Public perception regarding anterior cruciate ligament reconstruction

Transcription

1 Washington University School of eicine Digital Open Access Publications 2014 Public perception regaring anterior cruciate ligament reconstruction atthew J. atava Washington University School of eicine in St. Louis Daniel R. Howar Washington University School of eicine in St. Louis Lanon Polakof Washington University School of eicine in St. Louis Robert H. Brophy Washington University School of eicine in St. Louis Follow this an aitional works at: Recommene Citation atava, atthew J.; Howar, Daniel R.; Polakof, Lanon; an Brophy, Robert H.,,"Public perception regaring anterior cruciate ligament reconstruction." The Journal of Bone an Joint Surgery.96,10. e85. (2014). This Open Access Publication is brought to you for free an open access by Digital It has been accepte for inclusion in Open Access Publications by an authorize aministrator of Digital For more information, please contact

2 e85(1) COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED the Orthopaeic forum Public Perception Regaring Anterior Cruciate Ligament Reconstruction atthew J. atava, D, Daniel R. Howar, D, Lanon Polakof, BS, an Robert H. Brophy, D Backgroun: Relatively little information exists regaring the public s perception of anterior cruciate ligament (ACL) injuries an their treatment. The objective of this stuy was to test the hypothesis that the public s unerstaning of ACL surgery may be incorrect with regar to various aspects of this proceure an to ientify issues to emphasize in patient eucation. ethos: This stuy utilize a forty-three-question survey esigne to measure an iniviual s knowlege base an perception of ACL reconstruction with regar to the anatomy, function, inications, operative technique, risks, recovery time, an overall benefits of the proceure. Eligible iniviuals were between fifteen an sixty years of age. Stuy participants were recruite from an acaemic orthopaeic sports meicine clinic, a collegiate athletic training room, an various public venues. Results: A total of 210 iniviuals (106 men an 104 women) with a mean age of thirty were surveye. Eucational level of the responents varie wiely. Twenty-seven percent of the responents were employe in a health-care setting. Sixty-five percent of the responents rate their ACL knowlege level as little or none. Participants self-perception of ACL knowlege was highly correlate with their survey scores on questions with a specific correct answer (p < 0.001). Almost onethir thought that surgical treatment involve repair of the torn ligament rather than reconstruction. Over half (56%) of the responents preferre an autograft for ligament reconstruction, compare with 4% who preferre an allograft. The ability to return to sports after ACL surgery was the most important concern, followe by the risk of eveloping osteoarthritis. Conclusions: There is wie variability in the lay public s knowlege level of ACL injuries; a substantial number of misguie perceptions were ientifie. Return to sports an risk for future osteoarthritis following ACL surgery appear to be the most important factors to the lay public. Focusing eucational efforts on areas of knowlege eficits may be particularly important for patients of physicians who treat ACL injuries. Peer Review: This article was reviewe by the Eitor-in-Chief an one Deputy Eitor, an it unerwent bline review by two or more outsie experts. The Deputy Eitor reviewe each revision of the article, an it unerwent a final review by the Eitor-in-Chief prior to publication. Final corrections an clarifications occurre uring one or more exchanges between the author(s) an copyeitors. Disclosure: None of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of any aspect of this work. One or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. No author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. J Bone Joint Surg Am. 2014;96:e85(1-6)

3 NUBER e85(2) LIGAENT RECONSTRUCTION The anterior cruciate ligament (ACL) functions as a major supporting ligament in the knee; it provies the greatest restriction of anterior isplacement of the tibia relative to the femur 1,while also serving to limit tibial rotation an coronal plane angulation with the knee joint at full extension 2. The ACL is the most commonly isrupte ligament in the knee that requires surgical reconstruction after injury. An estimate 175,000 ACL reconstructions were performe in the Unite States in The number of ACL reconstructions has ramatically increase over the past several ecaes, in large part because of increase exercise patterns that preispose iniviuals to ACL injuries, as well as the passage of Title IX an subsequent increase female participation in sports. In aition to the immeiate knee instability ue to an ACL tear, patients are also at an increase risk of osteoarthritis from chronic instability, which occurs in 50% of patients within ten to twenty years following an ACL tear 4. As a result of the important implications of ACL injury, extensive basic science an clinical research has examine iagnostic testing, inications for surgery, preoperative management, surgical techniques, postoperative management, an outcomes following treatment for this wiesprea injury. Although the knowlege of clinicians an the scientific community regaring the ACL has greatly expane, there has been scant ata on the general public s unerstaning of ACL function, injury, reconstruction, an surgical outcome. Prior stuies evaluating these factors relevant to a patient s selection of an ACL graft choice conclue that physician recommenation was the primary influence, with personal research (incluing meical web sites) also commonly utilize 5,6. However, to the best of our knowlege, there have been no stuies ocumenting overall patient knowlege of ACL science or perceptions of treatment beyon those regaring graft selection. The increase in ACL injuries in both the general public an professional athletic populations, combine with increase meia coverage of athletic injuries, has cast a spotlight on ACL reconstructive surgery. Increase availability of electronic information has also allowe a greater transmission of meical information, although it is possible that this information is not expresse or interprete correctly. The purpose of this stuy was to gain insight into what the general public believes to be true about ACL injury an treatment, specifically in regar to the ligament s function, surgical reconstruction, an expecte outcomes of treatment. We hypothesize that the public s perceptions regaring the inications, risks, benefits, an rehabilitation relate to ACL reconstruction may be incomplete, espite the large number of ACL reconstructions performe in this country that often involve high-profile athletes. Potential misperceptions will not only negatively influence patient expectations regaring treatment but also hiner a patient s interaction with his or her treating physician. An objective assessment of the general public s knowlege base regaring this clinical conition will ultimately be beneficial in aressing patients perceptions, concerns, an expectations prior to an following treatment for an ACL tear. aterials an ethos This stuy was approve by the Washington University Human Stuies Committee prior to commencement. A forty-three-item questionnaire (see Appenix) was create that sought to investigate various aspects of ACL science, injury, treatment, complications, rehabilitation, an outcome. In aition, several items were esigne to etermine the responents emographic information, eucational level, exposure to ACL injury, prior surgical history, an activity level. Our responents ha a wie range of eucational an occupational backgrouns. Therefore, to facilitate comprehension, the questionnaire was written at the sixth-grae reaing level 7,8. The survey was esigne with commonly accepte principles of item generation, item reuction, questionnaire format, an pretesting 9. Item generation ientifie reasonable questions for inclusion in the survey. Item reuction was use to select a subset of the initially generate items to be inclue in the survey. Base on these items, a survey of thirty-seven questions was prepare in a preominantly multiple-choice format. The pilot questionnaire was then preteste 9 in a total of twenty-seven subjects with a mean age of forty-two years (range, twenty-one to eighty years). On average, the questionnaire took six minutes an thirty secons to complete, with a range of five minutes to eleven minutes an thirty secons. All of the questions were answere. No subject felt that the questionnaire was biase or offensive in any way. Several grammatical an content-relate changes were mae base on the comments of the responers. Finally, a pilot stuy was conucte in which the survey was complete by ten volunteers with various egrees of meical knowlege so that the questions coul be refine. The survey i not unergo reliability an valiity testing since it was esigne as an informative survey rather than a precise patient measure. Furthermore, the input of expert orthopaeic surgeons corroborate face valiity (the overall reasonableness an sensibility of an inex 10 )an content valiity (appropriate selection an aggregation of components qualitatively 10 ). We i not test for criterion valiity (how accurate an instrument is with respect to a reference stanar 11 ) or construct valiity (how well an inex escribes the construct it is intene to assess 12 ) because of the lack of stanar measures for comparison. Questions were constructe with use of a preominantly multiplechoice format. Some items require the responents to complete a Likert scale ealing with various egrees of activity level, with anchors ranging from less than one time in a month to four or more times in a week ; some questions require a yes or no response; an some questions aske the responent to circle the appropriate response on a scale of 1 to 10. Three questions ealt with emographic ata. Two questions inquire about eucational backgroun an work history. One question require the responents to specify their highest level performing various running, cutting, ecelerating, an pivoting activities in their healthiest an most active state over the past year base on the arx Activity Rating Scale 13. Six questions aske the responents about any prior injury or surgical history, as well as exposure to ACL surgery from their immeiate family. Seven questions ealt with ACL science such as basic anatomy an biomechanics. Nine items inquire about ACL treatment, incluing the inications an general techniques of ACL surgery. Three questions ealt with postoperative complications of ACL reconstruction. Seven questions involve topics of rehabilitation following treatment of an ACL tear, such as the nee for casting an timing of return to sports. Five questions ealt with topics pertaining to treatment outcomes, incluing the risk of a retear. Of the forty-three questions, twenty-seven were consiere factual an to have a single correct answer base on the currently accepte orthopaeic literature (e.g., To what two structures oes the ACL attach? ). The remaining sixteen questions i not have only one correct answer; they involve either personal information unique to the iniviual or sought to etermine the responent s opinion about various ACL-relate issues. A total of 210 responents complete the survey. The majority (65%) of these participants were recruite from the senior author s (.J..) orthopaeic practice after being seen for a problem unrelate to the knee. The remaining participants were recruite from the unergrauate campus of Washington University (25%) an from the general public (10%). Each participant complete the questionnaire in private without assistance from any of the coauthors

4 NUBER e85(3) LIGAENT RECONSTRUCTION TABLE I Correlation of Self-Rate Knowlege About the ACL with Performance on the Survey* Self-Rate Knowlege Number of Responents Percent Correct (ean ± SD) None 36 37% ± 15% Little % ± 13% oerate 56 58% ± 10% Consierable/extensive 17 64% ± 11% *ACL = anterior cruciate ligament an SD = stanar eviation. or their assistants. Each volunteer was given a $5.00 gift certificate for his or her participation. Statistical Analysis Data were analyze with use of SAS software (version 9.3); p values less than 0.05 were consiere significant. Chi-square tests were use to compare categorical variables, while Spearman correlation coefficients were use to assess the relationship between two continuous or orere categorical variables. Depening on the istribution of the variable, a t test or the Wilcoxon test was use to test hypotheses about the equality of means across groups. Results A total of 210 iniviuals (106 men an 104 women) with a mean age of thirty years (range, fifteen to fifty-six years) were surveye. The racial breakown of the survey participants was 74% Caucasian, 14% African-American, 8% Asian, an 3% Hispanic. The group was well eucate: 11% hel grauate or professional egrees, 39% ha college egrees, 35% ha some college eucation, 9% ha finishe high school, an 7% ha some high school eucation. Over one-quarter of the iniviuals (27%) were employe in a health-care setting. The activity level of the participants, as assesse by the arx Activity Rating Scale, varie wiely (Fig. 1). Sixty-five percent of the responents rate their ACL knowlege level as little or none. Corresponingly, only 51% of the factual questions were answere correctly. The responents self-perception of ACL knowlege was highly correlate with their scores on the survey (p < 0.001) (Table I). There was a positive correlation between activity level an the number of correct answers (p < ), but a negative correlation between age an the number of correct answers (p = 0.003). There was no relationship between the percentage of correct answers an sex, eucational level, or employment in a health-care setting. Sixteen survey participants amitte to having a history of a torn ACL. For those inicating that they ha experience an ACL tear, the number of correct answers was 14.9 ± 4.1. For the 194 participants who ha never ha an ACL tear, the number of correct answers was 14.7 ± 4.3 (p = 0.823). Overall unerstaning of ACL anatomy an function was fair. Only 34% knew that the ACL is attache to bone at both ens. However, 75% knew that the key purpose of the ACL is to provie knee stability; 84% unerstoo that a twisting injury with a plante foot was the most likely cause of an ACL injury. About one-half (51%) believe that the most ifficult movement with an injure ACL was changing irection while running, although 76% thought that a cutting sport, such as soccer, woul be more ifficult with an injure ACL compare with in-line activities. Only 30% of the survey participants knew that there was a ifference in risk for ACL injury between men an women, with a tren towar women knowing more frequently than men (p = 0.080). However, the survey i not specifically ask whether women or men were more likely to injury their ACL. Fig. 1 Distribution of the scores on the arx Activity Rating Scale among survey responents.

5 NUBER e85(4) LIGAENT RECONSTRUCTION TABLE II Relative Importance of Concerns About ACL Surgery* Specific Concern Score (ean ± SD) Ability to return to previous level of 8.4 ± 2.3 sports/activity Risk of eveloping osteoarthritis 7.3 ± 2.4 Pain immeiately after surgery 6.3 ± 2.8 Cost 6.2 ± 3.1 Scars 4.2 ± 2.7 *Patients use a rating scale from 1 to 10, with 10 being the highest level of concern. ACL = anterior cruciate ligament an SD = stanar eviation. Participant unerstaning of the treatment for ACL tears was fair. Approximately one-half (52%) of responents knew that a torn ACL woul not heal without surgery. Only 27% thought that it was necessary to have surgery for a torn ACL, although one-thir (33%) thought that a torn ACL requires surgery for the ability to walk. A similar percentage (32%) thought that surgery involve actual repair of the torn ligament. Over onehalf of the responents (56%) preferre an autograft for reconstruction compare with 4% who preferre an allograft. In terms of graft choice, 51% i not have an opinion as to which autograft woul be preferable; 19% preferre a hamstring autograft, 15% preferre a bone-patellar tenon-bone autograft, an 15% ha no preference. Twenty percent thought that an allograft woul permit faster return to sports, while 36% felt that an autograft woul not allow a faster return; 44% i not know. Eighty-two percent thought that a brace was require after ACL reconstruction. Public knowlege regaring the outcome following ACL reconstruction was not very extensive. Seventy-seven percent of participants knew that recurrent instability was a risk after ACL reconstruction. Forty-five percent thought that the risk of infection is greater than 10%. Forty-two percent thought that the risk of retearing the ACL is 25%, while 29% of the responents thought the risk of retear is 50%. Only 37% knew that surgery oes not ecrease the risk of osteoarthritis. Eighty-two percent thought that a brace is require to prevent surgical failure. The ability to return to sports was the most important concern with ACL surgery, followe by the risk of eveloping osteoarthritis (Table II). Patients were least concerne with the size of the scars from the surgery. Discussion To our knowlege, this is the first stuy that assesses the perception of ACL injury an its treatment from a segment of the population. In general, there is wie variability in the lay public s knowlege level of this conition, an a substantial number of misguie perceptions have been ientifie. Nevertheless, responents ha reasonable insight into how much they know (or o not know) about the ACL. Return to sports an risk for future osteoarthritis following ACL injury appear to be important factors to the lay public. Focusing eucational efforts on areas of knowlege eficits may be particularly important for patients of physicians an other health-care professionals who treat ACL injuries. In this stuy population, participants preferre an autograft rather than an allograft an care most about return to sports an the risk for future osteoarthritis after ACL reconstruction. It is unclear what factors are responsible for these preferences, although they are clearly relevant outcome measures. Only a minority of iniviuals is aware of the sex-base ifferences associate with the risk for ACL injury; however, the risk of reinjury after ACL reconstruction is perceive to be quite high. These are two areas that shoul be iscusse with patients. The lack of awareness about the sex-base ifference in ACL tear risk is surprising, although women appeare to be more aware of the ifference than men. Even so, the majority of both men an women either thought there was no ifference or i not know enough to have an opinion. Female athletes have a greater risk than male athletes for rupturing the ACL 14, an they are more likely to rupture the contralateral ACL after reconstruction 15. Although large cohorts of patients have no sex-base ifference in risk of recurrent ACL tears 14,16,17, female soccer players have a higher risk of ACL reinjury compare with their male counterparts 18. Thus, women may gain the most benefit from eucation to guie their expectations following ACL reconstruction. Self-awareness of knowlege eficits is important. Hopefully, patients who know less about the topic will pay more attention to iscussions with their health-care proviers an invest more effort to investigate their injury an its treatment. Inquiry into a patient s self-assesse level of knowlege in the clinic prior to iscussing surgery is important. Patients with a lower level of perceive knowlege may benefit from greater access to appropriate literature an a more etaile iscussion of the injury an its treatment options. Fortunately, base on the results of this stuy, younger an more active iniviuals who are more likely to sustain an ACL injury have a greater knowlege base about the ACL. Proviers shoul be aware that oler an less active patients with ACL tears may have less overall knowlege concerning this injury; they shoul be offere access to appropriate eucational materials an may benefit from a more thorough review in clinic. Base on the twentyseven factual questions, the sixteen participants who ha been previously iagnose with an ACL tear i not exhibit an improve unerstaning of the ACL. This coul be attribute to multiple factors, incluing an absence of self-eucation regaring the ACL, poor retention of prior iscussions pertaining to the ACL with a health-care provier, or the esire to pursue nonoperative treatment. Although two previous stuies have shown physician recommenation to be the strongest factor in patient selection of graft in ACL reconstruction 5,6, the moern practice of patientoriente care with active patient participation 19,20 puts increasing emphasis on patient preferences. In our stuy, over half of the responents preferre an autograft to an allograft. Furthermore, participants ha relatively little concern about the size of

6 NUBER e85(5) LIGAENT RECONSTRUCTION incisions. Given the potential rawbacks of allografts, incluing higher cost, risk of isease transmission, an a higher failure rate in active athletes, these finings suggest that an allograft may be optimal for limite inications. Responents were not well eucate about the outcomes of ACL reconstruction. The risk of recurrent instability is perceive to be very high, an many seem to think that surgery ecreases the risk of eveloping osteoarthritis. Surgeons shoul explain that ACL reconstruction has been proven to restore knee stability but oes not appear to ecrease the risk of eveloping osteoarthritis. This is particularly important given the two leaing concerns that iniviuals appear to have regaring outcomes after ACL reconstruction: return to sports an risk for osteoarthritis. Return to sports is a relatively achievable goal an has been proven in sports such as football an soccer 18,21. However, ientifying an treating factors that lea to later osteoarthritis after ACL reconstruction requires ongoing research. Surgeons shoul explain to patients that the ACL typically oes not heal without surgery, although surgery may not be necessary in all cases. Patients shoul be eucate on the risks of recurrent instability an postoperative infection, both of which are lower than most participants perceive. Furthermore, surgeons shoul be proactive about explaining to patients that espite the fact that ACL reconstruction is effective in restoring knee stability, it has not been shown to reuce the risk of eveloping osteoarthritis. Finally, women shoul be eucate about their increase risk for contralateral ACL rupture after ACL reconstruction. A limitation of our stuy is that it is a survey of relatively well-eucate iniviuals from one geographic location (a meium-size city in the central Unite States). The reliability of certain measures may be less for socioeconomically isavantage groups (those with less income or lower levels of eucation) or iniviuals whose impairments (such as poor sight or hearing) limit their ability to respon aequately to certain types of survey forms or questions 22. We i not assess the participants income or level of intelligence. However, all of the volunteers who complete the survey ha the ability to rea, write, an comprehen written material at or beyon the sixth-grae level. Seconly, the questions in this stuy were not valiate. There was a high percentage of on t know responses, which likely represents the honest limitations of participant knowlege, but may also reflect a weakness inherent in the stuy esign. Finally, we i not survey patients from the senior author s orthopaeic practice who ha sustaine an ACL tear or ha previously unergone ACL reconstruction. This selection bias was intentional in an attempt to ientify baseline information as oppose to an assessment of knowlege base on Internet research or wor of mouth as might occur in patients who ha been tol or suspecte that they ha an ACL tear. In conclusion, patient eucation is important uring the evaluation an treatment of any injury. Overall knowlege regaring ACL injury is limite in the general population, but iniviuals appear to have goo awareness of their relative level of knowlege. People are most concerne about return to sport an the risk of osteoarthritis after ACL reconstruction. ore stuy is neee to better characterize patient unerstaning of ACL injury an treatment across iverse populations in orer to guie not only physician-patient iscussions, but also to stimulate future ACL injury-relate research. Appenix The survey instrument use in this stuy is available with the online version of this article as a ata supplement at jbjs.org. n atthew J. atava, D Daniel R. Howar, D Lanon Polakof, BS Robert H. Brophy, D Department of Orthopeic Surgery, Washington University, South Outer Forty Drive, St. Louis, O aress for.j. atava: matavam@wuosis.wustl.eu References 1. Butler DL, Noyes FR, Groo ES. Ligamentous restraints to anterior-posterior rawer in the human knee. A biomechanical stuy. J Bone Joint Surg Am ar;62(2): Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports e Oct;33(10): Spinler KP, Wright RW. Clinical practice. Anterior cruciate ligament tear. N Engl J e Nov 13;359(20): Lohmaner LS, Englun P, Dahl LL, Roos E. The long-term consequence of anterior cruciate ligament an meniscus injuries: osteoarthritis. Am J Sports e Oct;35(10): Epub 2007 Aug Cheung SC, Allen CR, Gallo RA, a CB, Feeley BT. Patients attitues an factors in their selection of grafts for anterior cruciate ligament reconstruction. Knee Jan;19(1): Epub 2011 Jan Cohen SB, Yucha DT, Ciccotti C, Golstein DT, Ciccotti A, Ciccotti G. Factors affecting patient selection of graft type in anterior cruciate ligament reconstruction. Arthroscopy Sep;25(9): Safeer RS, Keenan J. Health literacy: the gap between physicians an patients. Am Fam Physician Aug 1;72(3): Weiss BD, Coyne C. Communicating with patients who cannot rea. N Engl J e Jul 24;337(4): Guyatt GH, Bombarier C, Tugwell PX. easuring isease-specific quality of life in clinical trials. CAJ Apr 15;134(8): Feinstein AR. Clinimetrics. New Haven: Yale University Press; p Feinstein AR. Clinimetrics. New Haven: Yale University Press; p Feinstein AR. Clinimetrics. New Haven: Yale University Press; p arx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development an evaluation of an activity rating scale for isorers of the knee. Am J Sports e ar-apr;29(2): Hettrich C, Dunn WR, Reinke EK; OON Group, Spinler KP. The rate of subsequent surgery an preictors after anterior cruciate ligament reconstruction: two- an 6-year follow-up results from a multicenter cohort. Am J Sports e Jul;41(7): Epub 2013 ay Sutton K, Bullock J. Anterior cruciate ligament rupture: ifferences between males an females. J Am Aca Orthop Surg Jan;21(1):

7 NUBER e85(6) LIGAENT RECONSTRUCTION 16. Salmon L, Russell V, usgrove T, Pinczewski L, Refshauge K. Incience an risk factors for graft rupture an contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy Aug;21(8): Spinler KP, Warren TA, Callison JC Jr, Secic, Fleisch SB, Wright RW. Clinical outcome at a minimum of five years after reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am Aug;87(8): Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Anrish JT, ccarty EC, Spinler KP. Return to play an future ACL injury risk after ACL reconstruction in soccer athletes from the ulticenter Orthopaeic Outcomes Network (OON) group. Am J Sports e Nov;40(11): Epub 2012 Sep Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-base octor-patient interaction analysis: II. Ientifying effective provier an patient behavior. e Care Jun;20(6): Kaplan SH, Greenfiel S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic isease. e Care ar;27(3)(suppl): S ccullough KA, Phelps KD, Spinler KP, atava J, Dunn WR, Parker RD, Reinke EK; OON Group. Return to high school- an college-level football after anterior cruciate ligament reconstruction: a ulticenter Orthopaeic Outcomes Network (OON) cohort stuy. Am J Sports e Nov;40(11): Epub 2012 Aug Aay LA, Cornelius LJ. Designing an conucting health surveys: a comprehensive guie. 3r e. San Francisco: Jossey-Bass; p 240.