Abstract
Objectives:
Despite attaining satisfactory knee function following anterior cruciate ligament (ACL) reconstruction, many athletes are unable to return to their pre-injury level of play. ACL tears are known to take a significant psychological toll on the injured athlete and an athlete’s “psychological readiness” may play a large role in their ability to return to sport. The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale is the only questionnaire to specifically assess the psychological readiness to return to sport after ACL reconstruction. Several factors have been identified to affect an athlete’s psychological readiness to return to sport including age and sex. However, the effect of graft choice on psychological readiness to return to sport have not been studied. The purpose of this study was to evaluate the effect of graft choice on the athlete’s psychological readiness to return to sport. We hypothesized that patients undergoing ACL reconstruction with quadriceps autograft (QA) would reach higher ACL-RSI scores earlier than patients using hamstring autograft (HA) and bone-patellar tendon- bone (BTB) autografts.
Methods:
The study was a prospective, non-randomized study involving high-level athletes undergoing primary ACL reconstruction with or without meniscal surgery. The participants were involved in varsity high-school, college or professional sports. Each athlete was placed in a group depending on if an all- soft-tissue quadriceps autograft (QA Group), bone-patellar tendon-bone autograft (BTB Group) or hamstring autograft (HA Group) was used for their reconstruction. Graft choice was made by the athlete after the benefits and risks of each graft were discussed in detail. Over the study period, thirty consecutive athletes in each group undergoing primary ACL reconstruction with each specific graft were entered into the study. Athletes undergoing concomitant surgery other than meniscal surgery were excluded from the study. The athletes were asked to fill out the ACL-RSI scale 6-months following surgery, at the time of release to full sport and 2-years following surgery. Current literature shows an ACL-RSI score of 65 or higher as being the score that best predicts return to sport. In addition to comparing the ACL-RSI raw scores between groups, we also compared the percentage of patients reaching an ACL-RSI score of 65 (A-R 65) between the graft types. In addition, patient reported outcomes (PROs) including the International Knee Documentation Committee (IKDC) and Lysholm surveys were completed at the same time points as the ACL-RSI scores. Clinical outcomes included return to sport (RTS), RTS at the same or higher level, time to RTS and graft re-tear. All patients underwent the same rehabilitation protocol regardless of the graft used. RTS was allowed based on appropriate progression through the rehab program, quadriceps strength 90% that of the non-operated leg and triple-hop test 90% the non-operative leg. Return to sport was defined as participation in an official game within the chosen sport of the athlete.
Results:
The demographics between the three groups was homogenous with the overall average age of the group being 19.1 years. The study included 43.3% high school, 50% college and 6.7% professional athletes with no difference between the groups. The HA group had an ACL-RSI score of 49.2 at 6- months, 59.2 at RTP and 61.7 at the 2-year follow up. The BTB group had scores of 48.1, 64.7 and 63.1 at 6-month, RTP and 2-years postoperatively. The QA group had significantly higher scores than both the HA and BTB groups at the 6-month time period (65.3), and RTP time point (70.6) and similar scores compared to the other two groups at the 2-year follow up (72.7). The HA and BTB groups had similar ACL-RSI raw scores throughout the study. The QA group had a higher percentage of patients reaching the A-R 65 level (53.3%) compared to the HA group (23.3%) and the BTB group (13.3%) at the 6-month postoperative time point. At the RTS time point, the QA group again had a significantly higher rate of patients reaching the A-R 65 level (65.4%) than the other two groups (33.3% HA and 36% BTB group). At the 2-year time point, there was no difference between the three groups with regards to reaching the A- R 65 level. The percentage of athletes reaching the A-R 65 level was not different between the HA and BTB groups at any time point. The IKDC and Lysholm scores were similar between the three groups at all time points. The overall RTP for the study was 82.2% and RTP at the same or higher level was 62.2%.
There was no significant difference in return to play between the three groups (HA group 77%, BTB group 83.3% and QA group 87%). Likewise, RTP at the same or higher level was similar between the groups at 57%, 63% and 67% for the HA, BTB and QA groups respectively. There was a significant difference between the QA group and the HA and BTB groups with respect to time to RTS. The average time to RTS for the QA group was 8.1 months compared to 10.5 months for the HA group and 9.6 months for the BTB group. All three groups showed a significant intragroup difference in the ACL-RSI score at all time points between the cohort of patients in each group who were able to return to sport at the same or higher level and those who could not. Clinically, graft re-tears occurred in 17% of the HA group, 10% of the BTB group and 0% of the QA group (p=.02).
Conclusions:
The QA lead to a higher ACL-RSI score and higher percentages of athletes reaching the A-R 65 level at the 6-month and RTS time points compared to both the hamstring and BTB groups. This fact may explain why the quad group was able to return to sport in significantly less time than the other two groups. The higher ACL-RSI score may be an indication of an athlete’s confidence in their reconstructed knee. This confidence after surgery may allow the athlete to break through the psychological barriers that can make return to sport difficult.