Summary

There was a consistent trend of patients being more concerned than surgeons about persistent knee pain, limb weakness and knee flexion range. Surgeons demonstrated more concern about ACL graft re-rupture than patients.

Abstract

Introduction

Understanding individual patient expectations and aspirations around the time of Anterior Cruciate Ligament Reconstruction (ACLR) surgery is paramount to delivering quality medical care that leads to patient satisfaction. Patients, influenced by a variety of sources, are likely to have different expectations about return to sport, persistent knee symptoms, clinical graft failure and reoperation than their Surgeon. Using modern shared decision making principles in discussions about the potential negative consequences of ACL Reconstruction can help bridge the gap between evidence based medicine and patient centred care.

We set out to identify the clinical factors which are most important to patients in defining a successful outcome after ACLR. In addition, we aimed to identify the potentially negative effects (eg. donor site morbidity) which are of greatest concern to patients. Finally, we aimed to assess where the key differences between patients and surgeons occurred in these perceptions about ACLR morbidity. Our hypothesis was that surgeons and patients would differ in the significance that they apportioned to commonly occurring post-ACLR donor site morbidity problems.

Methods

We constructed a standardised survey which asked all respondents to rank the most important features of a successful outcome after ACLR. Respondents were given a Likert scale (1-5) about how problematic they would find each individual problem from a list of commonly occurring donor site morbidities and other negative outcomes. In addition, clinical endpoints such as ACL re-rupture and return to theatres (all reasons) were assessed. The same standardised survey was completed by patients (min 12 months post ACLR) and by specialist sports knee surgeons. Student t-test and Mann-Whitney U test identified areas where there were significant differences between cohorts.

Results

We received completed surveys from 51 surgeons and 46 patients. Both Surgeons and Patients placed “return to sport at pre-injury level” as the most important metric of ACLR success (p = 0.14) but ranked “time to return to sport” as the least important metric of success. Surgeons were more concerned by “ACL graft re-rupture” than the Patients (4.82 vs 4.26; p = 0.01). In contrast, Patients were more concerned that surgeons about hamstring weakness (3.11 vs 2.21; p < 0.001), lower limb weakness with no impact on function (3.26 vs 2.2; p <0.001), block to deep knee flexion (3.41 vs 2.71; p = 0.005), pain at location of graft harvest (3.48 vs 2.92; p = 0.01), numb areas of skin (2.11 vs 1.72; p = 0.04) and occasional knee pains (2.7 vs 2.2; p = 0.006). “Size of surgical scars” was considered to be of low importance amongst surgeons and patients equally (1.41 vs 1.48; p = 0.82).

Conclusion

There was a consistent trend of patients being more concerned than surgeons about persistent knee pain, limb weakness and knee flexion range. Surgeons demonstrated more concern about ACL graft re-rupture than patients. Better understanding of patients’ concerns may lead to better pre-operative counselling and the potential for informed graft-choice discussions in the future.