Prospective analysis of health-related quality of life and clinical evaluations in patients with anterior cruciate ligament injury undergoing reconstruction

Health-related quality of life does not deteriorate while waiting for anterior cruciate reconstruction

PURPOSE

The aim of this study was to determine how preoperative health-related quality of life (HRQoL) is affected by the duration of the wait time (WT) for anterior cruciate ligament reconstruction (ACLR) once a decision is made to proceed with surgery.

METHODS

This was a multi-centre prospective cohort study. One hundred and twenty-two patients 14 years of age and above waiting for ACLR completed the International Knee Documentation Committee (IKDC) demographic, current health assessment and subjective knee evaluation (SKF) forms on the day of decision to operate and the day of surgery. Changes in scores were analyzed for the entire cohort, adjusted for WTs and a subset was compared for patients with isolated anterior cruciate ligament (ACL) tears and ACL tears with concurrent meniscal involvement. Changes in HRQoL scores from the day of the decision to operate to the 9-month postoperative appointments were also assessed.

RESULTS

Energy/Fatigue (p < 0.05), Pain (p < 0.05), General Health (p < 0.05) and the IKDC-SKF Score (p < 0.05) significantly increased between the day of the decision to operate and the day of surgery. Only the change in IKDC-SKF score remained significantly higher after adjusting for WT. Baseline HRQoL scores significantly improved by the 9-month postoperative appointment.

CONCLUSION

The length of time waiting for ACLR did not adversely influence HRQoL in this study. However, low preoperative HRQoL and the significant improvement in HRQoL of patients followed postoperatively suggest that timely surgery is beneficial for this patient population.

LEVEL OF EVIDENCE

Level II.

Impacts of Segond Fractures on Anterior Cruciate Ligament Reconstruction Outcomes

INTRODUCTION

Segond fractures, characterized by avulsion injuries at the lateral tibial condyle's anterolateral structure (ALS) attachment, often coincide with anterior cruciate ligament (ACL) injuries, potentially leading to knee instability. However, the influence of Segond fractures on knee stability after ACL reconstruction remains uncertain. Despite documented ALS reconstructions, there is a lack of consensus regarding the assessment of ALS failure and the criteria for surgical interventions. This study aimed to determine if Segond fracture presence impacts ACL reconstruction outcomes, utilizing patient-reported subjective assessments and healthcare providers' objective evaluations.

MATERIALS AND METHODS

This retrospective study encompassed 639 patients (328 males, 311 females; mean age 26.9 years) who underwent ACL reconstruction, with a follow-up of at least one year. Subjects were divided into two groups: Segond fractures diagnosed through radiographic findings (Group S+, n = 17) and no Segond fractures (Group S-, n = 622). Clinical evaluation included the 36-item Short Form Survey (SF-36), Lysholm score, visual analog scale (VAS) for knee pain, knee injury and osteoarthritis outcome score (KOOS), and knee instability assessment via Telos SE (Telos Japan, Tokyo, Japan). Statistical comparisons were performed between the two groups.

RESULTS

At the final follow-up, all SF-36 subscales improved in all eight subscales compared to before surgery, reaching national standard scores; no significant inter-group differences were evident. Lysholm scores were 93.0 ± 12.1 (Group S+) and 91.7 ± 10.9 (Group S-) (P = 0.62), VAS for knee pain was 10.0 ± 18.0 (Group S+) and 11.9 ± 16.9 (Group S-) (P = 0.62), total KOOS was 89.0 ± 17.4 (Group S+) and 90.7 ± 9.9 (Group S-) (P = 0.39), and anterior tibial translation differences were 2.8 ± 3.0 mm (Group S+) and 2.7 ± 2.9 mm (Group S-) (P = 0.73). All these values represent postoperative measurements. No significant discrepancies existed between groups across evaluation methods.

CONCLUSIONS

This study's results suggest that Segond fractures have minimal impact on clinical ACL reconstruction outcomes, as assessed through both patient-reported subjective evaluations and objective healthcare provider evaluations. Segond fractures' significance in postoperative outcomes questions the necessity of ALS reconstruction.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial

PURPOSE

To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients.

METHODS

Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed.

RESULTS

Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures.

CONCLUSIONS

Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care.

LEVEL OF EVIDENCE

I: Prospective randomized controlled trial.

Quadriceps Function and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction in Patients With or Without Knee Osteoarthritis

CONTEXT

Relationships between quadriceps function and patient-reported outcomes after anterior cruciate ligament reconstruction (ACLR) are variable and may be confounded by including patients at widely different time points after surgery. Understanding these relationships during the clinically relevant phases of recovery may improve our knowledge of specific factors that influence clinical outcomes.

OBJECTIVE

To identify the relationships between quadriceps function and patient-reported outcomes in patients <2 years (early) and >2 years (late) after ACLR, including those with posttraumatic knee osteoarthritis.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 72 patients after ACLR: early (n = 34, time from surgery = 9.0 ± 4.3 months), late (n = 30, time from surgery = 70.5 ± 41.6 months), or osteoarthritis (n = 8, time from surgery = 115.9 ± 110.0 months).

MAIN OUTCOME MEASURE(S)

The total Knee Injury and Osteoarthritis Outcome Score (KOOS) and Veterans RAND 12-Item Health Survey (VR-12) were used to quantify knee function and global health. Predictors of patient-reported outcomes were involved-limb and symmetry indices of quadriceps function (isokinetic strength [peak torque, total work, average power], maximum voluntary isometric contraction torque, fatigue index, central activation ratio, Hoffmann reflex, active motor threshold) and demographics (age, activity level, pain, kinesiophobia, time since surgery). Multiple linear regression analyses were used to predict KOOS and VR-12 scores in each group.

RESULTS

In the early patients, knee-extensor work, active motor threshold symmetry, pain, and activity level explained 67.8% of the variance in the KOOS score ( P < .001); knee-extensor work, activity level, and pain explained 53.0% of the variance in the VR-12 score ( P < .001). In the late patients, age and isokinetic torque symmetry explained 28.9% of the variance in the KOOS score ( P = .004). In the osteoarthritis patients, kinesiophobia and isokinetic torque explained 77.8% of the variance in the KOOS score ( P = .010); activity level explained 86.4% of the variance in the VR-12 score ( P = .001).

CONCLUSIONS

Factors of muscle function and demographics that explain patient-reported outcomes were different in patients early and late after ACLR and in those with knee osteoarthritis.

Mobile Web-Based Follow-up for Postoperative ACL Reconstruction: A Single-Center Experience

Background

The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons' offices, and readmissions.

Purpose

To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients.

Study Design

Case series; Level of evidence, 4.

Methods

Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience.

Results

Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application's efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal.

Conclusion

This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study's limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.

Current status of ACL reconstruction in Germany

INTRODUCTION

Reconstruction of the anterior cruciate ligament (ACL) is characterized by a variety of possibilities concerning its implementation. Different choices for grafts, fixation methods and tunnel positioning, as well as diverse technical tools are available and have clinical significance. Besides specific pre- and post-operative procedures, different indications for surgery and further surgeon-/clinic-related factors add variability to the treatment. In response to the lack of descriptive statistics about the implementation of these factors and the increasing numbers of ACL reconstructions this study has been conducted to display the current state of the treatment for ACL tears throughout Germany.

MATERIALS AND METHODS

709 clinics with surgical and orthopedic departments were provided an online-questionnaire that surveyed their statistical records (e.g. annually implemented operations, number of surgeons, duration of operations), implemented techniques (e.g. choice of grafts, construction of drilling tunnel, tibial/femoral fixation) and personal assessment (e.g. frequency/cause of graft failure, frequency/handling of infection). The response rate was 22 % (n = 155). Based on the statistical records a specialized group within the respondents was identified, enabling a cross-comparison between high- and low-volume surgeons.

RESULTS

On average, the German orthopedic surgeons in the clinics surveyed annually performs 35 ACL reconstructions, with each operation lasting an average of 67 min. After subdividing the data with references to annually performed surgeries into high- and low-volume-surgeons, differences and common features between the subgroups become apparent. Differences between high- and low-volume-surgeons, respectively, show shorter duration of both ACL reconstructions (55 vs. 71 min) and revision ACL reconstructions (75 vs. 90 min), higher membership rates in professional associations (83 vs. 38 % have at least one membership), more frequent implementation of stability examinations (47 vs. 21 %) and different frequencies of femoral drilling techniques (using the anterolateral portal in 71 vs. 54 %). With reference to evaluating operation dates, choosing grafts and assessing reasons for graft failure both groups share commonalities, as well as regarding the predominant use of monofixation for femoral fixation (88 % of the participants-mainly with endobutton in 38 % and transfixation pin in 27 %) and for tibial fixation (81 % of the participants-mainly with bioabsorbable screw in 60 %).

CONCLUSIONS

The treatment of ACL tears in the group of German clinics studied is characterized by a variety of surgical possibilities. This condition might reflect the entirety of clinics reconstructing ACL in Germany. For the first time, a descriptive statistical survey was implemented to display this variety and to provide insight into the current status quo. Within the entirety of surgeons implementing ACL reconstruction a specialized subgroup with a particular expertise seems to exist.

Prospective analysis using a patient-based health-related scale shows lower functional scores after posterior cruciate ligament reconstructions as compared with anterior cruciate ligament reconstructions of the knee

PURPOSE

This study evaluated the treatment outcome of posterior cruciate ligament (PCL) reconstruction using the Medical Outcome Study 36-item Short-Form Health Survey (SF-36), a patient-based quality of life (QOL) questionnaire comparing it with anterior cruciate ligament (ACL) reconstruction.

METHODS

Patients who underwent reconstruction at our center for PCL (n = 24) or ACL (n = 197) injury were studied. The patients were evaluated using SF-36, visual analogue scale (VAS) for knee pain, Lysholm scale, posterior or anterior tibial translation and range of motion (ROM) before surgery until 24 months after surgery. Results were compared.

RESULTS

In the ACL group, all evaluation methods showed significant improvement after surgery. In the PCL group, however, improvement was observed in only three of eight subscales of the SF-36, Lysholm score and posterior tibial translation after surgery. In intergroup comparison, the PCL group showed inferior performance in three subscales of the SF-36, Lysholm score and ROM for flexion compared with the ACL group.

CONCLUSIONS

The surgical outcome of PCL reconstruction was inferior to that of ACL reconstruction both in patient-based and conventional doctor-based assessments. An improved surgical technique for PCL is required.

Quality of Life Following ACL Reconstruction: Baseline Predictors of Patient-Reported Outcomes

The study by Dunn et al., "Baseline Predictors of Health-Related Quality of Life after Anterior Cruciate Ligament Reconstruction: A longitudinal analysis of a multicenter cohort at two and six years," evaluates patient factors that are predictive of outcomes following anterior cruciate ligament reconstruction. The current review critically analyzes the findings of this study in light of the current body of literature on the subject and assesses its contribution to the development of evidence-based guidelines. The authors' primary endpoint, the Short Form-36 (SF-36), is used ubiquitously in health care research and allows their results to be compared across different disease states and studies. Despite its widespread use, the SF-36 has been shown to be sensitive to outcomes following anterior cruciate ligament reconstruction. The authors' use of generic health-related quality of life outcome as a primary endpoint represents an important contribution to the field, and their findings allow for improved preoperative counseling by identifying baseline patient factors that predict outcomes following anterior cruciate ligament reconstruction. Furthermore, by deriving utilities from SF-36 scores, the authors are able to assess the value of anterior cruciate ligament reconstruction as compared to other medical and surgical procedures.

Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review

PURPOSE

Lack of return to sport following anterior cruciate ligament (ACL) reconstruction often occurs despite adequate restoration of knee function, and there is growing evidence that psychological difference among patients may play an important role in this discrepancy. The purpose of this review is to identify baseline psychological factors that are predictive of clinically relevant ACL reconstruction outcomes, including return to sport, rehab compliance, knee pain, and knee function.

METHODS

A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SportDiscus, which identified 1,633 studies for potential inclusion. Inclusion criteria included (1) prospective design, (2) participants underwent ACL reconstruction, (3) psychological traits assessed at baseline, and (4) outcome measures such as return to sport, rehabilitation compliance, and knee symptoms assessed. Methodological quality was evaluated with a modified Coleman score with several item-specific revisions to improve relevance to injury risk assessment studies in sports medicine.

RESULTS

Eight prospective studies were included (modified Coleman score 63 ± 4.9/90, range 55-72). Average study size was 83 ± 42 patients with median 9-month follow-up (range 3-60 months). Measures of self-efficacy, self-motivation, and optimism were predictive of rehabilitation compliance, return to sport, and self-rated knee symptoms. Pre-operative stress was negatively predictive, and measures of social support were positively predictive of knee symptoms and rehabilitation compliance. Kinesiophobia and pain catastrophizing at the first rehabilitation appointment did not predict knee symptoms throughout the early rehabilitation phase (n.s.).

CONCLUSIONS

Patient psychological factors are predictive of ACL reconstruction outcomes. Self-confidence, optimism, and self-motivation are predictive of outcomes, which is consistent with the theory of self-efficacy. Stress, social support, and athletic self-identity are predictive of outcomes, which is consistent with the global relationship between stress, health, and the buffering hypothesis of social support.

Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases

INTRODUCTION

To verify the usefulness of and optimal timing for conducting anterior cruciate ligament (ACL) reconstruction, we evaluated and compared baseline characteristics and surgical outcomes in patients with ACL injury divided into acute and chronic groups.

PATIENTS AND METHODS

101 patients after ACL reconstruction were studied. Patients who underwent surgery within 8 weeks after injury were classified as acute group (n = 40), and those having surgery after 8 weeks as chronic group (n = 61). SF-36, VAS, Lysholm score, anterior tibial translation, and pivot shift were assessed before surgery and 6, 18 and 30 months after surgery. The results of two groups were compared.

RESULTS

In the preoperative SF-36 survey, physical and mental health scores were lower than the national standard scores in both groups. Physical health score was significantly lower in acute group, although mental health score was not significantly different between two groups. Preoperative VAS and Lysholm score were significantly poorer in acute group compared to chronic group. However, preoperative anterior tibial translation and pivot shift were not significantly different between the two groups. In postoperative evaluations, all parameters were improved significantly compared to preoperative values in both groups, and no significant differences were observed between the two groups.

DISCUSSION

All evaluation methods showed significant improvements after surgery in both acute and chronic groups, confirming that ACL reconstruction is useful for both acute and chronic injuries. However, preoperative evaluations by SF-36, VAS, and Lysholm scale yielded different results in two groups, indicating the need to evaluate acute and chronic cases separately. Development of a specific evaluation method that is valid for any duration from injury to surgery is desirable.

Use of the short form health surveys as an outcome measure for anterior cruciate ligament reconstruction

PURPOSE

The purpose of the study was to report SF-36 data from a large cohort with anterior cruciate ligament (ACL) reconstruction surgery and compare between the SF-36 and SF-12.

METHODS

1,500 patients completed the SF-36 at a minimum 12 months following ACL reconstruction surgery. The items which make up the SF-12 were selected and subscale scores were calculated and compared with the SF-36. The physical and mental component summary scores were calculated for both versions and correlated with disease-specific outcomes and were compared between different patient groups. In addition, the percentage of patients with below average, average, or above average general health was tabulated.

RESULTS

Over 90% of the cohort scored in the average or above average range for both physical and mental health component summary scores. Correlations between SF-36 and SF-12 scores were above 0.8 for all subscales except general health. Mean differences between the two versions were small except for the bodily pain subscale for which the SF-12 was 8.17 points higher than the SF-36 (0-100 scoring). For both versions, disease-specific measures were more highly correlated with the physical component score than the mental component score. Both versions were able to similarly distinguish between primary and revision procedures and groups that were and were not participating in sports.

CONCLUSIONS

Following ACL reconstruction, patients generally have excellent health. The SF-12 provides a simple health outcome assessment following ACL reconstruction surgery and is an adequate alternative for the SF-36 for measures made at a single time point. The bodily pain subscale for the SF-12 may lack sensitivity, and disease-specific measures of pain should therefore also be included.

LEVEL OF EVIDENCE

I.