Quality of Life in ACL-Deficient Individuals
Quality of Life in ACL-Deficient Individuals
Background Physical and psychological impairments impacting quality of life (QOL) are common following ACL reconstruction. Rehabilitation alone is an effective alternative to reconstruction for some patients, warranting the investigation of QOL in ACL-deficient individuals.
Purpose To report and compare QOL in ACL-deficient individuals with population norms and ACL-reconstructed groups, and investigate relationships between participant characteristics and QOL.
Study design Systematic review and meta-analysis.
Methods We systematically identified and methodologically appraised all studies reporting QOL in ACL-deficient individuals ≥5 years following ACL rupture. Knee-related and health-related QOL scores in ACL-deficient cohorts were compared to ACL-reconstructed groups using a random-effects meta-analysis. Descriptive comparisons were made with population norms.
Results Eleven studies reported QOL in 473 ACL-deficient individuals, a mean of 10 (range 5–23) years following ACL rupture. Eight studies reported knee-related QOL using the Knee injury and Osteoarthritis Outcome Score QOL subscale (KOOS-QOL); scores (mean±SD) ranging from 54±17 to 77±22 were impaired compared to population norms. Health-related QOL, measured with the SF-36 domain scores in five studies, was similar to population norms, but impaired compared to physically active populations. Meta-analysis revealed no significant differences in KOOS-QOL (mean difference (95% CI) 2.9 (−3.3 to 9.1)) and SF-36 scores (for all SF-36 domains except Vitality) between ACL-deficient and ACL-reconstructed groups.
Conclusions This systematic review found impaired knee-related QOL in ACL-deficient individuals ≥5 years after ACL rupture, compared to population norms. Meta-analysis revealed similar knee-related QOL in ACL-deficient and ACL-reconstructed groups, and no difference in health-related QOL scores for seven of the eight SF-36 domains.
Over 127 000 ACL reconstructive surgeries are performed annually in the USA, most commonly in active adolescents and young adults. Rationales for performing an ACL reconstruction include facilitating a return to competitive sport and minimising the risk of post-traumatic knee osteoarthritis (OA). However, many ACL reconstructed individuals cease sports participation, develop accelerated knee osteoarthritis (OA), or experience ongoing fear of re-injury and poor knee-related quality of life (QOL). This highlights the need to explore longer term outcomes following non-operative management of ACL rupture. Rehabilitation alone may be a successful alternative to ACL reconstruction for many individuals.
A recent meta-analysis found that the rate of return to non-elite competitive sport following ACL reconstruction was surprisingly low (42%). Emerging evidence suggests that this rate is no higher than that achieved by individuals managed with rehabilitation alone. Several systematic reviews have also revealed either no significant difference in radiographic OA rates between groups of ACL reconstructed and non-operatively managed individuals, or a slightly higher prevalence of OA following ACL reconstruction. The low return to sport rates and presence of OA following ACL reconstruction may contribute to the impaired knee-related QOL we identified in this population (compared to general population norms) 5–20 years after ACL rupture. However, little is known about the long-term QOL of individuals following non-operative management of an ACL rupture, and how this compares with the QOL of individuals who undergo ACL reconstruction.
This systematic review is the first to investigate QOL in ACL-deficient individuals, enabling QOL comparisons between management approaches. Undergoing knee surgery may expose an individual to additional physical and psychological trauma, which could facilitate fear avoidance behaviours, impact future participation in desired activities and impair QOL. On the other hand, individuals who choose not to undergo surgery for ACL rupture may be more likely to experience limitations due to increased passive knee laxity. Considering the increasing frequency of ACL reconstruction procedures, reported knee-related QOL impairments 5–20 years after surgery, and the ongoing debate regarding the optimal management of an ACL-ruptured knee, investigation into long-term QOL in ACL-deficient individuals is warranted.
Specific factors (revision surgery, concomitant meniscus surgery, subsequent injury, and severe OA) have been associated with poor longer term QOL in individuals who choose to undergo ACL reconstruction. However, it is not known whether such factors are associated with QOL outcomes in individuals who remain ACL deficient. Exploring potential predictors of low QOL in ACL-deficient people may assist clinical decision-making by helping to identify patient subgroups most likely to benefit from non-operative management. This will also facilitate the development of evidence-based treatment guidelines and recommendations.
The primary aim of this study was to report QOL outcomes in ACL-deficient individuals, 5–25 years following ACL rupture. The secondary aims were to: (1) compare QOL in ACL-deficient individuals with published population norms; (2) compare QOL in ACL-deficient and ACL-reconstructed populations; and (3) investigate relationships between relevant participant characteristics and QOL outcomes in ACL-deficient individuals.
Abstract and Introduction
Abstract
Background Physical and psychological impairments impacting quality of life (QOL) are common following ACL reconstruction. Rehabilitation alone is an effective alternative to reconstruction for some patients, warranting the investigation of QOL in ACL-deficient individuals.
Purpose To report and compare QOL in ACL-deficient individuals with population norms and ACL-reconstructed groups, and investigate relationships between participant characteristics and QOL.
Study design Systematic review and meta-analysis.
Methods We systematically identified and methodologically appraised all studies reporting QOL in ACL-deficient individuals ≥5 years following ACL rupture. Knee-related and health-related QOL scores in ACL-deficient cohorts were compared to ACL-reconstructed groups using a random-effects meta-analysis. Descriptive comparisons were made with population norms.
Results Eleven studies reported QOL in 473 ACL-deficient individuals, a mean of 10 (range 5–23) years following ACL rupture. Eight studies reported knee-related QOL using the Knee injury and Osteoarthritis Outcome Score QOL subscale (KOOS-QOL); scores (mean±SD) ranging from 54±17 to 77±22 were impaired compared to population norms. Health-related QOL, measured with the SF-36 domain scores in five studies, was similar to population norms, but impaired compared to physically active populations. Meta-analysis revealed no significant differences in KOOS-QOL (mean difference (95% CI) 2.9 (−3.3 to 9.1)) and SF-36 scores (for all SF-36 domains except Vitality) between ACL-deficient and ACL-reconstructed groups.
Conclusions This systematic review found impaired knee-related QOL in ACL-deficient individuals ≥5 years after ACL rupture, compared to population norms. Meta-analysis revealed similar knee-related QOL in ACL-deficient and ACL-reconstructed groups, and no difference in health-related QOL scores for seven of the eight SF-36 domains.
Introduction
Over 127 000 ACL reconstructive surgeries are performed annually in the USA, most commonly in active adolescents and young adults. Rationales for performing an ACL reconstruction include facilitating a return to competitive sport and minimising the risk of post-traumatic knee osteoarthritis (OA). However, many ACL reconstructed individuals cease sports participation, develop accelerated knee osteoarthritis (OA), or experience ongoing fear of re-injury and poor knee-related quality of life (QOL). This highlights the need to explore longer term outcomes following non-operative management of ACL rupture. Rehabilitation alone may be a successful alternative to ACL reconstruction for many individuals.
A recent meta-analysis found that the rate of return to non-elite competitive sport following ACL reconstruction was surprisingly low (42%). Emerging evidence suggests that this rate is no higher than that achieved by individuals managed with rehabilitation alone. Several systematic reviews have also revealed either no significant difference in radiographic OA rates between groups of ACL reconstructed and non-operatively managed individuals, or a slightly higher prevalence of OA following ACL reconstruction. The low return to sport rates and presence of OA following ACL reconstruction may contribute to the impaired knee-related QOL we identified in this population (compared to general population norms) 5–20 years after ACL rupture. However, little is known about the long-term QOL of individuals following non-operative management of an ACL rupture, and how this compares with the QOL of individuals who undergo ACL reconstruction.
This systematic review is the first to investigate QOL in ACL-deficient individuals, enabling QOL comparisons between management approaches. Undergoing knee surgery may expose an individual to additional physical and psychological trauma, which could facilitate fear avoidance behaviours, impact future participation in desired activities and impair QOL. On the other hand, individuals who choose not to undergo surgery for ACL rupture may be more likely to experience limitations due to increased passive knee laxity. Considering the increasing frequency of ACL reconstruction procedures, reported knee-related QOL impairments 5–20 years after surgery, and the ongoing debate regarding the optimal management of an ACL-ruptured knee, investigation into long-term QOL in ACL-deficient individuals is warranted.
Specific factors (revision surgery, concomitant meniscus surgery, subsequent injury, and severe OA) have been associated with poor longer term QOL in individuals who choose to undergo ACL reconstruction. However, it is not known whether such factors are associated with QOL outcomes in individuals who remain ACL deficient. Exploring potential predictors of low QOL in ACL-deficient people may assist clinical decision-making by helping to identify patient subgroups most likely to benefit from non-operative management. This will also facilitate the development of evidence-based treatment guidelines and recommendations.
The primary aim of this study was to report QOL outcomes in ACL-deficient individuals, 5–25 years following ACL rupture. The secondary aims were to: (1) compare QOL in ACL-deficient individuals with published population norms; (2) compare QOL in ACL-deficient and ACL-reconstructed populations; and (3) investigate relationships between relevant participant characteristics and QOL outcomes in ACL-deficient individuals.
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