Summary
Following revision ACLR, patients demonstrated lower levels of psychological readiness, inferior knee outcomes, and delayed return to sports clearance compared to primary reconstructions.
Abstract
Background
Revision ACL reconstruction (ACLR) has demonstrated worse functional outcomes and higher reinjury rates in young patients. However, psychological outcomes associated with revision ACL surgery are not well understood. The purpose of this study was to investigate psychological readiness to return to sport and levels of psychological stress in young patients after revision ACLR.
Methods
This was a prospective cohort study of young patients who underwent revision ACLR. Enrolled participants were evaluated 6-months post-operatively with the following patient reported outcomes measures: Anterior Cruciate Ligament Return to Sport After Injury Scale (ACL-RSI), PROMIS-Psychological Stress Experience (PROMIS-PSE), International Knee Documentation Committee (IKDC/Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Scale (HSS Pedi-FABS). Patient reported outcomes of revision ACLR patients were compared to a cohort of primary ACLR patients. Propensity score matching between primary and revision cohorts (3:1) was performed for age, sex, and graft type.
Results
Matching resulted in 90 ACL reconstruction patients (60 primary, 30 revision). The revision cohort’s mean age was 19.0 (range, 14.1-28.34 years) and was 63% female. Revision patients were on average 15.9 years old at the time of their primary reconstruction, and the median time to revision surgery was 28 months (range 15-55) after primary reconstruction. In the matched analysis, the most common graft type in both the cohorts was BTB (primary, 73%, revision, 70%). Among both primary and revision ACL patients, a mild negative correlation was detected between IKDC and PROMIS-PSE scores (r=-0.32; 95% CI=-0.49, -0.12; p=0.002). Positive correlations were observed between the ACL-RSI and IKDC (r=0.50; 95% CI=0.32, 0.70; p<0.001) and Pedi-FABS (r=0.25; 95% CI=0.05, 0.43; p=0.02) scores.
Revision ACLR patients had lower psychological readiness scores (43.4 vs. 58.7, p=0.002) and lower Pedi-FABS scores (22 vs. 25, p=0.02), compared to primary ACLR patients. Regression analysis showed revision patients had a 17-point decrease in ACL-RSI scores compared to primary patients (ß=-16.9; 95% CI=-27.21, -6.67; p=0.002), controlling for age at primary surgery and propensity score. Revision patients had a 16% increase in the time to return to sports clearance compared to primary ACLR patients (95% CI=0.29, 2.60; p=0.01). No differences were noted in Pedi-IKDC/IKDC or PROMIS-PSE scores between the cohorts.
Conclusion
Revision ACLR patients had significantly lower levels of psychological readiness, inferior knee outcomes, and delayed return to sport clearance when compared to a matched cohort of primary ACLR patients. Greater attention to the psychological aspects of recovery in revision ACLR patients may be important to help optimize post-operative care and outcomes for this challenging patient population.