- Email: [email protected]
Quality of Life After Anterior Cruciate Ligament Reconstruction
466
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
115
Quality of Life After Anterior Cruciate Ligament Reconstruction Stephanie R. Filbay, B.Phty(Hons), Kay M. Crossley, PhD
WHAT IS QUALITY OF LIFE? The World Health Organization has defined quality of life (QOL) as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.1 The concept of QOL encompasses the following three principles: • QOL reflects an individual’s perceived discordance between their ideal or expected state and their current state and abilities. • QOL is a subjective concept; interpretation is specific to the individual and dependent on a wide range of personal factors, including cultural, behavioral, psychological, environmental, and societal influences. • QOL is a dynamic construct, which changes over time in line with the individual’s expectations, beliefs, circumstances, knowledge, and experiences.
Health-Related Quality of Life Health-related QOL refers to the impact of an individual’s health on their QOL. It is subject to the same principles outlined previously.
Knee-Related Quality of Life Knee-related QOL refers to the influence of an individual’s knee on their QOL. This is a useful measure following anterior cruciate ligament (ACL) injury, and it is influenced by a person’s surgical expectations and beliefs, and the impact of their knee on their ability to achieve their desires, goals, and ambitions. This impact depends on an individual’s life priorities and circumstances, which can change over time.
WHY SHOULD WE MEASURE QUALITY OF LIFE AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Arguably, improving a patient’s QOL should be the primary rationale for ACL reconstruction (ACLR). Every ACL-reconstructed patient has unique beliefs, ambitions, experiences, goals, and personal attributes. Such factors may explain variation in surgical outcomes and provide a rationale to shift toward more individualized, personalized patient-centered care. QOL measures can give context and meaning to objective measures that are commonly used to assess outcomes of ACLR. The impact of a physical impairment or symptom on an individual’s QOL should guide management strategies. ACLR can create physical and psychological trauma to an individual and has associated costs, risks, and complications. In order to weigh the risks, costs, and benefits, surgeons and patients must predict the likely impact of surgical ACLR on future QOL, well-being, and life satisfaction. Therefore information on longterm QOL following ACL rupture, and factors that may impact future QOL are of great value to both healthcare professionals and ACL-ruptured individuals.
HOW DO WE MEASURE QUALITY OF LIFE FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Patient-reported outcome measures are commonly used to measure QOL before and after ACLR. These measures can be generic, kneespecific, or ACL-specific. Generic, health-related QOL measures do not include knee-specific questions and have often been used in a range of populations with published results available for comparison. Knee-specific QOL measures ask questions pertaining to the knee, but are not specific to an ACL-ruptured population (e.g., validated for use in ACL, knee osteoarthritis, and meniscal pathology populations). Finally, ACL-specific QOL measures contain questions pertaining to the ACL-ruptured knee, and are most specific to this population. In Table 115.1 we outline the most common measures used to date, to measure QOL in ACL-reconstructed populations.
How Do We Choose an Appropriate Quality of Life Measure? A questionnaire should align with your treatment goals and measure factors of importance to the patient. The content of a questionnaire should be examined to enable the interpretation of findings. In some instances, domain or questionnaire titles may be misleading, and questions may not address issues of high importance to the individual patient. Secondly, assure the chosen measure is valid and reliable for use in ACL-ruptured individuals. If you are measuring treatment effect or change over time, the measure should be sensitive to change in an ACL-ruptured population. Additionally, published data on minimal clinically important difference/improvement or patient-acceptable symptomatic state can facilitate the interpretation of scores and change in scores over time.13
Potential Limitations of Patient-Reported Quality of Life Measures in Anterior Cruciate LigamentRuptured Populations
The challenge in measuring QOL lies in its uniqueness to individuals. Many of the existing measures of QOL fail to take account of this by imposing standardized models of QOL and preselected domains; they are thus measures of general health status rather than QOL.14 Most patient-reported outcomes used in ACLreconstructed populations contain restricted responses, which do not allow patients to rate the importance or impact of a physical impairment or activity limitation on their QOL. The ACL-QOL questionnaire contains items of highest relevance and importance; despite this, 25 of 31 ACL-QOL items were of little or no importance to ACL-ruptured individuals. (This was favorable to the 41 of 42 Knee Injury and Osteoarthritis Outcome Score [KOOS] items that were rated of little to no importance.7)
Comparison to Population Norms and Reference Groups Most QOL measures can be compared with published population norms. However, a typical ACL-ruptured individual is more
CHAPTER 115 Quality of Life After Anterior Cruciate Ligament Reconstruction
467
TABLE 115.1 Commonly Used Patient-Reported Measures of Quality of Life in Anterior Cruciate Ligament-Ruptured Populations Outcome Measure
Items/Domains
Knee-Related Quality of Life KOOS-QOL subscale2 Comprises four questions addressing knee awareness, knee-related lifestyle modifications, knee confidence, and knee-related difficulties
ACL-Specific Knee-Related Quality of Life ACL-QOL6 Contains 31 questions comprising five subscales (symptoms and physical complaints, work-related concerns, sports/recreation, lifestyle, and social and emotional) Health-Related Quality of Life SF-368 Comprises 36 questions across eight health domains: bodily pain, general health, mental health, physical function, role emotional, role physical, social function, and vitality
EQ-5D12
Contains five questions addressing mobility, self-care, usual activities, pain/discomfort, and anxiety/depression Features an additional question addressing perceived overall health status measured on a VAS
Considerations Valid for use in ACL-ruptured individuals,3 high test-retest reliability in patients with knee injury (KOOS-QOL ICCs from 0.83 to 0.95)4 Has been used extensively in ACL-ruptured populations and many results are available for comparison Quick and easy to complete It is possible to experience increased knee awareness and make positive lifestyle changes without a negative impact on quality of life. (This would result in a poor KOOS-QOL score.) Patients who consider their current knee function to be satisfactory between 6 and 24 months after ACLR reported a mean KOOS-QOL score of 73 (95% CI 71–75).5 The Minimal Detectable Change in patients with knee injury is 21.1 points.4 Valid, responsive to change, and reliable for use in ACL-ruptured individuals6 The only measure devised with the purpose of assessing quality of life in an ACL-ruptured population Includes items most relevant and important to ACL-ruptured individuals, compared with other knee-related measures7 Valid for use in ACL-ruptured individuals9 but may be subject to floor and ceiling effects in ACL populations10 The SF-36 is useful for measuring group changes over time after ACLR11; however, SF-36 subscales have low sensitivity to individual change after orthopaedic surgery.10 Extensive population norms are available from multiple countries and specific populations, including athletic populations. Can calculate a physical and mental summary component score Contains a VAS measure of self-perceived overall health status May not measure items of relevance or importance to ACL groups, potential for ceiling effect due to two of five items addressing self-care and walking mobility, and no reference to high-level activities
ACL, Anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ACL-QOL, quality of life assessment in anterior cruciate ligament d eficiency questionnaire; EQ-5D, Euro-Qol 5D; KOOS, Knee Injury and Osteoarthritis Outcome Score; SF-36, short-form 36; VAS, visual analogue scale.
active than the general population at the time of injury. Higher physical activity levels and sport participation have been related to better health-related QOL scores.15 Therefore comparison to general population norms may underestimate QOL impairment in ACL-ruptured individuals, who may have better QOL compared with the general population, but lower QOL compared with their teammates. Some measures, such as the short-form 36 (SF-36), have athletic population norms available for comparison, which can aid the interpretability of results. Knee-related QOL scores from healthy populations free from knee pain or injury can be misleading, since greater impairment would be expected following ACL rupture compared with individuals with no knee problems. Variability of QOL scores should be considered when comparing with individual scores. A mean score from an ACL-reconstructed cohort may not reflect different subgroups with high or low QOL scores. If an individual experiences persistent knee symptoms or functional impairments, the QOL is likely to be impaired compared with an average score reported from a group of patients, including those who are completely satisfied with their knee function and surgery.
WHAT DO WE KNOW ABOUT QUALITY OF LIFE AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Quality of Life Within the First 5 Years of Anterior Cruciate Ligament Reconstruction QOL is usually impaired in the acute injury and early postoperative periods, and it may persist until preinjury knee function is
restored or the patient reaches a state of satisfaction or acceptance with the knee abilities. Most ACLRs aim to restore knee function free from pain, swelling, or movement restrictions, allowing unrestricted participation in desired activities.16 Some individuals experience persistent knee difficulties or fear of reinjury that impacts on their ability to return to desired activities. In these instances, this can create a mismatch between expectations, desires, and abilities, with negative impacts on QOL. Within the first 5 years of ACLR, the average QOL scores reported for groups of ACL-reconstructed patients are impaired compared with healthy populations without knee impairments. Great variation in reported QOL limits the interpretation of these findings. What we can extrapolate from these studies are factors that were associated with poorer QOL outcomes in these individuals. An overview of the key findings in this area is provided in Table 115.2.
Quality of Life More Than 5 Years Following Anterior Cruciate Ligament Reconstruction Our systematic review summarized results from all studies reporting health-related or knee-related QOL 5–20 years after ACLR. We found that knee-related QOL measured with the KOOS was impaired compared with healthy population norms. In comparison, health-related QOL measured with the SF-36 was similar or better than population norms. Factors related to poor knee-related QOL included more knee pain, worse sport/recreational function, subsequent meniscal injury, severe radiographic osteoarthritis, and revision ACLR. Sustaining concomitant meniscal injury at the time of ACL rupture was associated with a poorer QOL more than 10 years following ACLR, but was not found to be significant in
115
468
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
TABLE 115.2 Summary of Current Evidence for Factors with Potential to Impact Quality of Life Less Than 5 Years after Anterior Cruciate Ligament Reconstruction Factors Not associated with QOL Within 5 Years of ACLR Autograft type did not influence ACL-QOL scores at 2 years (patellar tendon vs. quadruple-stranded vs. double-bundle hamstring tendon)17; KOOS-QOL or EQ-5D scores at 1 and 2 years (single- vs. double-bundle hamstring autografts)18; or SF-36 scores at 6, 12, and 24 months (single- vs. double-bundle).19,20 Contralateral versus unilateral graft harvest of semitendinosus gracilis tendons resulted in similar ACL-QOL scores at 3-, 6-, 12-, and 24-month follow-up.21 Graft tension (low graft tension vs. high graft tension) resulted in similar SF-36 and KOOS-QOL at 36-month follow-up.22 Early ACLR or delayed ACLR resulted in similar SF-36 and KOOS-QOL scores at 2 and 5 years.23,24 Concomitant meniscal lesions and partial-thickness cartilage lesions were not associated with KOOS-QOL at 2 years in 3476 patients from the Norwegian and Swedish Registries.25 Factors Associated with Poorer QOL within 5 Years of ACLR Return to sport was associated with better knee-related QOL 2 years26 and 1–7 years27 after ACLR. Concomitant full thickness cartilage lesions at the time of ACLR were associated with lower KOOS-QOL at 2- year25 and 2–5-year follow-up.28 Revision ACLR was associated with lower KOOS-QOL at 1 and 2 years29,30; KOOS-QOL and EQ-5D at 1, 2, and 5 years18,31; and SF-36 PCS scores at 2- and 6-year follow-up11, compared with primary ACLR. Revision surgery with an allograft (n = 590) resulted in worse KOOS-QOL at 2 years compared with revision surgery performed with an autograft technique (n = 583).32 High fear of reinjury was associated with low knee-related QOL 3–4 years following ACLR.33 Smokers in the Swedish ACL Register reported worse KOOS-QOL and SF-36 scores than nonsmokers at 1-, 2-, and 5-year follow-up.34 Single leg hop triple-hop ratio was associated with worse KOOS-QOL scores at 2-year follow-up.35 Older age predicted worse SF-36 PCS at 2 and 6 years following ACLR.11 PREOPERATIVE PREDICTORS OF POORER POSTOPERATIVE QOL WITHIN 5 YEARS OF ACLR Worse patient-reported preoperative QOL scores (SF-36, ACL-QOL) were associated with worse QOL scores 1 year after ACLR or knee arthroscopy,36 and lower SF-36 scores predicted worse SF-36 scores at 2- and 6-year follow-up.11 Worse self-predicted future knee self-efficacy measured preoperatively was predictive of knee-related QOL 1 year following ACLR.37 More anterior knee pain preoperatively was the strongest predictor of KOOS-QOL 1 year after ACLR.38 Lower preoperative activity level predicted poorer SF-36 RE and KOOS-QOL 3–6 years after ACLR39 and lower SF-36 MCS at 2- and 6-year follow-up.11 Fewer years of education predicted worse SF-36 PCS and MCS at 2 and 6 years following ACLR.11 Smoking at the time of ACLR predicted worse SF-36 PCS, and being a current or previous smoker predicted worse SF-36 MCS scores at 2 and 6 years following ACLR.11 Body mass index at the time of ACLR predicted poorer SF-36 PCS at 2- and 6-year follow-up.11 Chondromalacia of the lateral tibial plateau predicted worse SF-36 PCS at 2- and 6-year follow-up.11 QOL, Quality of life; ACLR, anterior cruciate ligament reconstruction; ACL-QOL, quality of life assessment in anterior cruciate ligament deficiency questionnaire; EQ-5D, Euro-Qol 5D; KOOS, Knee Injury and Osteoarthritis Outcome Score; MCS, mental component score; PCS, physical component score; RE, role emotional domain; SF-36, short-form 36.
studies with less than 10-years follow-up.40 Interestingly, a study published after this systematic review reported that having greater than 50% of the lateral meniscus excised or having no treatment done for a lateral meniscal tear was predictive of better SF-36 physical component scores at 2- and 6-year follow-up.11
an individual has symptomatic knee osteoarthritis or meniscal pathology, as the KOOS is valid and reliable in these populations. We do not recommend use of the Euro-Qol 5D due to the potential ceiling effect with two of five items addressing self-care and walking mobility, and no reference to high-level activities.
Quality of Life After Conservative Management of Anterior Cruciate Ligament Rupture
Further Questioning
Our recent systematic review investigated QOL more than 5 years after ACL rupture in people who did not receive an ACLR, and compared QOL between ACL-deficient and ACL-reconstructed groups. We found similar KOOS-QOL scores between ACLdeficient and ACL-reconstructed groups when average scores were pooled using a meta-analysis technique (Fig. 115.1A). The only between-group difference for health-related QOL was found for the SF-36 vitality domain (which addresses energy and fatigue), in which favorable scores were reported by ACL-reconstructed patients (see Fig. 115.1B). However, this difference was small and attributable to one larger study with moderate methodological quality, and it is unlikely to be of clinical relevance. Notably, the only randomized controlled trial comparing QOL outcomes among ACL-reconstructed and ACL-deficient groups reported no between-group differences for all QOL outcomes.41
CLINICAL RECOMMENDATIONS Which Quality of Life Measure Should I Use? The ACL-QOL contains more items of importance to ACLruptured individuals when compared with other knee-specific measures (including the KOOS), and it is recommended for use. One circumstance where the KOOS may be useful is when
Considering the aforementioned limitations in commonly used QOL measures, patient-centered questions might be a valuable adjunct to standardized patient-reported measures pre- and postoperatively. Table 115.3 features example questions that may assist in bridging the gap between standardized patient-reported questionnaires and a patient’s personal attributes, life priorities, ambitions, goals, and values.
Interpreting Low Scores and Change Over Time To enhance interpretation and determine the meaningfulness of change in QOL scores over time, clinicians could benefit from flagging questionnaire items of greatest importance to the patient and following these up at subsequent visits.
CONCLUSION Measuring the impact of a patient’s ACL-ruptured knee on QOL is of great importance. A review of the literature revealed factors with potential to negatively impact QOL following ACL rupture. More than one study supported the association between worse QOL scores and revision surgery, lower preoperative activity level, not returning to preinjury levels of sport, smoking, concomitant full-thickness cartilage lesions, and lower preoperative QOL scores. The identification of preoperative factors as predictors of
CHAPTER 115 Quality of Life After Anterior Cruciate Ligament Reconstruction Study
Mean difference [95% CI]
Frobell Lohmander Neuman Swirtun Tengma von Porat
–50 –25 0 25 Favors ACLR Favors ACLD
Mean difference [95% CI]
Total (95% CI)
115
2.91 [–3.25, 9.07]
A
Fithian Frobell Lohmander von Porat
KOOS-QOL
–5.00 [–14.63, 4.63] 0.00 [–8.48, 8.48] 6.00 [–5.11, 17.11] 14.00 [1.27, 26.73] 12.00 [0.99, 23.01] –4.00 [–11.81, 3.81]
Total (95% CI)
Study
SF–36 Vitality
–7.00 [–11.88, –2.12] –3.00 [–12.04, 6.04] –3.00 [–10.87, 4.87] –1.00 [–7.67, 5.67]
–7.00 [–11.25, –2.75] –3.00 [–9.52, 3.52] 1.00 [–4.58, 6.58] 1.00 [–3.48, 5.48]
–4.32 [–7.61, –1.04]
–2.09 [–6.31, 2.12]
Mean difference [95% CI] SF–36 Role Emotional
Fithian Frobell Lohmander von Porat Total (95% CI)
–50
Study
–4.00 [–8.07, 0.07] –5.00 [–12.59, 2.59] 0.00 [–6.10, 6.10] –1.00 [–5.34, 3.34]
–3.84 [–10.41, 2.72]
–2.42 [–4.94, 0.10]
Mean difference [95% CI]
Fithian Frobell Lohmander von Porat Total (95% CI)
0.11 [–5.68, 5.90]
–2.56 [–13.34, 8.21]
Total (95% CI)
–4.00 [–8.75, 0.75] –1.00 [–8.11, 6.11] –3.00 [–10.35, 4.35] 0.00 [–5.69, 5.69]
–0.17 [–5.83, 5.49]
–2.23 [–5.19, 0.74]
–25 0 25 50 Favors ACLR Favors ACLD
SF–36 Mental Health
–25 0 25 50 Favors ACL-R Favors ACLD
Mean difference [95% CI]
–6.00 [–14.16, 2.16] 4.00 [–8.15, 16.15] 7.00 [–3.07, 17.07] –2.00 [–9.49, 5.49]
–50
–25 0 25 50 Favors ACL-R Favors ACLD
–50
–25 0 25 50 Favors ACLR Favors ACLD SF–36 Bodily Pain
SF–36 Social Function
Mean difference [95% CI] –13.00 [–20.93, –5.07] –5.00 [–18.40, 8.40] 14.00 [0.45, 27.55] –3.00 [–13.16, 7.16]
Mean difference [95% CI]
Fithian Frobell Lohmander von Porat
C
SF–36 Physical Function
–50
–8.00 [–12.75, –3.25] 3.00 [–3.82, 9.82] 4.00 [–1.22, 9.22] 2.00 [–2.61, 6.61]
–50
Study
Mean difference [95% CI]
–9.00 [–15.81, –2.19] –8.00 [–20.95, 4.95] 8.00 [–4.39, 20.39] –3.00 [–10.22, 4.22]
–50 –25 0 25 50 Favors ACL-R Favors ACLD
B
50
Mean difference [95% CI]
–50 –25 0 25 50 Favors ACL-R Favors ACLD Study
469
–50
SF–36 Role Physical
–25 0 25 50 Favors ACLR Favors ACLD SF–36 General Health
–25 0 25 50 Favors ACLR Favors ACLD
Fig. 115.1. Forest plots of random-effects meta-analysis of Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QOL) scores (A), Shortform 36 (SF-36) domains contributing to the Physical Component Score (B), and SF-36 domains contributing to the Mental Component Score (C). Mean differences (boxes) and 95% confidence intervals (CIs, whiskers) are presented for individual studies reporting data for anterior cruciate ligament (ACL)-deficient and ACL-reconstructed subgroups. The pooled mean difference and 95% confidence interval are represented by the diamond. A negative mean difference indicates a favorable knee-related QOL outcome for ACL-reconstructed participants. ACLR, Anterior cruciate ligament reconstruction; ACLD, anterior cruciate ligament deficient. (Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033–1041 [Manuscript ID bjsports-2015-094864.R2, in press].)
470
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
TABLE 115.3 Example of Patient-Centered Questions to Accompany Standardized Quality of Life Measures To what degree is your knee impacting your quality of life? In what way is your knee impacting your current happiness? What do you really want to be able to do that you cannot do because of your knee? What are your current life priorities? Do you see these changing in the future? Is there anything that is important to you that was not covered in this questionnaire? Could knee difficulties prevent you from achieving your goals and ambitions? What do you expect to achieve from this ACLR? ACLR, Anterior cruciate ligament reconstruction.
postoperative QOL highlights the potential for future screening of individuals who may be at risk of poor QOL outcomes. We outlined the strengths and limitations of QOL measures for use in ACL-reconstructed populations, and identified the ACL-QOL as the preferred measure for use in ACL-ruptured individuals. We also recommend including patient-centered questioning to enhance the meaningfulness and interpretability of findings. SELECTED READINGS
Carr AJ, Gibson B, Robinson PG. Measuring quality of life: is quality of life determined by expectations or experience? Br Med J. 2001;322:1240–1243. Carr AJ, Higginson IJ. Are quality of life measures patient centered? Br Med J. 2001;322:1357–1360.
116
Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Healthrelated quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014;42:1247–1255. Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033–1041. [in press]. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br Med J. 2013;346:f232. Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis. 2007;66(suppl 3):iii40–iii41. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med. 1998;26:350–357. Roos EM, Roos H, Lohmander S, Ekdahl C, Beynnon B. Knee injury and osteoarthritis outcome score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96. Shapiro ET, Richmond JC, Rockett SE, McGrath MM, Donaldson WR. The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries. Am J Sports Med. 1996;24:196–200. Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific quality-oflife instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med. 2007;35:1450–1458.
A complete reference list can be found online at ExpertConsult.com.
Allografts Have Higher Failure Rates Than Autografts in Anterior Cruciate Ligament Reconstruction in Young, Active Patients Mark F. Sommerfeldt, MD, FRCSC, Christopher C. Kaeding, MD
INTRODUCTION Anterior cruciate ligament (ACL) injury is a common knee injury suffered predominantly by active individuals.1 Groups at highest risk for ACL tear include professional and amateur athletes, with annual incidence rates estimated to be between 0.15% and 3.67% and 0.03% and 1.62%, respectively.1 The treatment of ACL tears has evolved considerably over the last several decades, and in young, active patients generally involves surgical reconstruction of the ligament.2 Several issues related to the treatment of ACL injuries remain a matter of debate, particularly those pertaining to graft choice.3–5 Among panelists at a global summit on ACL reconstruction in 2011, the most popular graft choice among orthopaedic surgeons was hamstring tendon autograft (53.1%), followed by bone–patellar tendon–bone (BPTB) autograft (22.8%), allograft (13.5%), and quadriceps tendon autograft (10.6%).6 Allograft use has increased in recent years, and its reported use ranges from 11% internationally to 22% in the United States.7–9 There are several advantages to the allograft concept, including
lack of donor site morbidity (knee flexion strength deficit after hamstring harvest, anterior knee pain after BPTB harvest),10,11 decreased operative time,12 and lower risk of inadequate graft size or quality.13 Inherent with use of any allograft tissue are several disadvantages, including risk of disease transmission and cost of procurement and processing.14 The purpose of this chapter is to discuss the use of allograft for ACL reconstruction. Issues pertaining to graft preparation will be explored, and the literature that focuses on basic science research as well as clinical outcomes after ACL reconstruction using allograft will be reviewed.
GRAFT PREPARATION Despite accepting that allograft use has a role in orthopaedic surgery, many orthopaedic surgeons have expressed concerns regarding the safety of allograft tissue and the effect of sterilization procedures on mechanical and biologic properties of
REFERENCES
1. WHOQOL Group. The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41:1403–1409. 2. Roos EM, Roos H, Lohmander S, Ekdahl C, Beynnon B. Knee injury and osteoarthritis outcome score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96. 3. Gill TM, Feinstein AR. A critical appraisal of the quality of qualityof-life measurements. J Am Med Assoc. 1994;272:619–626. 4. Collins N, Misra D, Felson D, Crossley KM, Roos EM. Measures of knee function. Arthritis Care Res. 2011;63:S1–S21. 5. Ingelsrud LH, Granan LP, Terwee CB, Engebretsen L, Roos EM. Proportion of patients reporting acceptable symptoms or treatment failure and their associated KOOS values at 6 to 24 months after anterior cruciate ligament reconstruction: a study from the Norwegian knee ligament registry. Am J Sports Med. 2015;43:1902–1907. 6. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med. 1998;26:350–357. 7. Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific qualityof-life instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med. 2007;35:1450–1458. 8. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute; 1993. 9. Shapiro ET, Richmond JC, Rockett SE, McGrath MM, Donaldson WR. The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries. Am J Sports Med. 1996;24:196–200. 10. Busija L, Osborne RH, Nilsdotter A, Buchbinder R, Roos EM. Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery. Health Qual Life Outcomes. 2008;6:55. 11. Dunn WR, Wolf BR, Harrell Jr FE, Reinke EK, Huston LJ, Spindler KP. 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. J Bone Joint Surg Am. 2015;97:551–557. 12. EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208. 13. Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis. 2007;66(suppl 3):iii40–iii41. 14. Carr AJ, Higginson IJ. Are quality of life measures patient centered? Br Med J. 2001;322:1357–1360. 15. Huffman GR, Park J, Roser-Jones C, Sennett BJ, Yagnik G, Webner D. Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population. J Bone Joint Surg Am. 2008;90:471–476. 16. Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49:335–342. 17. Mohtadi N, Chan D, Barber R, Oddone Paolucci E. A randomized clinical trial comparing patellar tendon, hamstring tendon, and double-bundle ACL reconstructions: patient-reported and clinical outcomes at a minimal 2-year follow-up. Clin J Sport Med. 2015; 25:321–331. 18. Bjornsson H, Andernord D, Desai N, et al. No difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish national knee ligament register. Arthroscopy. 2015;31:659– 664. 19. Ochiai S, Hagino T, Senga S, Saito M, Haro H. Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques. Arch Orthop Trauma Surg. 2012;132:393–398. 20. Núñez M, Sastre S, Núñez E, Lozano L, Nicodemo C, Segur JM. Health-related quality of life and direct costs in patients with anterior cruciate ligament injury: single-bundle versus double-bundle reconstruction in a low-demand cohort—a randomized trial with 2 years of follow-up. Arthroscopy. 2012;28:929–935. 21. McRae S, Leiter J, McCormack R, Old J, MacDonald P. Ipsilateral versus contralateral hamstring grafts in anterior cruciate ligament
reconstruction: a prospective randomized trial. Am J Sports Med. 2013;41:2492–2499. 22. Fleming BC, Fadale PD, Hulstyn MJ, et al. The effect of initial graft tension after anterior cruciate ligament reconstruction: a randomized clinical trial with 36-month follow-up. Am J Sports Med. 2013;41:25– 34. 23. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br Med J. 2013;346:f232. 24. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363:331–342. 25. Rotterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Aroen A. Effect of meniscal and focal cartilage lesions on patient-reported outcome after anterior cruciate ligament reconstruction: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med. 2013;41:535–543. 26. McCullough KA, Phelps KD, Spindler KP, et al. Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40:2523–2529. 27. Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48:1613–1619. 28. Røtterud JH, Risberg MA, Engebretsen L, Årøen A. Patients with focal full-thickness cartilage lesions benefit less from ACL reconstruction at 2-5 years follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;20:1533–1539. 29. Lind M, Menhert F, Pedersen AB. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc. 2009;17:117–124. 30. Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med. 2012;40:1551–1557. 31. Kievit AJ, Jonkers FJ, Barentsz JH, Blankevoort L. A cross-sectional study comparing the rates of osteoarthritis, laxity, and quality of life in primary and revision anterior cruciate ligament reconstructions. Arthroscopy. 2013;29:898–905. 32. Wright RW, Huston LJ, Haas AK, et al. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med. 2014;42:2301–2310. 33. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393–397. 34. Kvist J, Kartus J, Karlsson J, Forssblad M. Results from the Swedish national anterior cruciate ligament register. Arthroscopy. 2014;30:803– 810. 35. Reinke EK, Spindler KP, Lorring D, et al. Hop tests correlate with IKDC and KOOS at minimum of 2 years after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1806–1816. 36. Bryant D, Stratford P, Marx R, Walter S, Guyatt G. Patients can provide a valid assessment of quality of life, functional status, and general health on the day they undergo knee surgery. J Bone Joint Surg Am. 2008;90:264–270. 37. Thomeé P, Währborg P, Börjesson M, Thomeé R, Eriksson B, Karlsson J. Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16:118–127. 38. Heijne A, Äng BO, Werner S. Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J Med Sci Sports. 2009;19:842–849. 39. Månsson O, Kartus J, Sernert N. Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction. Scand J Med Sci Sports. 2013;23:15–22. 40. Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Health-related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014;42:1247–1255. 41. Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033– 1041. [in press].
470.e1
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
115
Quality of Life After Anterior Cruciate Ligament Reconstruction Stephanie R. Filbay, B.Phty(Hons), Kay M. Crossley, PhD
WHAT IS QUALITY OF LIFE? The World Health Organization has defined quality of life (QOL) as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.1 The concept of QOL encompasses the following three principles: • QOL reflects an individual’s perceived discordance between their ideal or expected state and their current state and abilities. • QOL is a subjective concept; interpretation is specific to the individual and dependent on a wide range of personal factors, including cultural, behavioral, psychological, environmental, and societal influences. • QOL is a dynamic construct, which changes over time in line with the individual’s expectations, beliefs, circumstances, knowledge, and experiences.
Health-Related Quality of Life Health-related QOL refers to the impact of an individual’s health on their QOL. It is subject to the same principles outlined previously.
Knee-Related Quality of Life Knee-related QOL refers to the influence of an individual’s knee on their QOL. This is a useful measure following anterior cruciate ligament (ACL) injury, and it is influenced by a person’s surgical expectations and beliefs, and the impact of their knee on their ability to achieve their desires, goals, and ambitions. This impact depends on an individual’s life priorities and circumstances, which can change over time.
WHY SHOULD WE MEASURE QUALITY OF LIFE AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Arguably, improving a patient’s QOL should be the primary rationale for ACL reconstruction (ACLR). Every ACL-reconstructed patient has unique beliefs, ambitions, experiences, goals, and personal attributes. Such factors may explain variation in surgical outcomes and provide a rationale to shift toward more individualized, personalized patient-centered care. QOL measures can give context and meaning to objective measures that are commonly used to assess outcomes of ACLR. The impact of a physical impairment or symptom on an individual’s QOL should guide management strategies. ACLR can create physical and psychological trauma to an individual and has associated costs, risks, and complications. In order to weigh the risks, costs, and benefits, surgeons and patients must predict the likely impact of surgical ACLR on future QOL, well-being, and life satisfaction. Therefore information on longterm QOL following ACL rupture, and factors that may impact future QOL are of great value to both healthcare professionals and ACL-ruptured individuals.
HOW DO WE MEASURE QUALITY OF LIFE FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Patient-reported outcome measures are commonly used to measure QOL before and after ACLR. These measures can be generic, kneespecific, or ACL-specific. Generic, health-related QOL measures do not include knee-specific questions and have often been used in a range of populations with published results available for comparison. Knee-specific QOL measures ask questions pertaining to the knee, but are not specific to an ACL-ruptured population (e.g., validated for use in ACL, knee osteoarthritis, and meniscal pathology populations). Finally, ACL-specific QOL measures contain questions pertaining to the ACL-ruptured knee, and are most specific to this population. In Table 115.1 we outline the most common measures used to date, to measure QOL in ACL-reconstructed populations.
How Do We Choose an Appropriate Quality of Life Measure? A questionnaire should align with your treatment goals and measure factors of importance to the patient. The content of a questionnaire should be examined to enable the interpretation of findings. In some instances, domain or questionnaire titles may be misleading, and questions may not address issues of high importance to the individual patient. Secondly, assure the chosen measure is valid and reliable for use in ACL-ruptured individuals. If you are measuring treatment effect or change over time, the measure should be sensitive to change in an ACL-ruptured population. Additionally, published data on minimal clinically important difference/improvement or patient-acceptable symptomatic state can facilitate the interpretation of scores and change in scores over time.13
Potential Limitations of Patient-Reported Quality of Life Measures in Anterior Cruciate LigamentRuptured Populations
The challenge in measuring QOL lies in its uniqueness to individuals. Many of the existing measures of QOL fail to take account of this by imposing standardized models of QOL and preselected domains; they are thus measures of general health status rather than QOL.14 Most patient-reported outcomes used in ACLreconstructed populations contain restricted responses, which do not allow patients to rate the importance or impact of a physical impairment or activity limitation on their QOL. The ACL-QOL questionnaire contains items of highest relevance and importance; despite this, 25 of 31 ACL-QOL items were of little or no importance to ACL-ruptured individuals. (This was favorable to the 41 of 42 Knee Injury and Osteoarthritis Outcome Score [KOOS] items that were rated of little to no importance.7)
Comparison to Population Norms and Reference Groups Most QOL measures can be compared with published population norms. However, a typical ACL-ruptured individual is more
CHAPTER 115 Quality of Life After Anterior Cruciate Ligament Reconstruction
467
TABLE 115.1 Commonly Used Patient-Reported Measures of Quality of Life in Anterior Cruciate Ligament-Ruptured Populations Outcome Measure
Items/Domains
Knee-Related Quality of Life KOOS-QOL subscale2 Comprises four questions addressing knee awareness, knee-related lifestyle modifications, knee confidence, and knee-related difficulties
ACL-Specific Knee-Related Quality of Life ACL-QOL6 Contains 31 questions comprising five subscales (symptoms and physical complaints, work-related concerns, sports/recreation, lifestyle, and social and emotional) Health-Related Quality of Life SF-368 Comprises 36 questions across eight health domains: bodily pain, general health, mental health, physical function, role emotional, role physical, social function, and vitality
EQ-5D12
Contains five questions addressing mobility, self-care, usual activities, pain/discomfort, and anxiety/depression Features an additional question addressing perceived overall health status measured on a VAS
Considerations Valid for use in ACL-ruptured individuals,3 high test-retest reliability in patients with knee injury (KOOS-QOL ICCs from 0.83 to 0.95)4 Has been used extensively in ACL-ruptured populations and many results are available for comparison Quick and easy to complete It is possible to experience increased knee awareness and make positive lifestyle changes without a negative impact on quality of life. (This would result in a poor KOOS-QOL score.) Patients who consider their current knee function to be satisfactory between 6 and 24 months after ACLR reported a mean KOOS-QOL score of 73 (95% CI 71–75).5 The Minimal Detectable Change in patients with knee injury is 21.1 points.4 Valid, responsive to change, and reliable for use in ACL-ruptured individuals6 The only measure devised with the purpose of assessing quality of life in an ACL-ruptured population Includes items most relevant and important to ACL-ruptured individuals, compared with other knee-related measures7 Valid for use in ACL-ruptured individuals9 but may be subject to floor and ceiling effects in ACL populations10 The SF-36 is useful for measuring group changes over time after ACLR11; however, SF-36 subscales have low sensitivity to individual change after orthopaedic surgery.10 Extensive population norms are available from multiple countries and specific populations, including athletic populations. Can calculate a physical and mental summary component score Contains a VAS measure of self-perceived overall health status May not measure items of relevance or importance to ACL groups, potential for ceiling effect due to two of five items addressing self-care and walking mobility, and no reference to high-level activities
ACL, Anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ACL-QOL, quality of life assessment in anterior cruciate ligament d eficiency questionnaire; EQ-5D, Euro-Qol 5D; KOOS, Knee Injury and Osteoarthritis Outcome Score; SF-36, short-form 36; VAS, visual analogue scale.
active than the general population at the time of injury. Higher physical activity levels and sport participation have been related to better health-related QOL scores.15 Therefore comparison to general population norms may underestimate QOL impairment in ACL-ruptured individuals, who may have better QOL compared with the general population, but lower QOL compared with their teammates. Some measures, such as the short-form 36 (SF-36), have athletic population norms available for comparison, which can aid the interpretability of results. Knee-related QOL scores from healthy populations free from knee pain or injury can be misleading, since greater impairment would be expected following ACL rupture compared with individuals with no knee problems. Variability of QOL scores should be considered when comparing with individual scores. A mean score from an ACL-reconstructed cohort may not reflect different subgroups with high or low QOL scores. If an individual experiences persistent knee symptoms or functional impairments, the QOL is likely to be impaired compared with an average score reported from a group of patients, including those who are completely satisfied with their knee function and surgery.
WHAT DO WE KNOW ABOUT QUALITY OF LIFE AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? Quality of Life Within the First 5 Years of Anterior Cruciate Ligament Reconstruction QOL is usually impaired in the acute injury and early postoperative periods, and it may persist until preinjury knee function is
restored or the patient reaches a state of satisfaction or acceptance with the knee abilities. Most ACLRs aim to restore knee function free from pain, swelling, or movement restrictions, allowing unrestricted participation in desired activities.16 Some individuals experience persistent knee difficulties or fear of reinjury that impacts on their ability to return to desired activities. In these instances, this can create a mismatch between expectations, desires, and abilities, with negative impacts on QOL. Within the first 5 years of ACLR, the average QOL scores reported for groups of ACL-reconstructed patients are impaired compared with healthy populations without knee impairments. Great variation in reported QOL limits the interpretation of these findings. What we can extrapolate from these studies are factors that were associated with poorer QOL outcomes in these individuals. An overview of the key findings in this area is provided in Table 115.2.
Quality of Life More Than 5 Years Following Anterior Cruciate Ligament Reconstruction Our systematic review summarized results from all studies reporting health-related or knee-related QOL 5–20 years after ACLR. We found that knee-related QOL measured with the KOOS was impaired compared with healthy population norms. In comparison, health-related QOL measured with the SF-36 was similar or better than population norms. Factors related to poor knee-related QOL included more knee pain, worse sport/recreational function, subsequent meniscal injury, severe radiographic osteoarthritis, and revision ACLR. Sustaining concomitant meniscal injury at the time of ACL rupture was associated with a poorer QOL more than 10 years following ACLR, but was not found to be significant in
115
468
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
TABLE 115.2 Summary of Current Evidence for Factors with Potential to Impact Quality of Life Less Than 5 Years after Anterior Cruciate Ligament Reconstruction Factors Not associated with QOL Within 5 Years of ACLR Autograft type did not influence ACL-QOL scores at 2 years (patellar tendon vs. quadruple-stranded vs. double-bundle hamstring tendon)17; KOOS-QOL or EQ-5D scores at 1 and 2 years (single- vs. double-bundle hamstring autografts)18; or SF-36 scores at 6, 12, and 24 months (single- vs. double-bundle).19,20 Contralateral versus unilateral graft harvest of semitendinosus gracilis tendons resulted in similar ACL-QOL scores at 3-, 6-, 12-, and 24-month follow-up.21 Graft tension (low graft tension vs. high graft tension) resulted in similar SF-36 and KOOS-QOL at 36-month follow-up.22 Early ACLR or delayed ACLR resulted in similar SF-36 and KOOS-QOL scores at 2 and 5 years.23,24 Concomitant meniscal lesions and partial-thickness cartilage lesions were not associated with KOOS-QOL at 2 years in 3476 patients from the Norwegian and Swedish Registries.25 Factors Associated with Poorer QOL within 5 Years of ACLR Return to sport was associated with better knee-related QOL 2 years26 and 1–7 years27 after ACLR. Concomitant full thickness cartilage lesions at the time of ACLR were associated with lower KOOS-QOL at 2- year25 and 2–5-year follow-up.28 Revision ACLR was associated with lower KOOS-QOL at 1 and 2 years29,30; KOOS-QOL and EQ-5D at 1, 2, and 5 years18,31; and SF-36 PCS scores at 2- and 6-year follow-up11, compared with primary ACLR. Revision surgery with an allograft (n = 590) resulted in worse KOOS-QOL at 2 years compared with revision surgery performed with an autograft technique (n = 583).32 High fear of reinjury was associated with low knee-related QOL 3–4 years following ACLR.33 Smokers in the Swedish ACL Register reported worse KOOS-QOL and SF-36 scores than nonsmokers at 1-, 2-, and 5-year follow-up.34 Single leg hop triple-hop ratio was associated with worse KOOS-QOL scores at 2-year follow-up.35 Older age predicted worse SF-36 PCS at 2 and 6 years following ACLR.11 PREOPERATIVE PREDICTORS OF POORER POSTOPERATIVE QOL WITHIN 5 YEARS OF ACLR Worse patient-reported preoperative QOL scores (SF-36, ACL-QOL) were associated with worse QOL scores 1 year after ACLR or knee arthroscopy,36 and lower SF-36 scores predicted worse SF-36 scores at 2- and 6-year follow-up.11 Worse self-predicted future knee self-efficacy measured preoperatively was predictive of knee-related QOL 1 year following ACLR.37 More anterior knee pain preoperatively was the strongest predictor of KOOS-QOL 1 year after ACLR.38 Lower preoperative activity level predicted poorer SF-36 RE and KOOS-QOL 3–6 years after ACLR39 and lower SF-36 MCS at 2- and 6-year follow-up.11 Fewer years of education predicted worse SF-36 PCS and MCS at 2 and 6 years following ACLR.11 Smoking at the time of ACLR predicted worse SF-36 PCS, and being a current or previous smoker predicted worse SF-36 MCS scores at 2 and 6 years following ACLR.11 Body mass index at the time of ACLR predicted poorer SF-36 PCS at 2- and 6-year follow-up.11 Chondromalacia of the lateral tibial plateau predicted worse SF-36 PCS at 2- and 6-year follow-up.11 QOL, Quality of life; ACLR, anterior cruciate ligament reconstruction; ACL-QOL, quality of life assessment in anterior cruciate ligament deficiency questionnaire; EQ-5D, Euro-Qol 5D; KOOS, Knee Injury and Osteoarthritis Outcome Score; MCS, mental component score; PCS, physical component score; RE, role emotional domain; SF-36, short-form 36.
studies with less than 10-years follow-up.40 Interestingly, a study published after this systematic review reported that having greater than 50% of the lateral meniscus excised or having no treatment done for a lateral meniscal tear was predictive of better SF-36 physical component scores at 2- and 6-year follow-up.11
an individual has symptomatic knee osteoarthritis or meniscal pathology, as the KOOS is valid and reliable in these populations. We do not recommend use of the Euro-Qol 5D due to the potential ceiling effect with two of five items addressing self-care and walking mobility, and no reference to high-level activities.
Quality of Life After Conservative Management of Anterior Cruciate Ligament Rupture
Further Questioning
Our recent systematic review investigated QOL more than 5 years after ACL rupture in people who did not receive an ACLR, and compared QOL between ACL-deficient and ACL-reconstructed groups. We found similar KOOS-QOL scores between ACLdeficient and ACL-reconstructed groups when average scores were pooled using a meta-analysis technique (Fig. 115.1A). The only between-group difference for health-related QOL was found for the SF-36 vitality domain (which addresses energy and fatigue), in which favorable scores were reported by ACL-reconstructed patients (see Fig. 115.1B). However, this difference was small and attributable to one larger study with moderate methodological quality, and it is unlikely to be of clinical relevance. Notably, the only randomized controlled trial comparing QOL outcomes among ACL-reconstructed and ACL-deficient groups reported no between-group differences for all QOL outcomes.41
CLINICAL RECOMMENDATIONS Which Quality of Life Measure Should I Use? The ACL-QOL contains more items of importance to ACLruptured individuals when compared with other knee-specific measures (including the KOOS), and it is recommended for use. One circumstance where the KOOS may be useful is when
Considering the aforementioned limitations in commonly used QOL measures, patient-centered questions might be a valuable adjunct to standardized patient-reported measures pre- and postoperatively. Table 115.3 features example questions that may assist in bridging the gap between standardized patient-reported questionnaires and a patient’s personal attributes, life priorities, ambitions, goals, and values.
Interpreting Low Scores and Change Over Time To enhance interpretation and determine the meaningfulness of change in QOL scores over time, clinicians could benefit from flagging questionnaire items of greatest importance to the patient and following these up at subsequent visits.
CONCLUSION Measuring the impact of a patient’s ACL-ruptured knee on QOL is of great importance. A review of the literature revealed factors with potential to negatively impact QOL following ACL rupture. More than one study supported the association between worse QOL scores and revision surgery, lower preoperative activity level, not returning to preinjury levels of sport, smoking, concomitant full-thickness cartilage lesions, and lower preoperative QOL scores. The identification of preoperative factors as predictors of
CHAPTER 115 Quality of Life After Anterior Cruciate Ligament Reconstruction Study
Mean difference [95% CI]
Frobell Lohmander Neuman Swirtun Tengma von Porat
–50 –25 0 25 Favors ACLR Favors ACLD
Mean difference [95% CI]
Total (95% CI)
115
2.91 [–3.25, 9.07]
A
Fithian Frobell Lohmander von Porat
KOOS-QOL
–5.00 [–14.63, 4.63] 0.00 [–8.48, 8.48] 6.00 [–5.11, 17.11] 14.00 [1.27, 26.73] 12.00 [0.99, 23.01] –4.00 [–11.81, 3.81]
Total (95% CI)
Study
SF–36 Vitality
–7.00 [–11.88, –2.12] –3.00 [–12.04, 6.04] –3.00 [–10.87, 4.87] –1.00 [–7.67, 5.67]
–7.00 [–11.25, –2.75] –3.00 [–9.52, 3.52] 1.00 [–4.58, 6.58] 1.00 [–3.48, 5.48]
–4.32 [–7.61, –1.04]
–2.09 [–6.31, 2.12]
Mean difference [95% CI] SF–36 Role Emotional
Fithian Frobell Lohmander von Porat Total (95% CI)
–50
Study
–4.00 [–8.07, 0.07] –5.00 [–12.59, 2.59] 0.00 [–6.10, 6.10] –1.00 [–5.34, 3.34]
–3.84 [–10.41, 2.72]
–2.42 [–4.94, 0.10]
Mean difference [95% CI]
Fithian Frobell Lohmander von Porat Total (95% CI)
0.11 [–5.68, 5.90]
–2.56 [–13.34, 8.21]
Total (95% CI)
–4.00 [–8.75, 0.75] –1.00 [–8.11, 6.11] –3.00 [–10.35, 4.35] 0.00 [–5.69, 5.69]
–0.17 [–5.83, 5.49]
–2.23 [–5.19, 0.74]
–25 0 25 50 Favors ACLR Favors ACLD
SF–36 Mental Health
–25 0 25 50 Favors ACL-R Favors ACLD
Mean difference [95% CI]
–6.00 [–14.16, 2.16] 4.00 [–8.15, 16.15] 7.00 [–3.07, 17.07] –2.00 [–9.49, 5.49]
–50
–25 0 25 50 Favors ACL-R Favors ACLD
–50
–25 0 25 50 Favors ACLR Favors ACLD SF–36 Bodily Pain
SF–36 Social Function
Mean difference [95% CI] –13.00 [–20.93, –5.07] –5.00 [–18.40, 8.40] 14.00 [0.45, 27.55] –3.00 [–13.16, 7.16]
Mean difference [95% CI]
Fithian Frobell Lohmander von Porat
C
SF–36 Physical Function
–50
–8.00 [–12.75, –3.25] 3.00 [–3.82, 9.82] 4.00 [–1.22, 9.22] 2.00 [–2.61, 6.61]
–50
Study
Mean difference [95% CI]
–9.00 [–15.81, –2.19] –8.00 [–20.95, 4.95] 8.00 [–4.39, 20.39] –3.00 [–10.22, 4.22]
–50 –25 0 25 50 Favors ACL-R Favors ACLD
B
50
Mean difference [95% CI]
–50 –25 0 25 50 Favors ACL-R Favors ACLD Study
469
–50
SF–36 Role Physical
–25 0 25 50 Favors ACLR Favors ACLD SF–36 General Health
–25 0 25 50 Favors ACLR Favors ACLD
Fig. 115.1. Forest plots of random-effects meta-analysis of Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QOL) scores (A), Shortform 36 (SF-36) domains contributing to the Physical Component Score (B), and SF-36 domains contributing to the Mental Component Score (C). Mean differences (boxes) and 95% confidence intervals (CIs, whiskers) are presented for individual studies reporting data for anterior cruciate ligament (ACL)-deficient and ACL-reconstructed subgroups. The pooled mean difference and 95% confidence interval are represented by the diamond. A negative mean difference indicates a favorable knee-related QOL outcome for ACL-reconstructed participants. ACLR, Anterior cruciate ligament reconstruction; ACLD, anterior cruciate ligament deficient. (Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033–1041 [Manuscript ID bjsports-2015-094864.R2, in press].)
470
SECTION XXIV Outcomes After Anterior Cruciate Ligament Reconstruction
TABLE 115.3 Example of Patient-Centered Questions to Accompany Standardized Quality of Life Measures To what degree is your knee impacting your quality of life? In what way is your knee impacting your current happiness? What do you really want to be able to do that you cannot do because of your knee? What are your current life priorities? Do you see these changing in the future? Is there anything that is important to you that was not covered in this questionnaire? Could knee difficulties prevent you from achieving your goals and ambitions? What do you expect to achieve from this ACLR? ACLR, Anterior cruciate ligament reconstruction.
postoperative QOL highlights the potential for future screening of individuals who may be at risk of poor QOL outcomes. We outlined the strengths and limitations of QOL measures for use in ACL-reconstructed populations, and identified the ACL-QOL as the preferred measure for use in ACL-ruptured individuals. We also recommend including patient-centered questioning to enhance the meaningfulness and interpretability of findings. SELECTED READINGS
Carr AJ, Gibson B, Robinson PG. Measuring quality of life: is quality of life determined by expectations or experience? Br Med J. 2001;322:1240–1243. Carr AJ, Higginson IJ. Are quality of life measures patient centered? Br Med J. 2001;322:1357–1360.
116
Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Healthrelated quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014;42:1247–1255. Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033–1041. [in press]. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br Med J. 2013;346:f232. Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis. 2007;66(suppl 3):iii40–iii41. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med. 1998;26:350–357. Roos EM, Roos H, Lohmander S, Ekdahl C, Beynnon B. Knee injury and osteoarthritis outcome score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96. Shapiro ET, Richmond JC, Rockett SE, McGrath MM, Donaldson WR. The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries. Am J Sports Med. 1996;24:196–200. Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific quality-oflife instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med. 2007;35:1450–1458.
A complete reference list can be found online at ExpertConsult.com.
Allografts Have Higher Failure Rates Than Autografts in Anterior Cruciate Ligament Reconstruction in Young, Active Patients Mark F. Sommerfeldt, MD, FRCSC, Christopher C. Kaeding, MD
INTRODUCTION Anterior cruciate ligament (ACL) injury is a common knee injury suffered predominantly by active individuals.1 Groups at highest risk for ACL tear include professional and amateur athletes, with annual incidence rates estimated to be between 0.15% and 3.67% and 0.03% and 1.62%, respectively.1 The treatment of ACL tears has evolved considerably over the last several decades, and in young, active patients generally involves surgical reconstruction of the ligament.2 Several issues related to the treatment of ACL injuries remain a matter of debate, particularly those pertaining to graft choice.3–5 Among panelists at a global summit on ACL reconstruction in 2011, the most popular graft choice among orthopaedic surgeons was hamstring tendon autograft (53.1%), followed by bone–patellar tendon–bone (BPTB) autograft (22.8%), allograft (13.5%), and quadriceps tendon autograft (10.6%).6 Allograft use has increased in recent years, and its reported use ranges from 11% internationally to 22% in the United States.7–9 There are several advantages to the allograft concept, including
lack of donor site morbidity (knee flexion strength deficit after hamstring harvest, anterior knee pain after BPTB harvest),10,11 decreased operative time,12 and lower risk of inadequate graft size or quality.13 Inherent with use of any allograft tissue are several disadvantages, including risk of disease transmission and cost of procurement and processing.14 The purpose of this chapter is to discuss the use of allograft for ACL reconstruction. Issues pertaining to graft preparation will be explored, and the literature that focuses on basic science research as well as clinical outcomes after ACL reconstruction using allograft will be reviewed.
GRAFT PREPARATION Despite accepting that allograft use has a role in orthopaedic surgery, many orthopaedic surgeons have expressed concerns regarding the safety of allograft tissue and the effect of sterilization procedures on mechanical and biologic properties of
REFERENCES
1. WHOQOL Group. The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41:1403–1409. 2. Roos EM, Roos H, Lohmander S, Ekdahl C, Beynnon B. Knee injury and osteoarthritis outcome score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96. 3. Gill TM, Feinstein AR. A critical appraisal of the quality of qualityof-life measurements. J Am Med Assoc. 1994;272:619–626. 4. Collins N, Misra D, Felson D, Crossley KM, Roos EM. Measures of knee function. Arthritis Care Res. 2011;63:S1–S21. 5. Ingelsrud LH, Granan LP, Terwee CB, Engebretsen L, Roos EM. Proportion of patients reporting acceptable symptoms or treatment failure and their associated KOOS values at 6 to 24 months after anterior cruciate ligament reconstruction: a study from the Norwegian knee ligament registry. Am J Sports Med. 2015;43:1902–1907. 6. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med. 1998;26:350–357. 7. Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific qualityof-life instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med. 2007;35:1450–1458. 8. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute; 1993. 9. Shapiro ET, Richmond JC, Rockett SE, McGrath MM, Donaldson WR. The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries. Am J Sports Med. 1996;24:196–200. 10. Busija L, Osborne RH, Nilsdotter A, Buchbinder R, Roos EM. Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery. Health Qual Life Outcomes. 2008;6:55. 11. Dunn WR, Wolf BR, Harrell Jr FE, Reinke EK, Huston LJ, Spindler KP. 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. J Bone Joint Surg Am. 2015;97:551–557. 12. EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208. 13. Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis. 2007;66(suppl 3):iii40–iii41. 14. Carr AJ, Higginson IJ. Are quality of life measures patient centered? Br Med J. 2001;322:1357–1360. 15. Huffman GR, Park J, Roser-Jones C, Sennett BJ, Yagnik G, Webner D. Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population. J Bone Joint Surg Am. 2008;90:471–476. 16. Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49:335–342. 17. Mohtadi N, Chan D, Barber R, Oddone Paolucci E. A randomized clinical trial comparing patellar tendon, hamstring tendon, and double-bundle ACL reconstructions: patient-reported and clinical outcomes at a minimal 2-year follow-up. Clin J Sport Med. 2015; 25:321–331. 18. Bjornsson H, Andernord D, Desai N, et al. No difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish national knee ligament register. Arthroscopy. 2015;31:659– 664. 19. Ochiai S, Hagino T, Senga S, Saito M, Haro H. Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques. Arch Orthop Trauma Surg. 2012;132:393–398. 20. Núñez M, Sastre S, Núñez E, Lozano L, Nicodemo C, Segur JM. Health-related quality of life and direct costs in patients with anterior cruciate ligament injury: single-bundle versus double-bundle reconstruction in a low-demand cohort—a randomized trial with 2 years of follow-up. Arthroscopy. 2012;28:929–935. 21. McRae S, Leiter J, McCormack R, Old J, MacDonald P. Ipsilateral versus contralateral hamstring grafts in anterior cruciate ligament
reconstruction: a prospective randomized trial. Am J Sports Med. 2013;41:2492–2499. 22. Fleming BC, Fadale PD, Hulstyn MJ, et al. The effect of initial graft tension after anterior cruciate ligament reconstruction: a randomized clinical trial with 36-month follow-up. Am J Sports Med. 2013;41:25– 34. 23. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br Med J. 2013;346:f232. 24. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363:331–342. 25. Rotterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Aroen A. Effect of meniscal and focal cartilage lesions on patient-reported outcome after anterior cruciate ligament reconstruction: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med. 2013;41:535–543. 26. McCullough KA, Phelps KD, Spindler KP, et al. Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40:2523–2529. 27. Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48:1613–1619. 28. Røtterud JH, Risberg MA, Engebretsen L, Årøen A. Patients with focal full-thickness cartilage lesions benefit less from ACL reconstruction at 2-5 years follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;20:1533–1539. 29. Lind M, Menhert F, Pedersen AB. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc. 2009;17:117–124. 30. Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med. 2012;40:1551–1557. 31. Kievit AJ, Jonkers FJ, Barentsz JH, Blankevoort L. A cross-sectional study comparing the rates of osteoarthritis, laxity, and quality of life in primary and revision anterior cruciate ligament reconstructions. Arthroscopy. 2013;29:898–905. 32. Wright RW, Huston LJ, Haas AK, et al. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med. 2014;42:2301–2310. 33. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393–397. 34. Kvist J, Kartus J, Karlsson J, Forssblad M. Results from the Swedish national anterior cruciate ligament register. Arthroscopy. 2014;30:803– 810. 35. Reinke EK, Spindler KP, Lorring D, et al. Hop tests correlate with IKDC and KOOS at minimum of 2 years after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1806–1816. 36. Bryant D, Stratford P, Marx R, Walter S, Guyatt G. Patients can provide a valid assessment of quality of life, functional status, and general health on the day they undergo knee surgery. J Bone Joint Surg Am. 2008;90:264–270. 37. Thomeé P, Währborg P, Börjesson M, Thomeé R, Eriksson B, Karlsson J. Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16:118–127. 38. Heijne A, Äng BO, Werner S. Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J Med Sci Sports. 2009;19:842–849. 39. Månsson O, Kartus J, Sernert N. Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction. Scand J Med Sci Sports. 2013;23:15–22. 40. Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Health-related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014;42:1247–1255. 41. Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033– 1041. [in press].
470.e1