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

Abstract

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 < .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 >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management. Registration: NCT02931084 ( ClinicalTrials.gov identifier).

Fear of Reinjury Following Surgical and Nonsurgical Management of Anterior Cruciate Ligament Injury: An Exploratory Analysis of the NACOX Multicenter Longitudinal Cohort Study

“…Some patients and clinicians made a shared decision to undergo early ACLR within 3 months from injury. 30 The main reasons for nonsurgical treatment were “no knee instability” and “no problems with knee function.” 30 The main reason for undergoing early ACLR (within 31 days of injury) was “high activity demands.” 30 In the subacute phase (32 days to 5 months after injury), “instability/giving way” and high-activity demands were the main reasons for undergoing ACLR, and a later ACLR decision was most often due to instability/giving way. 30 …”

Treatment decision-making process after an anterior cruciate ligament injury: patients’, orthopaedic surgeons’ and physiotherapists’ perspectives

“…However, there was a high number of responses stating that the physiotherapist or orthopaedic surgeon was not involved in the decision. Previous research has shown that the orthopaedic surgeon might not always be involved in a non-ACLR decision [ 8 ], and perhaps a physiotherapist is not always involved when an early decision for ACLR is taken. In contrast, orthopaedic surgeons and physiotherapists do state that they rate the importance of each other’s assessments highly [ 6 ].…”

“…There are some studies of patients’ perspectives regarding choice of treatment after an ACL injury [ 7 , 8 , 19 , 20 ], but to the authors´ knowledge, studies on a decision-making process that involves the perspectives of the patient, the orthopaedic surgeon and the physiotherapist are lacking. Hence, in order to provide evidence-based care and shared decision-making about the choice of treatment for patients with an ACL injury, we need to further investigate how the treatment decision-making process is experienced by patients, orthopaedic surgeons and physiotherapists.…”

“…It is recommended that ACLR should be considered when the patient suffers from functional instability, has high activity demands and/or has a concomitant injury that should be treated with initial surgery [1][2][3][4][5]. It seems, from previous research, that high activity demands are the most important factor for the treatment decision [6][7][8], but to authors knowledge, neither the decision-making process nor the collaboration between patient and caregiver have been clearly described.…”

Low percentage of patients passed the ‘Back in Action’ test battery 9 months after bone-patellar tendon-bone anterior cruciate ligament reconstruction

“…1,2 An ACL reconstruction is recommended in patients who intend to return to high-level sports. 3,4 However, previous studies demonstrated that only 55e80% of patients return to the pre-injury level of sports. 5,6 Furthermore, a re-injury rate up to 20% is observed in young and active patients.…”