Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Health Sciences


Rehabilitation Sciences

First Advisor

Dr. Carl G. Mattacola

Second Advisor

Dr. Robert A. English


Autologous chondrocyte implantation (ACI) is a cell based therapy for the treatment of articular cartilage defects. Numerous studies have reported outcomes following ACI using a variety of patient reported outcomes (PROs), but no clear recommendations exist regarding which PRO is the most responsive to changes following ACI. Few studies have documented changes in performance based assessments (PBAs) following ACI. Response shift theory proposes that residual changes in self-report measures occur over time. Failing to account for response shift may result in over or under reporting of outcomes from which clinical decisions are made. The purposes of this dissertation were 1) review the literature concerning ACI outcomes to determine the responsiveness of PROs to changes in self-reported function following ACI, 2) evaluate the reliability of PBAs among ACI patients, 3) develop a descriptive timeline for the return of function 1 year following ACI using both PROs and PBAs, and 4) utilize PROs and PBAs to evaluate patients undergoing ACI for evidence of response shift.

All PRO and PBA measures were collected preoperatively and 3, 6, and 12 months postoperatively. A retrospective then-test PRO evaluation of function prior to surgery was completed at 6 and 12 months. Response shift was calculated by subtracting the original pre-test score from the then-test score.

A systematic review and meta-analyses of existing ACI outcome studies resulted in the recommendation of the International Knee Documentation Committee Subjective Knee Form (IKDC) and Lysholm Knee Scale as highly responsive PROs among ACI patients of varying activity levels. Despite significant increases in PRO scores as early as 6 months following ACI, improvement in PBAs at 12 months following ACI were limited to stride length, walking speed, and step-up force. Finally, no evidence of a group level effect for response shift was observed. These results support the validity of traditional pre-test/post-test research designs with no need to account for response shift when evaluating treatment effects of ACI on the group level. However, the Western Ontario and McMasters University Osteoarthritis Index (WOMAC) did show evidence of a measurable response shift on a patient by patient basis.