 10 is assigned based on the level of activity that the
patient selects. A score of 0 represents “sick leave or disability pension because of knee
problems,” whereas a score of 10 corresponds to participation in national and international
elite competitive sports. Activity levels 6–10 can only be achieved if the person participates
in recreational or competitive sport.10

Lysholm Knee Scoring Scale Distribution

In this showed (after 6 months) from 25 patient, 14 patient (56%) of the patients had
excellent result, while 11 patient (44%) had good. None of the patients had poor result.
Knee score Total (patients) Percentage (%)
Excellent 14 56
Good 11 44
Fair 0 0
Poor 0 0
 Lysholm Knee Score
15
excellent
10
good
5
fair
0 poor
knee score

Figure 7. Lysholm Knee Scoring Scale Distribution

Lysholm Score to evaluate outcomes of knee ligament surgery, particularly symptoms

of instability. Intended populations is patients with knee ligament injury and anteromedial,
anterolateral, combined anteromedial/anterolateral, posterolateral rotatory, or straight
posterior instability. The original scale included 8 items: 1) limp; 2) support; 3) stair
climbing; 4) squatting; 5) walking, running, and jumping; and 6) thigh atrophy. The revised
scale also includes 8 items: 1) limp, 2) support, 3) locking, 4) instability, 5) pain, 6) swelling,
7) stair climbing, and 8) squatting. The factor analysis of the Lysholm-G revealed three
factors that could be interpreted related to 1) transfer and changing body position (the items
“limp”, “support”, “stair-climbing”, and “squatting”); 2) joint function (the items “locking”
and “instability”); and 3) signs of inflammation (the items “pain” and “swelling”). However,
given that instability and locking are problems more specific to patients with ACL or
meniscal injuries An overall score of 0 to 100 points is calculated, with 95 to 100 points
indicatingan excellent outcome; 84 to 94 points, a good outcome; 65 to 83 points, a fair
outcome; and <65 points, a poor outcome.3,10,11

The Lysholm Tegner score should be regarded in relation to the activity level. Patients
who have reached the desired high activity level and have a high score may have better
function than patients with a high score but a low activity level, for example patients who are
not fully rehabilitated or those who have adapted to their disability. The Lysholm Tegner
rating system is well documented according to all the analyzed properties.5
Johnson and Smith (2001) stated that the Lysholm score and the Tegner activity rating
had been adequately tested, and were easy to use, making them ideal as “golden standards” to
which future measures can be compared. In a structured review of 16 patient-assessed knee
evaluation instruments, Garrat et al. (2004) stated that KOOS presented good evidence of
reliability, content and construct validity, and responsiveness. This review has shown that the
 Lysholm-Tegner rating scale is the most widely used evaluation system. Consequently, score
results in different types of knee injuries are easy to find for purposes of comparison.5
4. CONCLUSION
This study showed the profile of patients who underwent arthroscopic knee surgery
which mostly done in young adult patients. The most common actual injury was ACL injury
and the activity that mostly leads to the injury was soccer. The data also showed that
reconstruction of cruciate ligament was performed in all patients. The follow-up evaluation
consisted of Tegner Activity Score and Lysholm Knee Scoring Scale. In this study, the
Lysholm-G score and Tegner activity score demonstrated generally acceptable validity and
reliability,justifying their use as outcome measures for patients with TKA. Thus, the Lysholm
score combined with the Tegner score might be a simple and concise assessment tool to
assess the outcomes of TKA
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