Clinical Review

Current Concepts in Clinical Research: Anterior Cruciate Ligament Outcome Instruments

Publish date: May 4, 2018

Molly Day, MD, ATC

Kyle Hancock, MD

Natalie Glass, PhD

Matthew Bollier, MD

TAKE-HOME POINTS

PRO instruments are widely used to capture patient perception of general health, QOL, daily function, and pain, and are an essential part of evaluation after ACL reconstruction.
ACL outcome measures vary widely in regards to their validity, reliability, minimal clinically important difference, and applicability to specific patient populations.
There is currently no standardized instrument universally accepted as superior following ACL reconstruction.
In most cases, a general health outcome measure should be used in combination with a condition-specific rating scale.
Activity rating scales, such as Marx or Tegner, should be included when evaluating patients with low-activity lifestyles.

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ABSTRACT

Outcome instruments have become an essential part of the evaluation of functional recovery after anterior cruciate ligament (ACL) reconstruction. Although the clinical examination provides important objective information to assess graft integrity, stability, range of motion, and strength, these measurements do not take the patient’s perception into account. There are many knee outcome instruments, and it is challenging for surgeons to understand how to interpret clinical research and utilize these measures in a practical way. The purpose of this review is to provide an overview of the most commonly used outcome measures in patients undergoing ACL reconstruction and to examine and compare the psychometric performance (validity, reliability, responsiveness) of these measurement tools.

Anterior cruciate ligament (ACL) reconstruction is one of the most common elective orthopedic procedures.¹ Despite advances in surgical techniques, ACL reconstruction is associated with a lengthy recovery time, decreased performance, and increased rate of reinjury.² Patients undergoing ACL reconstruction are often active individuals who participate in demanding activities, and accurate assessment of their recovery helps to guide recovery counseling. In addition to objective clinical outcomes measured through physical examination, patient-reported outcome (PRO) instruments add the patient’s perspective, information critical in determining a successful outcome. A variety of outcome instruments have been used and validated for patients with ACL tears. It is important for orthopedic surgeons to know the advantages and disadvantages of each outcome tool in order to interpret clinical studies and assess postoperative patients.

Over the last 10 years, there has been an increase in the number of knee instruments and rating scales designed to measure PROs, with >54 scores designed for the ACL-deficient knee.³ No standardized instrument is currently universally accepted as superior following ACL reconstruction across the spectrum of patient populations. Clinicians and researchers must carefully consider an outcome instrument’s utility based on specific patient populations in which it has been evaluated. Appropriate selection of outcome measures is of fundamental importance for adequate demonstration of the efficacy and value of treatment interventions, especially in an era of healthcare reform with a focus on providing high-quality and cost-effective care.

The purpose of this review is to highlight current tools used to measure outcomes after ACL reconstruction. Current outcome measures vary widely in regards to their validity, reliability, minimal clinically important difference, and applicability to specific patient populations. We have thus identified the measures most commonly used today in studies and clinical follow-up after ACL reconstruction and their various advantages and limitations. This information may enhance the orthopedic surgeon’s understanding of what outcome measures may be utilized in clinical studies.

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