Age, sex and graft choice are associated with the achievement of a patient acceptable symptom state five years after primary ACL reconstruction.

Abstract

To determine the proportion of patients and the factors associated with the achievement of a patient-acceptable symptom state (PASS) 5 years after primary anterior cruciate ligament reconstruction (ACLR). Patients who underwent primary ACLR between 2005 and 2018 at Capio Artro Clinic, Stockholm, Sweden, were eligible for inclusion. The primary outcome was the achievement of a PASS on each Knee injury and Osteoarthritis Outcome Score (KOOS) subscale at the 5-year follow-up. Multivariable logistic regression analyses were used to assess associations with age, sex, time from injury to surgery, pre-injury Tegner activity level, graft type, cartilage injury, meniscal resection or repair, and symmetrical 6-month limb symmetry index (LSI ≥ 90%) in isokinetic extension and flexion strength and single-leg-hop performance. A total of 2663 patients were analysed. The proportion of patients achieving a PASS varied between the KOOS subscales as follows: Pain 64.8%; Symptoms 93.8%; Activities of Daily Living (ADL) 49.1%; Sport and Recreation (Sport&Rec) 65.4% and Quality of Life (QoL) 73.5%. Age ≥30 years was positively associated with PASS across all subscales. Female sex reduced the odds of achieving a PASS on the Pain (OR 0.80; 95% confidence interval [CI] 0.65-0.99; p = 0.04), Symptoms (OR 0.57; 95% CI 0.36-0.90; p = 0.02) and Sport&Rec (OR 0.73; CI 95% 0.59-0.90; p = 0.004) subscales. A surgical delay of ≥3 months was negatively associated with the achievement of a PASS on the QoL (OR 0.71; 95% CI 0.51-0.99; p = 0.04) subscale. Medial meniscus (MM) repair reduced the odds of achieving a PASS on the Sport&Rec (OR 0.61; 95% CI 0.41-0.92; p = 0.02) and QoL (OR 0.56; 95% CI 0.37-0.86; p = 0.01) subscales. Hamstring tendon (HT) autograft rather than bone-patellar-tendon-bone autograft had increased odds of achieving a PASS on the Sport&Rec (OR 2.13; 95% CI 1.31-3.47; p = 0.002) subscale. Achieving a LSI ≥ 90% in isokinetic extension strength was associated with a PASS on ADL (OR 1.01; 95% CI 1.00-1.02; p = 0.02) and QoL (OR 1.01; 95% CI 1.00-1.02; p = 0.02) subscales, whereas an LSI ≥ 90% in single-leg-hop test was associated with a PASS on the Symptoms (OR 1.03; 95% CI 1.01-1.05; p < 0.001), ADL (OR 1.01; 95% CI 1.00-1.02; p = 0.02), Sport&Rec (OR 1.01; 95% CI 1.01-1.02; p = .003), and QoL (OR 1.01; 95% CI 1.00-1.02; p = 0.01) subscales. The achievement of a PASS was over 64% on at least four out of five KOOS subscales 5 years after ACLR. Older age (≥ 30 years) was consistently associated with higher odds of achieving a PASS, while female sex was associated with lower odds. MM repair was associated with reduced odds of achieving a PASS on the Sport&Rec subscale, whereas the use of HT grafts was associated with higher odds on the same subscale. Symmetrical isokinetic extension strength and single-leg-hop test performance at 6 months were associated with higher odds of achieving a PASS; however, the effect sizes were small, suggesting limited clinical relevance. Level III.