Treatment Decision after Anterior Cruciate Ligament Injury, and Evaluation of Measurement Properties of a Patient Reported Outcome Measure

Background: After an ACL injury, treatment aims to restore knee function. Evaluation of treatment progress is important, and adequate measurement methods are necessary. The International Knee Documentation Committee- Subjective Knee Form (IKDC-SKF) is a common patient-reported outcome measure (PROM) used after ACL injury. It evaluates symptoms, function and physical activity. The IKDC-SKF had not been translated to Swedish language for use in Swedish clinical and research settings. The measurement properties of the IKDC-SKF had been tested, but no assessment of methodological quality of the studies investigating it, nor compiling of results, was published. Sooner or later after an ACL injury, a treatment decision must be made. Treatment options are either ACL reconstruction (ACLR) plus rehabilitation, or rehabilitation alone. There are guidelines stating that a decision for ACLR should be made if the patient has high activity demands and/or knee instability. It is unclear which factors orthopaedic surgeons and physiotherapists prioritise when recommending ACLR. It is also unclear when the decision for treatment is taken, on what grounds, and how treatment decision correlates to patients reported symptoms and function. Aims: The overall aim of this thesis was to evaluate the measurement properties of a patient-reported measure for evaluation of function after ACL injury and treatment, and to overview the treatment decision process after an ACL injury. Methods: A systematic review was conducted to assess the measurement properties of the IKDC-SKF. The IKDC-SKF was translated from English to Swedish, and the Swedish version was tested for reliability, validity, responsiveness and interpretability. A survey study was conducted, where 98 orthopaedic surgeons and 391 physiotherapists rated 21 predefined factors based on importance to the decision for ACLR. Orthopadic surgeons and physiotherapists rated how important they considered their own, their counterparts’ and patient’s wishes for treatment decision making. In a prospective cohort study, patients with an ACL injury were followed from within 6 weeks up to 12 months after injury. Data regarding treatment chosen, when and why, 11were described and compared to patient-reported pre-injury activity level, instability and function. Results: The English and Swedish version of the IKDC-SKF had good measurement properties and interpretability. Swedish orthopaedic surgeons and physiotherapists considered young age, high activity demands, knee-demanding occupation, and knee instability despite adequate rehabilitation indications to recommend ACLR. An early decision for ACLR was primarily based on high activity demands. A later decision was mainly due to instability and high activity demands. A decision taken later than five months after injury was based mainly on instability. A decision for non-operative treatment taken and maintained during the first 12 months after injury was mainly due to sufficient function or no instability problems, and patients were older than other groups. Conclusions: The patient-reported outcome measurement IKDC-SKF was suitable for evaluation and assessment in patients with ACL injury. ACLR as treatment after an ACL injury was recommended for young patients and/or those with high activity demands (i.e. knee demanding occupation and/or instability despite adequate rehabilitation). An early decision for ACLR was more often based on high activity demands, while later decisions were more often based upon perceived instability. Non-operative treatment decisions were often based upon lack of instability problems or sufficient knee function. Self-reported instability and function during the first three months after ACL injury were no different in patients who chose ACLR treatment or who chose non-operative treatment.Bakgrund: Efter en främre korsbandsskada syftar behandlingen att återställa knäfunktionen. Utvärdering av framstegen är av vikt, och adekvata mätmetoder för detta är nödvändigt. International Knee Documentation Committtee Subjective Knee Form (IKDC-SKF) är ett patientskattningsformulär som är välanvänt över hela världen vid främre korsbandsskador. Det utvärderar symptom, funktion och fysisk aktivitet. Det har inte funnits tillgängligt på svenska tidigare och det har heller inte funnits någon sammanställning över formulärets mätegenskaper. Efter en främre korsbandsskada måste förr eller senare beslut om behandling fattas, om patienten ska genomgå en rekonstruktionsoperation för främre korsbandet, med efterföljande rehabilitering, eller enbart rehabilitering. Det finns riktlinjer som gör gällande att en korsbandsrekonstruktion kan vara ett adekvat alternativ när patienten har höga aktivitetskrav eller lider av instabilitet i knäleden. Det är dock ej fastställt vilka faktorer ortopedläkare och fysioterapeuter anser viktiga för att rekommendera rekonstruktionsoperation. Det är inte heller klargjort när efter skada och på vilka grunder faktiska behandlingsbeslut fattas, och hur orsaken till beslutet hänger samman med patientens självrapporterade symptom och funktion. Syfte: Det övergripande syftet med avhandlingen var att utvärdera mätegenskaper för ett patientskattningsformulär som utvärderar funktion efter en främre korsbandsskada, samt att överblicka beslutsprocessen för behandling efter en främre korsbandsskada. Metod: En systematisk genomgång utfördes av studier som utvärderat mätegenskaper för IKDC-SKF. Studierna värderades avseende metodologi och resultat. IKDC-SKF översattes till svenska, och den svenska versionens mätegenskaper prövades. En enkätstudie utfördes där 98 svenska ortopedläkare och 391 svenska fysioterapeuter fick skatta 21 faktorers betydelse för valet att rekommendera rekonstruktionsoperation av främre korsbandet. Ortopedläkare och fysioterapeuter fick även skatta vikten av sin egen och motpartens bedömning samt patientens önskan, i valet av behandling. I en prospektiv kohortstudie följdes 219 patienter med en främre korsbandsskada, från 6 veckor och upp till 12 månader efter skadan. Data om vilken behandling patienten genomgått, när behandling valdes och grunder för behandling samlades in från patient och ortopedläkare och jämfördes med patientskattad aktivitetsnivå innan skada, instabilitet och funktion. Resultat: Den systematiska genomgången av IKDC-SKF och prövningen av den svenska versionens mätegenskaper visade att IKDC-SKF uppvisar goda mätegenskaper och går att tolka i kliniken? Svenska ortopedläkare och fysioterapeuter anser att ung ålder, höga aktivitetskrav, knäkrävande arbete och instabilitet trots adekvat rehabilitering är faktorer som indicerar behov av rekonstruktionsoperation av främre korsbandet.  Ett tidigt beslut för rekonstruktionsoperation efter främre korsbandsskada fattas i hög grad på grund av höga aktivitetskrav, och dessa patienter har även högre aktivitetsnivå innan skada. Ett senare beslut för rekonstruktionsoperation fattas i hög grad på grund av instabilitet och höga aktivitetskrav, medan ett sent beslut fattas i hög grad på grund av instabilitet. Ett beslut att enbart behandla med rehabilitering fattas i hög grad på grund av att patienten har tillräckligt god funktion eller inte har några besvär från instabilitet. Det var inga skillnader i patientskattad funktion och instabilitet mellan de patienter där rekonstruktionsoperation valdes och de som valde att behandla med enbart rehabilitering. Sammanfattning: IKDC-SKF visar goda mätegenskaper och kan rekommenderas för användning hos patienter med en främre korsbandsskada och andra knärelaterade diagnoser. Efter en främre korsbandsskada fattas ett tidigt beslut för rekonstruktionsoperation på grund av höga aktivitetskrav. Ett senare beslut för rekonstruktionsoperation fattas när patienten lider av instabilitet och nedsatt knäfunktion, medan ett beslut för enbart rehabilitering valdes när funktion och knästabilitet var god. Det var inga skillnader mellan patienter där man valt rekonstruktionsoperation och enbart rehabilitering, avseende skattad funktion och instabilitet. Både ortopedläkarens och fysioterapeutens bedömning samt patientens önskan är viktig i valet av behandling

The Swedish version of the Anterior Cruciate Ligament Quality Of Life measure (ACL-QOL) : translation and measurement properties

Purpose To translate the ACL-QOL from English to Swedish and evaluate measurement properties for use after surgical and non-surgical management of anterior cruciate ligament (ACL) injury. Methods The ACL-QOL was translated from English to Swedish and data were pooled from 13 cohorts to enable a comprehensive evaluation of measurement properties in line with COSMIN guidelines. We evaluated internal consistency, test-re-test reliability, measurement error, structural validity [confirmatory factor analysis (CFA)], construct validity and responsiveness (hypothesis testing), and floor/ceiling effects. Results were stratified by time since injury (&amp;lt;= 1.5 years; 2-10 years, 15-25 years; &amp;gt; 30 years) and ACL management strategy [surgical (n = 1163), non-surgical (n = 570)]. Results The Swedish ACL-QOL had sufficient internal consistency (total and domain scores) for use in surgically managed (Cronbachs alpha &amp;gt;= 0.744) and non-surgically managed (&amp;gt;= 0.770) ACL-injured individuals at all time-points. Test-re-test reliability was sufficient [intraclass correlation coefficients: all domains &amp;gt; 0.80, total score 0.93 (95% CI 0.86-0.96)]. The standard error of measurement was 5.6 for the total score and ranged from 7.0 to 10.3 for each domain. CFA indicated sufficient SRMR values when using the total score or five domains; however, CFI and RMSEA values did not meet cut-offs for good model fit. Hypothesis testing indicated sufficient construct validity and responsiveness. Floor effects were negligible and ceiling effects were negligible or minor. Conclusion The Swedish version of the ACL-QOL has sufficient internal consistency, test-re-test reliability, construct validity and responsiveness, for use in people with ACL injury managed with or without ACL surgery. Model fit could be improved and investigation into the source of misfit is warranted.Funding Agencies|CAUL; Linkoping University, Sweden; National Health and Medical Research Council (NHMRC) [1194428]</p

Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients, roles are in the treatment decision. A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients preferences. Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patients wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patients wishes as important for the decision to recommend ACL reconstruction. Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. Diagnostic study: Level III

Decision Making for Treatment After ACL Injury From an Orthopaedic Surgeon and Patient Perspective: Results From the NACOX Study

Background: In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made. Purpose: To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate. Results: The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older (P = .031) and had a lower preinjury activity level than did those in the acute-phase (P &amp;lt; .01) and subacute-phase (P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury. Conclusion: Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for &amp;gt;3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management.Funding Agencies|Swedish Medical Research CouncilSwedish Medical Research Council (SMRC)European Commission; Swedish Research Council for Sport Science; Medical Research Council of Southeast SwedenUK Research &amp; Innovation (UKRI)Medical Research Council UK (MRC); ALF Grants Region Ostergotland</p

Natural corollaries and recovery after acute ACL injury: the NACOX cohort study protocol

Introduction Anterior cruciate ligament (ACL) injury can result in joint instability, decreased functional performance, reduced physical activity and quality of life and an increased risk for post-traumatic osteoarthritis. Despite the development of new treatment techniques and extensive research, the complex and multifaceted nature of ACL injury and its consequences are yet to be fully understood. The overall aim of the NACOX study is to evaluate the natural corollaries and recovery after an ACL injury. Methods and analysis The NACOX study is a multicentre prospective prognostic cohort study of patients with acute ACL injury. At seven sites in Sweden, we will include patients aged 15-40 years, within 6 weeks after primary ACL injury. Patients will complete questionnaires at multiple occasions over the 3 years following injury or the 3 years following ACL reconstruction (for participants who have surgical treatment). In addition, a subgroup of 130 patients will be followed with clinical examinations, several imaging modalities and biological samples. Data analyses will he specific to each aim. Ethics and dissemination This study has been approved by the regional Ethical committee in Linkoping, Sweden (Dnr 2016/44-31 and 2017/221-32). We plan to present the results at national and international conferences and in peer-reviewed scientific journals. Participants will receive a short summary of the results following completion of the study.Funding Agencies|Swedish Medical Research Council [VR 2015-03687]; Swedish Research Council for Sport Science [CIF P2016-0063, P2017-0151]; Medical Research Council of Southeast Sweden FORSS [FORSS -662081]; Medical Faculty at Linkoping University, Sweden</p