Comparison of Two Methods to Measure Return to Pre-Injury Level of Sports after Anterior Cruciate Ligament (ACL) Reconstruction

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1 Comparison of Two Methods to Measure Return to Pre-Injury Level of Sports after Anterior Cruciate Ligament (ACL) Reconstruction Mohammad A Yabroudi PT, MSc, Bart Muller MD, Chung-Liang Lai MD, Andrew Lynch DPT, Alicia Oostdyk MPH, Freddie Fu MD, Christopher Harner MD, James Irrgang PhD, PT, ATC. Departments of Orthopaedic Surgery and Physical Therapy University of Pittsburgh and Center for Sports Medicine University of Pittsburgh Medical Center AOSSM 2013

2 Background Return to sports is a primary goal for ACL reconstruction. Recent studies indicate that return to prior level of sports participation after ACL reconstruction ranges from 45% - 63%. 1,2 The purpose of this study was to evaluate return to pre-injury level of sports participation (RTPS) after ACL reconstruction using a strict comprehensive definition for RTPS. 1. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med Jan;40(1): Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:

3 Methods Subjects q Eligible if they: Were between 14 and 50 years of age at the time of primary unilateral ACL reconstruction by a surgeon affiliated with the UPMC Center for Sports Medicine. Had surgery between 1 and 5 years from date of informed consent. q Excluded if they: Had prior knee injury or surgery to the surgical or contralateral knee. Procedures Participants completed a survey to determine their pre-injury and postsurgery sports activity and participation levels. 3 phase mailing & follow-up phone calls to maximize response rate

4 Methods Return to Pre-injury Level of Sports based on Global question v Did you return to your pre-injury level of sports? This means the same frequency, duration, and intensity of sports. answered Yes or No Comprehensive method to determine Return to Sport v Subject had to have the same type, frequency and Marx activity score after surgery as before injury. v Type of sport Strenuous sports activities Moderate sports activities Light sports activities No sports v Frequency of sport 4 to 7 times per week 1 to 3 times per week 1 to 3 times per month Less than one time per month v Marx Activity Score (MAS) Frequency of running, cutting, decelerating, and pivoting activities. Items summed to create score that ranges from 0 to 16

5 Methods Patient Reported Function The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) was used to compare symptoms and function between patients who did and did not achieve the return to preinjury level of sports comprehensive criteria. Data Analysis Descriptive statistics including frequency counts and percentages for each definition of RTPS and reasons for not returning to sports were summarized. Differences between patients who did and did not achieve the RTPS criteria evaluated using Independent Samples t-test (SPSS).

6 Results 247 participants (mean age, 26.7±10.4 years) completed the survey at an average of 3.4±1.2 years after ACL reconstruction. Type of sport before injury Frequency of sport before injury 4-7 times per 1-3 times per 1-3 times per 1 time per Total week week month month Strenuous sports activities Moderate sports activities Light sports activities No sports Total Type of sport after surgery Frequency of sport after surgery 4-7 times per 1-3 times per 1-3 times per 1 time per Total week week month month Strenuous sports activities Moderate sports activities Light sports activities No sports Total % were females vs. 46.5% males.

7 Results Based on the global question of RTPS, 125 (50.6%) reported they had returned to their pre-injury level of sports participation. Using comprehensive RTPS criteria, 119 (48.2%) participants returned to their pre-injury level of sports participation. Comprehensive RTPS Global RTPS Yes No Total Yes No Total Table 1: Summary of Global and Comprehensive return to pre-injury level of sports participation after ACLR 28 (22.4%) of the 125 individuals that met the global RTPS criteria did not meet the comprehensive RTPS criteria (Table1). 100 (82%) of the 122 individuals that did not meet the global RTPS criteria also did not meet the comprehensive RTPS criteria.

8 Results Of those 100 patients that responded negatively to the global RTPS question and did not meet the comprehensive RTPS criteria, the reasons for not returning to prior level of sports included: Fear of re-injury 63% Lacked confidence in the knee 41% Ongoing problems with their knee 41% Work or family obligations 29% No longer eligible for participation in sports 12%

9 Results Patients who met both the comprehensive RTPS criteria and global RTPS question had fewer symptoms and better function based on the IKDC-SKF than those who met neither criteria (87.7±10.1 vs. 77.8±14.4, p 0.001). Patients with conflicting RTPS classifications did not have significantly different IKDC-SKF scores (only comprehensive RTPS v. only global RTPS: 80.9±11.8 vs. 83.8±10.9, p=0.37)

10 Conclusion The percentages of RTPS based on the global RTPS question and comprehensive RTPS criteria are similar. However, 20 % of this cohort had a conflicting classification for return to sports. A combination of the proposed comprehensive RTPS criteria and the global RTPS question clearly delineated the high functioning and low functioning patients. Two cohorts with conflicting RTPS classifications were also identified and require further investigation. Fear of re-injury, lack of confidence, and ongoing knee problems play a greater role in preventing RTPS than lifestyle changes. These issues need to be addressed to improve RTPS after ACL reconstruction.