Clinical Sports Medicine Update

Timeline for Maximal Subjective

Outcome Improvement After
Anterior Cruciate Ligament Reconstruction
Avinesh Agarwalla,* BS, Richard N. Puzzitiello,* BS, Joseph N. Liu,y MD,
Gregory L. Cvetanovich,z MD, Anirudh K. Gowd,* BS, Nikhil N. Verma,* MD,
Brian J. Cole,* MD, MBA, and Brian Forsythe,*§ MD
Investigation performed at Rush University Medical Center, Chicago, Illinois, USA

Background: Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes.
Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return
to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics.
Purpose: To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome
measures (PROMs).
Study Design: Systematic review.
Methods: A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to
a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6
months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clin-
ically important difference.
Results: This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant
improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction,
but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Doc-
umentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was
noted beyond that.
Conclusion: After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no
further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive
metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm.
Clinical Relevance: After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.
Keywords: maximal medical improvement; minimal clinically important difference; anterior cruciate ligament; patient-reported
outcome measures

Anterior cruciate ligament (ACL) tears are one of the most
common traumatic knee injuries experienced by athletes in
the United States.53 Management typically includes opera-
tive reconstruction to restore knee stability and function
and reduce discomfort, with the goal of returning athletes
to preinjury functionality.57 Outcome reporting from ACL
reconstruction includes objective clinical measures, such as
anterior laxity, flexion, and extension, as well as return to
sport, and subjective patient-reported outcome mea-
sures.8,10,14,15 Return to play is often viewed as the goal of
ACL reconstruction and is used by physicians to establish
The American Journal of Sports Medicine
1–9
DOI: 10.1177/0363546518803365
Ó 2018 The Author(s)
a successful intervention.29 However, at the time of return
to sport, patients may not be participating at their previous
levels of function.1 Improved function, return to play, and
decreased pain are the most valued metrics by patients after
ACL reconstruction.21,32,40 The Lysholm scale, International
Knee Documentation Committee (IKDC) questionnaire, and
Knee injury and Osteoarthritis Outcome Score (KOOS) are
outcome measures that assess patient symptomatology and
function with knee-specific questions. However, Short Form
Health Surveys are utilized to assess a patient’s general
health.30,39 Together, these types of assessments yield a sum-
mation of a patient’s limitations, symptoms, and satisfaction,
thereby recapitulating a patient’s overall well-being.
A change in an outcome metric may be statistically sig-
nificant; however, this change may not be meaningfully
detectable by the patient. Thus, the emphasis has shifted
from utilizing statistical significance toward assessing the

1
2 Agarwalla et al The American Journal of Sports Medicine

clinically significant improvement of these patient-reported

Records idenfied through Addional records idenfied
outcome measures.20 The minimal clinically important dif- database searching through other sources
ference (MCID), defined as the smallest change in an out- (n = 7,241) (n = 16)
come that a patient perceives as being clinically
significant, is commonly used to interpret patient-reported
outcome measures.22,38,47 Maximal medical improvement Records aer duplicates removed
was previously described as the point where a patient’s con- (n = 2,567)
dition has stabilized and any intervention beyond this point
will not improve one’s physical or emotional state.6,26 While
maximal medical improvement has traditionally been
Records screened Records excluded
defined through clinical evaluation, it was recently rede- (n = 2,547) (n = 2,283)
fined as the time point when no further subjective improve-
ment is perceived, as summarized via patient-reported
outcome measures that no longer exceed an MCID.63 Full-text arcles assessed Full-text arcles excluded
Using these patient-centered measures, we aim to for eligibility due to failure to meet
define when patients perceive that they have reached max- (n = 284) inclusion/exclusion criteria
(n = 250)
imal subjective medical improvement after arthroscopic
ACL reconstruction. Establishing the time point where
Studies included in
maximal subjective medical improvement occurs will allow
qualitave synthesis
physicians to educate and disseminate realistic expecta- (n = 34)
tions to patients in their postoperative care after ACL
1 arcle excluded due to
reconstruction, while enabling clinical decision making to reporng separate cohort
be improved and become more efficient. We hypothesize at each me point
that patients will exhibit maximal clinically detectable 1 arcle excluded due to
unreported raw data
improvement by 1 year and will no longer demonstrate 2 arcles due to data
any improvement beyond 1 year. reported in a graph

Studies included in
METHODS quantave synthesis
(n = 30)

Search Strategy
The PubMed database was searched on January 5, 2018,
with the following search terms: anterior cruciate ligament
and ACL in combination with 2 years, 2-year, 24 months,
24-months, as well as randomized control trial. This cap-
tured 2547 articles that reported data at the 2-year time
point. The titles and abstracts of the resulting studies
were reviewed by 2 independent reviewers (A.A., R.N.P.).
The full text of the article was reviewed if the abstract
mentioned the collection of any clinical outcome at 2
years or if there was uncertainty about outcome reporting.
The citations of included articles were also reviewed to
identify articles that were missed by the initial query.
Selection criteria included studies published since 2000,
that reported clinical outcomes after arthroscopic ACL
Figure 1. PRISMA (Preferred Reporting Items for Systemic
Reviews and Meta-Analyses) flow diagram of inclusion
process.
reconstruction among skeletally mature patients at 1
year, 2 years, and at least 1 additional time point before
2 years. Studies that met inclusion criteria and reported
outcomes at an additional time point beyond 2 years
were also included in this investigation (Figure 1). Articles
were excluded if reconstruction was performed for a par-
tially torn ACL, outcomes were reported for a skeletally
immature patient, outcomes were included at a single
time point, or outcomes were not reported at 2 years. If
a study was included and reported a clinical outcome score

§
Address correspondence to Brian Forsythe, MD, Midwest Orthopaedics at Rush, Division of Sports Medicine, Rush University Medical Center, 1611 W
Harrison St, Chicago, IL 60612, USA (email: brian.forsythe@rushortho.com).
*Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.
y
Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA.
z
Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
One or more of the authors has declared the following potential conflict of interest or source of funding: G.L.C. has received education payments from
Smith & Nephew, Arthrex, and Medwest Associates. N.N.V. has received research support from Arthrex, DJ Orthopaedics, and Arthrosurface; has received
royalties from Arthroscopy and Smith & Nephew; holds stock or stock options from Cymedica, Minivasice, and OMeros; is a paid consultant for Orthosur-
face, Minivasice, Medacta, and Smith & Nephew; and has received other financial support from Pacira Pharmaceuticals. B.J.C. has received research sup-
port from Aesculap/B. Braun; holds stock or stock options from Biometrix and Aqua Boom; receives intellectual property royalties from DJ Orthopaedics,
Elsevier, Encore Medical, and Arthrex; has received other financial support from Athletico, Lifenet Health, and Carticept; is a paid consultant for and has
received research support from Arthrex, Geistlich Pharma, Vericel, Zimmer Biomet, Anika Therapeutics, Genzyme, Pacira Pharmaceuticals, and Isto Tech-
nologies; and has received hospitality payments from GE Healthcare. B.F. has received research support from Arthrex and Stryker; is a consultant for
Stryker and Sonoma Orthopaedics; has received fellowship support from Ossur and Smith & Nephew; holds stock or stock options from Jace Medical;
and has received education payments from Arthrosurface and Medwest Associates. AOSSM checks author disclosures against the Open Payments Data-
base (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. XX, No. X, XXXX Maximal Subjective Improvement After ACL Reconstruction 3

TABLE 1
Studies Meeting Inclusion Criteria for Analysis

First Author Year Journal Study Design Level of Evidence

Aune2 2001 American Journal of Sports Medicine Randomized controlled trial 1

Tay58 2018 Arthroscopy Retrospective cohort study 3
Wang61 2017 Arthritis Research and Therapy Randomized controlled trial 1
Minzlaff32 2018 Knee Surgery, Sports, Traumatology, Arthroscopy Prospective cohort study 2
Runer50 2018 Knee Surgery, Sports, Traumatology, Arthroscopy Retrospective cohort study 3
Yasen62 2017 Knee Prospective cohort study 2
Schurz54 2016 Arthroscopy Retrospective cohort study 3
Lubowitz27 2015 Arthroscopy Randomized controlled trial 2
Mohtadi33 2015 Clinical Journal of Sport Medicine Randomized controlled trial 1
Del Torto9 2015 Knee Surgery, Sports, Traumatology, Arthroscopy Retrospective cohort study 3
Koga24 2014 American Journal of Sports Medicine Retrospective cohort study 3
Ballal3 2013 Arthroscopy Retrospective cohort study 3
Lubowitz28 2013 Arthroscopy Randomized controlled trial 1
Ochiai41 2012 Archives of Orthopedic and Trauma Surgery Prospective cohort study 2
Beynnon4 2011 American Journal of Sports Medicine Randomized controlled trial 1
Oiestad42 2010 American Journal of Sports Medicine Prospective cohort study 2
Jagodzinski18 2010 American Journal of Sports Medicine Randomized controlled trial 1
Ghalayini13 2010 Knee Randomized controlled trial 1
Risberg48 2009 American Journal of Sports Medicine Randomized controlled trial 1
Hill16 2005 American Journal of Sports Medicine Randomized controlled trial 2
Peterson45 2001 Arthroscopy Prospective cohort study 2
Jarvela19 2008 American Journal of Sports Medicine Randomized controlled trial 1
Otsuka43 2003 American Journal of Sports Medicine Prospective cohort study 2
Beynnon5 2005 American Journal of Sports Medicine Randomized controlled trial 1
Maletis31 2007 American Journal of Sports Medicine Randomized controlled trial 1
Moller34 2001 Knee Surgery, Sports, Traumatology, Arthroscopy Randomized controlled trial 1
Fink12 2000 Arthroscopy Randomized controlled trial 1
Ruffilli49 2016 European Journal of Orthopedic Surgery and Traumatology Randomized controlled trial 1
Kautzner23 2015 International Orthopedics Randomized controlled trial 1
Seijas55 2016 Archives of Orthopedic and Trauma Surgery Prospective cohort study 2

at only 2 time points, that particular outcome metric was
not recorded for this investigation.
Data Extraction
Data extraction included title, journal, first author, date of
publication, study design, enrollment at each reported
time point, study intervention, type of graft, graft fixation
at the femoral and tibial sockets, concomitant injuries,
incidence of complications, frequency of reruptures, and
patient-reported outcome measures. Clinical outcome scores
included the KOOS, IKDC, Cincinnati Rating System, Short
Form–12 Physical Component (SF-12 Physical), Short
Form–12 Mental Component (SF-12 Mental), Lysholm,
and Tegner Activity Scale. A distribution-based method con-
structed from statistical characteristics of the obtained sam-
ples was used to calculate MCID for those outcome metrics
that had a calculated MCID.37,44,47 MCIDs were previously
established for the IKDC (MCID = 9), Lysholm (MCID = 10),
SF-12 Physical (MCID = 5.1), and SF-12 Mental (MCID =
4.3).37 An MCID was also established for each subscore of
the KOOS: Pain (MCID = 1.7), Symptoms (MCID = 1.7),
Activities of Daily Living (MCID = 1.3), Sports (MCID =
2.2), and Quality of Life (MCID = 2.4).44 If multiple MCIDs
were previously reported for an individual patient-reported
outcome measure, the smallest MCID was used for analysis.
Instead of finding the average MCID for that outcome mea-
sure, the smallest MCID was used because a discernible
change in pain or function was noted at that MCID, which
justifies a minimally important clinical improvement. Addi-
tionally, using the smallest MCID would result in more fre-
quent visits and/or a longer duration to maximal medical
subjective improvement, owing to increased sensitivity of
detecting a change in outcome metrics. For scores without
an established MCID, statistical significance was used to
analyze the change in outcome measures.
Data Analysis
Data for each patient-reported outcome measure were ana-
lyzed by the use of reported means and standard deviations.
Clinical outcomes were compared in the following intervals: 6
weeks to 3 months, 3 months to 6 months, 6 months to 1 year,
and 1 to 2 years via weighted averages. The overall weighted
average score was calculated with the number of patients fol-
lowed up at each time point for each study. Standard devia-
tion was used to report the distribution of pooled statistics. If
a singular study reported a score at an individual time point
4 Agarwalla et al The American Journal of Sports Medicine

TABLE 2 were excluded because data were reported solely in the

Pooled Characteristics form of a graph, which prevented accurate data extraction.
and Patient Data of Included Studies Another study reported data as a change in scores from
baseline; however, baseline data were not provided, and
n (%) or Mean 6 SD the study was removed. An additional study was excluded
Levels of evidence (n = 30) because it reported a separate cohort of patients at each
1 17 time point. Thus, 30 studies were included for analysis
2 7 (Table 1). Three of the included studies did not report
3 6 patient-reported outcome measures at multiple time
Age, y 29.5 6 5.5 points, but objective clinical measures were provided. The
Sex mean 6 SD number of subjective clinical outcomes
Male 1310 (58.2) reported in these studies was 1.9 6 1.1. Collectively,
Female 940 (41.8) 2253 patients underwent ACL reconstruction across all
Chondral injuries (n = 917) 173 (18.9)
included studies. Pooled characteristics of the included
Meniscal injuries (n = 1219) 566 (46.4)
Graft type (n = 2253)
studies are provided in Table 2.
Bone–patellar tendon–bone 763 (33.9) The following clinical outcome scores were reported:
Hamstring 1167 (51.8) IKDC, KOOS, Lysholm, Tegner Activity Scale, SF-12
Artificial graft 24 (1.1) Physical and Mental, Knee Society Score, and the Cincin-
Tibialis 206 (9.1) nati Rating System. The difference in the means of the
Quadriceps 93 (4.1) clinical outcome scores and their progression toward
Femoral fixation (n = 2086) becoming minimally clinically significant are depicted in
Interference screw 761 (36.5) Table 3. The IKDC, Lysholm, and SF-12 Physical did not
Suspensory device 1087 (52.1) demonstrate a significant improvement exceeding the
Cross-pin 238 (11.4)
MCID at 6 months to 1 year, 1 to 2 years, or 6 months to
Tibial fixation (n = 2086)
Interference screw 1482 (71.1)
2 years. The SF-12 Mental subscore did not exceed the
Suspensory device 253 (12.1) MCID at any postoperative time point. The KOOS Pain,
Suture 247 (11.8) Symptoms, Quality of Life, and Sports subscores exhibited
Staple 104 (4.9) clinically detectable improvements until postoperative 1
year but did not exhibit any improvement beyond 1 year
(Table 4). The KOOS daily activity subscore exhibited
with no reported standard deviation, that clinical outcome a clinically detectable improvement until postoperative 6
measure was not analyzed at that period. A clinically signif- months and then did not illustrate any improvement
icant difference was defined as a change in the mean outcome beyond that period (Table 4). The IKDC and each KOOS
score that exceeded a previously determined MCID for that subscore exhibited minimal improvement after 1 year (Fig-
particular outcome (P \ .05).37,63 Maximal medical improve- ure 2, A and B). The Tegner Activity Scale did not have an
ment was determined by identifying the latest period where established MCID, and it demonstrated a statistically sig-
the change in singular outcome score did not exceed the nificant improvement up to postoperative 2 years. Two
MCID. If a change in score did not exceed the MCID at con- studies used the Knee Society Score as a clinical outcome
secutive time points, nonconsecutive time points were com- measure.27,28 Although no MCID has been established for
pared up to the final period to identify a clinically this outcome measure, there was no statistically signifi-
significant improvement. Concomitant injuries, complica- cant improvement beyond postoperative 1 year (Table 5).
tions, return to play, and retears were coalesced from studies Last, only 2 studies reported the Cincinnati Rating Sys-
reporting such outcomes and were reported descriptively. tem, which exhibited a statistically significant improve-
ment until postoperative 2 years.2,48
Two of the included studies reported specific return-to-
Statistical Analysis
play information.23,24 Fifty-six percent of patients (45 of
Statistical analysis was conducted with Microsoft Excel. 81) returned to their preinjury activity levels 8 months
All means were pooled for studies with reported data at postoperatively,23 and 100% (137 patients) returned to
a single time point. Standard deviation was used to report sport at 9 months.24 Complications were reported by 26
distribution of all pooled statistics. The Student t test was studies (87%): 149 total complications (6.3%) were
used for all statistical comparisons among various time reported, with 69 (2.9%) graft reruptures. The duration
points. All comparisons were 2-tailed, and a P \ .05 was from surgery to graft rerupture was reported in 7 stud-
considered statistically significant. ies,3,18,23,31,45,49,62 with 1.1% of ACL grafts rupturing
within 6 months and 2.3% rupturing at least 1 year after
index surgery (P = .12). Because of incomplete and hetero-
RESULTS geneous reporting, an average time of graft rupture could
not be provided. Other reported complications included
Thirty-four studies reported outcomes at 1 year, 2 years, 12 (0.5%) infections, 31 (1.31%) meniscal repairs, and 77
and an additional time point before 2 years. Two studies (3.3%) unspecified.
AJSM Vol. XX, No. X, XXXX Maximal Subjective Improvement After ACL Reconstruction 5

TABLE 3
Patient-Reported Outcomes at Different Postoperative Time Pointsa

Preop to 6 wk to 6 wk to 3 mo to 3 mo to 6 mo to 6 mo to 1y
6 wk 3 mo 6 mo 6 mo 1y 1y 2y to 2 y

IKDC (MCID = 9) (n = 722)

Significant clinical improvement? (P = .05) Yes No Yes Yes Yes No No No
Difference between means 9.6 4.3 16.7 12.4 18.3 5.9 8.9 3.0
P value \.001 \.001 \.001 \.001 \.01 ..99 0.6 \.99
Lysholm (MCID = 10) (n = 858)
Significant clinical improvement? (P = .05) No Yes Yes No No No No No
Difference between means 8.6 11.6 17.9 6.4 8.8 2.4 4.0 1.6
P value .99 \.001 \.001 ..99 ..99 ..99 ..99 ..99
SF-12 Physical (MCID = 5.1) (n = 276)
Significant clinical improvement? (P = .05) No No Yes Yes Yes No No No
Difference between means 0.9 4.3 10.0 5.7 9.2 3.5 4.2 0.6
P value ..99 ..99 \.001 .001 \.001 ..99 ..99 ..99
SF-12 Mental (MCID = 4.3) (n = 276)
Significant clinical improvement? (P = .05) No No No No No No No No
Difference between means 0.9 0.6 –2.2 –2.8 –0.5 2.3 2.9 0.7
P value ..99 ..99 ..99 ..99 ..99 ..99 ..99 ..99
Tegner Activity Scale (MCID = undetermined) (n = 536)
Significant clinical improvement? (P = .05) NA — — NA NA NA NA NA
Difference between means –0.01 — — 1.5 2.3 0.8 1.2 0.4
P value .55 — — \.001 \.001 \.001 \.001 \.001

a
Dashes (—) indicate unavailable time points. IKDC, International Knee Documentation Committee; MCID, minimal clinically important
difference; NA, not available; preop, preoperative; SF-12 Mental, Short Form–12 Mental Component; SF-12 Physical, Short Form–12 Phys-
ical Component.

TABLE 4
KOOS and Tegner Activity Scale at Different Postoperative Periodsa

Preop to 3 mo 3 mo to 6 mo 3 mo to 1 y 6 mo to 1 y 6 mo to 2 y 1 y to 2 y

KOOS–Activities of Daily Living (MCID = 1.3) (n = 173)

Significant clinical improvement? (P = .05) Yes Yes Yes No No No
Difference between means 5.6 6.5 7.8 7.7 3.4 –3.3
P value \.001 \.001 \.001 .66 .99 ..99
KOOS–Pain (MCID = 1.7) (n = 173)
Significant clinical improvement? (P = .05) Yes Yes Yes Yes Yes No
Difference between means 8.7 5.5 8.7 3.2 2.7 –0.5
P value \.001 \.001 \.001 \.001 .005 ..99
KOOS–Quality of Life (MCID = 2.4) (n = 173)
Significant clinical improvement? (P = .05) Yes Yes Yes Yes Yes No
Difference between means 17.0 8.9 20.7 11.9 12.0 0.2
P value \.001 \.001 \.001 \.001 \.001 ..99
KOOS–Symptoms (MCID = 1.7) (n = 173)
Significant clinical improvement? (P = .05) Yes Yes Yes Yes Yes No
Difference between means 7.2 8.5 10.5 2.0 3.0 1.0
P value \.001 \.001 \.001 .24 .0007 .95
KOOS–Sports (MCID = 2.2) (n = 173)
Significant clinical improvement? (P = .05) Yes Yes Yes Yes Yes No
Difference between means 11.2 15.7 22.8 7.0 8.8 1.8
P value \.001 \.001 \.001 \.001 \.001 .75
Tegner Activity Scale (MCID = undetermined) (n = 536)
Significant clinical improvement? (P = .05) NA NA NA NA NA NA
Difference between means –0.01 1.5 2.3 0.8 1.2 0.4
P value .55 \.001 \.001 \.001 \.001 \.001

a
KOOS, Knee injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; NA, not applicable; preop,
preoperative.
6 Agarwalla et al The American Journal of Sports Medicine

TABLE 5
Knee Society Score Outcomes at Different Postoperative Time Pointsa

Preop to 6 wk 6 wk to 1 y 6 wk to 2 y 1 y to 2 y

Knee Society Score–Function (MCID = undetermined) (n = 207)

Significant clinical improvement? (P = .05) NA NA NA NA
Difference between means 21.5 10.6 11.3 0.8
P value \.001 \.001 \.001 ..99
Knee Society Score–Pain (MCID = undetermined) (n = 207)
Significant clinical improvement? (P = .05) NA NA NA NA
Difference between means 18.7 7.8 6.3 –1.5
P value \.001 ..99 ..99 ..99

a
MCID, minimal clinically important difference; NA, not applicable; preop, preoperative.

A B
100 100
90 90
80 80

Outcome Scores
Outcome Score

70 70
KOOS Daily
60 IKDC 60
50 50 KOOS Pain
40 Lysholm 40
KOOS QoL
30 SF-12 P 30
20 20 KOOS Symptoms
SF-12 M
10 10 KOOS Sports
0 0
0 1.5 3 6 9 12 15 18 21 24 0 1.5 3 6 9 12 15 18 21 24
Months Postoperavely Months Postoperavely

Figure 2. Trend in (A) patient-reported clinical outcomes and (B) KOOS subscores after ACL reconstruction. ACL, anterior cru-
ciate ligament; IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score; QoL,
Quality of Life; SF-12 M, Short Form–12 Mental Component; SF-12 P, Short Form–12 Physical Component.

DISCUSSION several 5-option questions. The reliability, internal consis-

This systematic review established that patients reach max-
imal medical improvement 1 year after ACL reconstruction.
According to previously established MCIDs for the KOOS
to determine interval improvements, patients reported sub-
jective maximal improvement 1 year postoperatively and
exhibited no additional significant improvement beyond
1 year. Other patient-reported outcome measures, such as
the Lysholm, IKDC, and SF-12 Physical, exhibited no
clinically detectable improvement beyond postoperative 6
months.
After ACL reconstruction, patients exhibited interval
improvement in disease-specific patient-reported outcome
measures until postoperative 1 year. Maximal medical sub-
jective improvement was established 1 year postopera-
tively because the KOOS exhibited clinically significant
improvements until this point. However, the Lysholm
and IKDC questionnaires did not demonstrate clinically
significant improvement beyond 6 months. The IKDC,
KOOS, and Lysholm are commonly utilized disease-spe-
cific patient-reported outcome measures that assess knee
symptomatology and function; however, the KOOS con-
tains multiple subcategories that are each composed of
tency, dimensionality, and construct validity of the KOOS
may allow the survey to be more responsive to minute yet
clinically detectable changes as compared with the IKDC
and Lysholm.51,60 Alternatively, the IKDC and Lysholm
questionnaires may impose a ceiling effect in that they
do not have the specificity to capture continued improve-
ment beyond the 6-month interval. It was previously estab-
lished that the ceiling effect was present in the upper
extremity injuries of athletes,17 while Ra et al46 deter-
mined that a ceiling effect was also present with the
IKDC and Lysholm surveys within the ACL reconstruction
population. While the Lysholm, IKDC, and KOOS are dis-
ease-specific questionnaires, the Short Form Health Sur-
veys provide an assessment of patients’ generalized
quality of life. As with the IKDC and Lysholm, improve-
ments in the SF-12 Physical did not exceed clinical signif-
icance beyond 6 months. Additionally, the SF-12 Mental
demonstrated no clinically significant difference at any
time interval. ACL injury and its subsequent recovery
may not have an overall effect on mental status; however,
the preoperative SF-12 Mental is highly correlated with
return to play and clinically significant outcomes.40
Patients with higher preoperative SF-12 Mental scores
AJSM Vol. XX, No. X, XXXX
may demonstrate more resilience with the recovery process
and return to sport. Thus, the preoperative SF-12 Mental
may recapitulate resilience and be used as a surrogate
measure of psychological factors that influence return to
sport and subjective clinical outcomes.37
Determining when a patient can return to sport is a mul-
tifactorial equation in which time from surgery and subjec-
tive improvement are not the sole variables. Sensitive
objective measures, such as the single-legged hop test, thigh
circumference, and muscle strength, are frequently
assessed during return-to-play evaluation, as limb asymme-
try is associated with an increased risk of injury.10,14,36,52
According to previously established thresholds, patients
reached a patient-acceptable symptom state35—a
patient-reported outcome measure–based methodology of
establishing satisfaction—by postoperatively 12 months.
Although return to sport typically occurs between 6 and
13 months postoperatively,25 Ardern et al1 demonstrated
that 81% of patients return to sport at 12 months. How-
ever, only 33% of those patients returned to play at their
preinjury activity levels at that time point. As such, utiliz-
ing subjective patient outcomes may better define interval
improvements from ACL reconstruction. Maximal medi-
cal improvement and patient-acceptable symptom state
both demonstrated that patients were satisfied and
exhibited no additional interval improvement beyond
postoperative 1 year.35
The findings of this investigation can be used to improve
preoperative counseling and management of patient
expectations. Patient expectations after ACL reconstruc-
tion are high, with 91% expecting to return to their previ-
ous levels of sport.11 Appropriately establishing a patient’s
expectation is critical in achieving positive outcomes and
reducing dissatisfaction.11 While most patients return to
activity 6 to 13 months postoperatively,25 the findings of
this investigation can be used to inform patients that
they should expect clinically detectable interval improve-
ments even after they have returned to sport until postop-
erative 1 year. With an increased emphasis on shared
decision making to inform patients of clinical success,7,56
establishing a time point for maximal medical improve-
ment enables clinicians to improve patient-centered care
by (1) allocating the majority of resources during the period
when postoperative improvement is rapidly changing and
(2) advising patients that they will still see subjective
improvement up to 12 months after operative treatment.
We suggest that combining a patient’s perception of recov-
ery with a clinical examination that validates functional
recovery would be the optimal means of determining
a patient’s return to sport.
This study is limited because of the heterogeneity of the
included studies with regard to operative techniques and
rehabilitation protocols, as well as the lack of standardiza-
tion in assessing objective clinical measures. Additionally,
no study reported data between 6 months and 1 year, and
only a single study reported outcomes between 1 and 2
years. Without reporting at interim time points, improve-
ments that occurred earlier would not be captured. A
potential limitation of this study is that 50% of studies
were level 2 or 3 evidence. However, level of evidence
Maximal Subjective Improvement After ACL Reconstruction 7
should not hinder the outcomes of this study, since
patient-reported outcome measures are recorded prospec-
tively, even if the study was conducted retrospectively.
The final limitation of this investigation is that an estab-
lished MCID is specific to the patient population within
the study that the MCID was derived. Applying an
MCID to another study assumes that those populations
are similar.59 Despite the limitations of this study, the
sample sizes at each time point were large enough to suffi-
ciently power measurements at each interval and instill
confidence in the results.
CONCLUSION
After ACL reconstruction, maximal medical improvement
is established 1 year postoperatively, with no further
detectable clinical improvement beyond this time point
based on current patient-reported outcome measures.
The KOOS may be a more responsive metric to subjective
improvements in this patient cohort than other patient-
reported outcomes, such as the IKDC and Lysholm.
REFERENCES
1. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury
level of competitive sport after anterior cruciate ligament reconstruc-
tion surgery: two-thirds of patients have not returned by 12 months
after surgery. Am J Sports Med. 2011;39(3):538-543.
2. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand ham-
string tendon autograft compared with patellar tendon-bone auto-
graft for anterior cruciate ligament reconstruction: a randomized
study with two-year follow-up. Am J Sports Med. 2001;29(6):
722-728.
3. Ballal MS, Khan Y, Hastie G, Hatcher A, Coogan S, McNicholas MJ.
Functional outcome of primary hamstring anterior cruciate ligament
reconstruction in patients with different body mass index classes.
Arthroscopy. 2013;29(8):1314-1321.
4. Beynnon BD, Johnson RJ, Naud S, et al. Accelerated versus nonac-
celerated rehabilitation after anterior cruciate ligament reconstruc-
tion: a prospective, randomized, double-blind investigation
evaluating knee joint laxity using roentgen stereophotogrammetric
analysis. Am J Sports Med. 2011;39(12):2536-2548.
5. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior
cruciate ligament reconstruction: a prospective, randomized, dou-
ble-blind comparison of programs administered over 2 different
time intervals. Am J Sports Med. 2005;33(3):347-359.
6. Bhatia S, Piasecki DP, Nho SJ, et al. Early return to work in workers’
compensation patients after arthroscopic full-thickness rotator cuff
repair. Arthroscopy. 2010;26(8):1027-1034.
7. Bozic KJ, Belkora J, Chan V, et al. Shared decision making in
patients with osteoarthritis of the hip and knee: results of a random-
ized controlled trial. J Bone Joint Surg Am. 2013;95(18):1633-1639.
8. Davis JC, Bryan S. Patient reported outcome measures (PROMs)
have arrived in sports and exercise medicine: why do they matter?
Br J Sports Med. 2015;49(24):1545-1546.
9. Del Torto M, Enea D, Panfoli N, Filardo G, Pace N, Chiusaroli M.
Hamstrings anterior cruciate ligament reconstruction with and with-
out platelet rich fibrin matrix. Knee Surg Sports Traumatol Arthrosc.
2015;23(12):3614-3622.
10. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Bach BR
Jr. Return to play following anterior cruciate ligament reconstruction.
J Am Acad Orthop Surg. 2015;23(5):283-296.
8 Agarwalla et al
11. Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary
and revision anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc. 2016;24(1):201-207.
12. Fink C, Benedetto KP, Hackl W, Hoser C, Freund MC, Rieger M. Bio-
absorbable polyglyconate interference screw fixation in anterior cru-
ciate ligament reconstruction: a prospective computed tomography–
controlled study. Arthroscopy. 2000;16(5):491-498.
13. Ghalayini SR, Helm AT, Bonshahi AY, Lavender A, Johnson DS,
Smith RB. Arthroscopic anterior cruciate ligament surgery: results
of autogenous patellar tendon graft versus the Leeds-Keio synthetic
graft five year follow-up of a prospective randomised controlled trial.
Knee. 2010;17(5):334-339.
14. Graziano J, Chiaia T, de Mille P, Nawabi DH, Green DW, Cordasco
FA. Return to sport for skeletally immature athletes after ACL recon-
struction: preventing a second injury using a quality of movement
assessment and quantitative measures to address modifiable risk
factors. Orthop J Sports Med. 2017;5(4):2325967117700599.
15. Hambly K, Griva K. IKDC or KOOS: which one captures symptoms
and disabilities most important to patients who have undergone initial
anterior cruciate ligament reconstruction? Am J Sports Med.
2010;38(7):1395-1404.
16. Hill PF, Russell VJ, Salmon LJ, Pinczewski LA. The influence of sup-
plementary tibial fixation on laxity measurements after anterior cruci-
ate ligament reconstruction with hamstring tendons in female
patients. Am J Sports Med. 2005;33(1):94-101.
17. Hsu JE, Nacke E, Park MJ, Sennett BJ, Huffman GR. The Disabilities
of the Arm, Shoulder, and Hand questionnaire in intercollegiate ath-
letes: validity limited by ceiling effect. J Shoulder Elbow Surg.
2010;19(3):349-354.
18. Jagodzinski M, Geiges B, von Falck C, et al. Biodegradable screw
versus a press-fit bone plug fixation for hamstring anterior cruciate
ligament reconstruction: a prospective randomized study. Am J
Sports Med. 2010;38(3):501-508.
19. Jarvela T, Moisala AS, Sihvonen R, Jarvela S, Kannus P, Jarvinen M.
Double-bundle anterior cruciate ligament reconstruction using ham-
string autografts and bioabsorbable interference screw fixation: pro-
spective, randomized, clinical study with 2-year results. Am J Sports
Med. 2008;36(2):290-297.
20. Jevsevar DS, Sanders J, Bozic KJ, Brown GA. An introduction to clin-
ical significance in orthopaedic outcomes research. JBJS Rev.
2015;3(5):01874474-201503050-00002.
21. Kahlenberg CA, Nwachukwu BU, Ferraro RA, Schairer WW, Stein-
haus ME, Allen AA. How are we measuring patient satisfaction after
anterior cruciate ligament reconstruction? Orthop J Sports Med.
2016;4(12):2325967116673971.
22. Katz NP, Paillard FC, Ekman E. Determining the clinical importance
of treatment benefits for interventions for painful orthopedic condi-
tions. J Orthop Surg Res. 2015;10:24.
23. Kautzner J, Kos P, Hanus M, Trc T, Havlas V. A comparison of ACL
reconstruction using patellar tendon versus hamstring autograft in
female patients: a prospective randomised study. Int Orthop.
2015;39(1):125-130.
24. Koga H, Muneta T, Yagishita K, et al. Effect of notchplasty in ana-
tomic double-bundle anterior cruciate ligament reconstruction. Am
J Sports Med. 2014;42(8):1813-1821.
25. Lai CCH, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of
elite athletes return to preinjury sport after anterior cruciate ligament
reconstruction: a systematic review with meta-analysis of return to
sport rates, graft rupture rates and performance outcomes. Br J
Sports Med. 2018;52(2):128-138.
26. Lee S, Cvetanovich GL, Mascarenhas R, et al. Ability to return to
work without restrictions in workers compensation patients undergo-
ing hip arthroscopy. J Hip Preserv Surg. 2017;4(1):30-38.
27. Lubowitz JH, Schwartzberg R, Smith P. Cortical suspensory button
versus aperture interference screw fixation for knee anterior cruciate
ligament soft-tissue allograft: a prospective, randomized controlled
trial. Arthroscopy. 2015;31(9):1733-1739.
The American Journal of Sports Medicine
28. Lubowitz JH, Schwartzberg R, Smith P. Randomized controlled trial
comparing all-inside anterior cruciate ligament reconstruction tech-
nique with anterior cruciate ligament reconstruction with a full tibial
tunnel. Arthroscopy. 2013;29(7):1195-1200.
29. Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for
defining ‘‘successful outcome’’ after ACL injury and reconstruction:
a Delaware-Oslo ACL cohort investigation. Br J Sports Med.
2015;49(5):335-342.
30. Makhni EC, Padaki AS, Petridis PD, et al. High variability in outcome
reporting patterns in high-impact ACL literature. J Bone Joint Surg
Am. 2015;97(18):1529-1542.
31. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ. A prospective
randomized study of anterior cruciate ligament reconstruction:
a comparison of patellar tendon and quadruple-strand semitendino-
sus/gracilis tendons fixed with bioabsorbable interference screws.
Am J Sports Med. 2007;35(3):384-394.
32. Minzlaff P, Heidt T, Feucht MJ, et al. Patient satisfaction with health is
substantially improved following ACL reconstruction. Knee Surg
Sports Traumatol Arthrosc. 2018;26(2):582-588.
33. Mohtadi N, Chan D, Barber R, Oddone Paolucci E. A randomized clin-
ical trial comparing patellar tendon, hamstring tendon, and double-
bundle ACL reconstructions: patient-reported and clinical outcomes
at a minimal 2-year follow-up. Clin J Sport Med. 2015;25(4):321-331.
34. Moller E, Forssblad M, Hansson L, Wange P, Weidenhielm L. Bracing
versus nonbracing in rehabilitation after anterior cruciate ligament
reconstruction: a randomized prospective study with 2-year follow-
up. Knee Surg Sports Traumatol Arthrosc. 2001;9(2):102-108.
35. Muller B, Yabroudi MA, Lynch A, et al. Defining thresholds for the
patient acceptable symptom state for the IKDC subjective knee
form and KOOS for patients who underwent ACL reconstruction.
Am J Sports Med. 2016;44(11):2820-2826.
36. Myer GD, Martin L Jr, Ford KR, et al. No association of time from sur-
gery with functional deficits in athletes after anterior cruciate ligament
reconstruction: evidence for objective return-to-sport criteria. Am J
Sports Med. 2012;40(10):2256-2263.
37. Nwachukwu BU, Chang B, Voleti PB, et al. Preoperative short form
health survey score is predictive of return to play and minimal clini-
cally important difference at a minimum 2-year follow-up after ante-
rior cruciate ligament reconstruction. Am J Sports Med. 2017;45(12):
2784-2790.
38. Nwachukwu BU, Fields K, Chang B, Nawabi DH, Kelly BT, Ranawat
AS. Preoperative outcome scores are predictive of achieving the
minimal clinically important difference after arthroscopic treatment
of femoroacetabular impingement. Am J Sports Med. 2017;45(3):
612-619.
39. Nwachukwu BU, Hamid KS, Bozic KJ. Measuring value in orthopae-
dic surgery. JBJS Rev. 2013;1(1):01874474-201311000-00003.
40. Nwachukwu BU, Voleti PB, Berkanish P, et al. Return to play and
patient satisfaction after ACL reconstruction: study with minimum
2-year follow-up. J Bone Joint Surg Am. 2017;99(9):720-725.
41. Ochiai S, Hagino T, Senga S, Saito M, Haro H. Prospective evaluation
of patients with anterior cruciate ligament reconstruction using
a patient-based health-related survey: comparison of single-bundle
and anatomical double-bundle techniques. Arch Orthop Trauma
Surg. 2012;132(3):393-398.
42. Oiestad BE, Holm I, Aune AK, et al. Knee function and prevalence of
knee osteoarthritis after anterior cruciate ligament reconstruction:
a prospective study with 10 to 15 years of follow-up. Am J Sports
Med. 2010;38(11):2201-2210.
43. Otsuka H, Ishibashi Y, Tsuda E, Sasaki K, Toh S. Comparison of
three techniques of anterior cruciate ligament reconstruction with
bone–patellar tendon–bone graft: differences in anterior tibial transla-
tion and tunnel enlargement with each technique. Am J Sports Med.
2003;31(2):282-288.
44. Paradowski PT, Witonski D, Keska R, Roos EM. Cross-cultural trans-
lation and measurement properties of the Polish version of the Knee
injury and Osteoarthritis Outcome Score (KOOS) following anterior
AJSM Vol. XX, No. X, XXXX
cruciate ligament reconstruction. Health Qual Life Outcomes.
2013;11:107.
45. Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft
patellar tendon anterior cruciate ligament reconstruction: a 5-year
follow-up. Arthroscopy. 2001;17(1):9-13.
46. Ra HJ, Kim HS, Choi JY, Ha JK, Kim JY, Kim JG. Comparison of the
ceiling effect in the Lysholm score and the IKDC subjective score for
assessing functional outcome after ACL reconstruction. Knee.
2014;21(5):906-910.
47. Rai SK, Yazdany J, Fortin PR, Avina-Zubieta JA. Approaches for esti-
mating minimal clinically important differences in systemic lupus
erythematosus. Arthritis Res Ther. 2015;17:143.
48. Risberg MA, Holm I. The long-term effect of 2 postoperative rehabil-
itation programs after anterior cruciate ligament reconstruction: a ran-
domized controlled clinical trial with 2 years of follow-up. Am J
Sports Med. 2009;37(10):1958-1966.
49. Ruffilli A, Pagliazzi G, Ferranti E, Busacca M, Capannelli D, Buda R.
Hamstring graft tibial insertion preservation versus detachment in
anterior cruciate ligament reconstruction: a prospective randomized
comparative study. Eur J Orthop Surg Traumatol. 2016;26(6):657-664.
50. Runer A, Wierer G, Herbst E, et al. There is no difference between
quadriceps- and hamstring tendon autografts in primary anterior cru-
ciate ligament reconstruction: a 2-year patient-reported outcome
study. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):605-614.
51. Salavati M, Akhbari B, Mohammadi F, Mazaheri M, Khorrami M. Knee
injury and Osteoarthritis Outcome Score (KOOS): reliability and valid-
ity in competitive athletes after anterior cruciate ligament reconstruc-
tion. Osteoarthritis Cartilage. 2011;19(4):406-410.
52. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence
and risk factors for graft rupture and contralateral rupture after anterior
cruciate ligament reconstruction. Arthroscopy. 2005;21(8):948-957.
53. Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior
cruciate ligament tears and reconstruction: a 21-year population-
based study. Am J Sports Med. 2016;44(6):1502-1507.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Maximal Subjective Improvement After ACL Reconstruction 9
54. Schurz M, Tiefenboeck TM, Winnisch M, et al. Clinical and functional
outcome of all-inside anterior cruciate ligament reconstruction at
a minimum of 2 years’ follow-up. Arthroscopy. 2016;32(2):332-337.
55. Seijas R, Ares O, Sallent A, Alvarez P, Cusco X, Cugat R. Return to
prelesional Tegner level after anatomic anterior cruciate ligament
reconstruction. Arch Orthop Trauma Surg. 2016;136(12):1695-
1699.
56. Sepucha K, Atlas SJ, Chang Y, et al. Patient decision aids improve
decision quality and patient experience and reduce surgical rates
in routine orthopaedic care: a prospective cohort study. J Bone Joint
Surg Am. 2017;99(15):1253-1260.
57. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Har-
rell FE Jr. Anterior cruciate ligament reconstruction autograft choice:
bone-tendon-bone versus hamstring. Does it really matter? A sys-
tematic review. Am J Sports Med. 2004;32(8):1986-1995.
58. Tay KS, Tan AHC. Clinical outcomes, return to sports, and patient
satisfaction after anterior cruciate ligament reconstruction in young
and middle-aged patients in an asian population—a 2-year follow-
up study. Arthroscopy. 2018;34(4):1054-1059.
59. Terwee CB, Roorda LD, Dekker J, et al. Mind the MIC: large variation
among populations and methods. J Clin Epidemiol. 2010;63(5):524-
534.
60. Wang D, Jones MH, Khair MM, Miniaci A. Patient-reported outcome
measures for the knee. J Knee Surg. 2010;23(3):137-151.
61. Wang Y, Shimmin A, Ghosh P, et al. Safety, tolerability, clinical, and
joint structural outcomes of a single intra-articular injection of alloge-
neic mesenchymal precursor cells in patients following anterior cru-
ciate ligament reconstruction: a controlled double-blind
randomised trial. Arthritis Res Ther. 2017;19(1):180.
62. Yasen SK, Borton ZM, Eyre-Brook AI, et al. Clinical outcomes of ana-
tomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
Knee. 2017;24(1):55-62.
63. Zuke WA, Leroux TS, Gregory BP, et al. Establishing maximal med-
ical improvement after arthroscopic rotator cuff repair. Am J Sports
Med. 2018;46(4):1000-1007.