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

Abstract: 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.