Quality of Life After Anterior Cruciate Ligament Reconstruction

What is Quality of Life?

The World Health Organization has defined quality of life (QOL) as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns . The concept of QOL encompasses the following three principles:

QOL reflects an individual’s perceived discordance between their ideal or expected state and their current state and abilities.
QOL is a subjective concept; interpretation is specific to the individual and dependent on a wide range of personal factors, including cultural, behavioral, psychological, environmental, and societal influences.
QOL is a dynamic construct, which changes over time in line with the individual’s expectations, beliefs, circumstances, knowledge, and experiences.

Health-Related Quality of Life

Health-related QOL refers to the impact of an individual’s health on their QOL. It is subject to the same principles outlined previously.

Knee-Related Quality of Life

Knee-related QOL refers to the influence of an individual’s knee on their QOL. This is a useful measure following anterior cruciate ligament (ACL) injury, and it is influenced by a person’s surgical expectations and beliefs, and the impact of their knee on their ability to achieve their desires, goals, and ambitions. This impact depends on an individual’s life priorities and circumstances, which can change over time.

Why should we Measure Quality of Life after Anterior Cruciate Ligament Reconstruction?

Arguably, improving a patient’s QOL should be the primary rationale for ACL reconstruction (ACLR). Every ACL-reconstructed patient has unique beliefs, ambitions, experiences, goals, and personal attributes. Such factors may explain variation in surgical outcomes and provide a rationale to shift toward more individualized, personalized patient-centered care. QOL measures can give context and meaning to objective measures that are commonly used to assess outcomes of ACLR. The impact of a physical impairment or symptom on an individual’s QOL should guide management strategies. ACLR can create physical and psychological trauma to an individual and has associated costs, risks, and complications. In order to weigh the risks, costs, and benefits, surgeons and patients must predict the likely impact of surgical ACLR on future QOL, well-being, and life satisfaction. Therefore information on long-term QOL following ACL rupture, and factors that may impact future QOL are of great value to both healthcare professionals and ACL-ruptured individuals.

How do we Measure Quality of Life Following Anterior Cruciate Ligament Reconstruction?

Patient-reported outcome measures are commonly used to measure QOL before and after ACLR. These measures can be generic, knee-specific, or ACL-specific. Generic, health-related QOL measures do not include knee-specific questions and have often been used in a range of populations with published results available for comparison. Knee-specific QOL measures ask questions pertaining to the knee, but are not specific to an ACL-ruptured population (e.g., validated for use in ACL, knee osteoarthritis, and meniscal pathology populations). Finally, ACL-specific QOL measures contain questions pertaining to the ACL-ruptured knee, and are most specific to this population. In Table 115.1 we outline the most common measures used to date, to measure QOL in ACL-reconstructed populations.

TABLE 115.1

Commonly Used Patient-Reported Measures of Quality of Life in Anterior Cruciate Ligament-Ruptured Populations

Outcome Measure	Items/Domains	Considerations
Knee-Related Quality of Life
KOOS-QOL subscale	Comprises four questions addressing knee awareness, knee-related lifestyle modifications, knee confidence, and knee-related difficulties	Valid for use in ACL-ruptured individuals, high test-retest reliability in patients with knee injury (KOOS-QOL ICCs from 0.83 to 0.95) Has been used extensively in ACL-ruptured populations and many results are available for comparison Quick and easy to complete It is possible to experience increased knee awareness and make positive lifestyle changes without a negative impact on quality of life. (This would result in a poor KOOS-QOL score.) Patients who consider their current knee function to be satisfactory between 6 and 24 months after ACLR reported a mean KOOS-QOL score of 73 (95% CI 71–75). The Minimal Detectable Change in patients with knee injury is 21.1 points.
ACL-Specific Knee-Related Quality of Life
ACL-QOL	Contains 31 questions comprising five subscales (symptoms and physical complaints, work-related concerns, sports/recreation, lifestyle, and social and emotional)	Valid, responsive to change, and reliable for use in ACL-ruptured individuals The only measure devised with the purpose of assessing quality of life in an ACL-ruptured population Includes items most relevant and important to ACL-ruptured individuals, compared with other knee-related measures
Health-Related Quality of Life
SF-36	Comprises 36 questions across eight health domains: bodily pain, general health, mental health, physical function, role emotional, role physical, social function, and vitality	Valid for use in ACL-ruptured individuals but may be subject to floor and ceiling effects in ACL populations The SF-36 is useful for measuring group changes over time after ACLR ; however, SF-36 subscales have low sensitivity to individual change after orthopaedic surgery. Extensive population norms are available from multiple countries and specific populations, including athletic populations. Can calculate a physical and mental summary component score
EQ-5D	Contains five questions addressing mobility, self-care, usual activities, pain/discomfort, and anxiety/depression Features an additional question addressing perceived overall health status measured on a VAS	Contains a VAS measure of self-perceived overall health status May not measure items of relevance or importance to ACL groups, potential for ceiling effect due to two of five items addressing self-care and walking mobility, and no reference to high-level activities

ACL, Anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ACL-QOL, quality of life assessment in anterior cruciate ligament deficiency questionnaire; EQ-5D , Euro-Qol 5D; KOOS, Knee Injury and Osteoarthritis Outcome Score; SF-36, short-form 36; VAS, visual analogue scale.

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