The Journal of Bone and Joint Surgery (American) 84:1560-1572 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.
Determinants of Patient Satisfaction with Outcome After Anterior Cruciate Ligament Reconstruction
Mininder S. Kocher, MD, MPH,
J. Richard Steadman, MD,
Karen Briggs, MBA,
David Zurakowski, PhD,
William I. Sterett, MD and
Richard J. Hawkins, MD
Investigation performed at the Steadman Hawkins Clinic, Vail, Colorado
Mininder S. Kocher, MD, MPH
Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, Harvard School of Public Health, 300 Longwood Avenue, Boston, MA 02115. E-mail address: mininder.kocher{at}tch.harvard.edu
David Zurakowski, PhD
Harvard Medical School, Department of Biostatistics, Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115
J. Richard Steadman, MD
Karen Briggs, MBA
William I. Sterett, MD
Richard J. Hawkins, MD
Steadman Hawkins Clinic, Steadman Hawkins Sports Medicine Foundation, 181 West Meadow Drive, Vail, CO 81657
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Steadman Hawkins Sports Medicine Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Background: The purpose of this study was to identify the determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament.
Methods: A cohort of 201 patients undergoing primary reconstruction of the anterior cruciate ligament was studied prospectively. All patients were followed for a minimum of two years (mean, 35.9 months). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Nonparametric univariate analysis and multivariable modeling were performed to identify determinants of satisfaction.
Results: The demographic variables were not found to have a significant association (p > 0.05) with patient satisfaction. The variables at surgery demonstrated a significant association (p < 0.05) with patient satisfaction only with respect to the status of the lateral meniscus, the presence of osteophytes, and concurrent plica excision. The objective variables at follow-up revealed that patients were significantly less satisfied (p < 0.05) if they had a flexion contracture, increased laxity of the involved leg on the manual maximum test as measured on a KT-1000 device, an abnormal result on the pivot-shift examination, effusion, or tenderness at the medial joint line or patella. With regard to the subjective symptoms at follow-up, patients were found to be significantly (p < 0.05) less satisfied with the outcome if they had symptoms of pain, swelling, partial giving-way, full giving-way, locking, noise, stiffness, or a limp. Analysis of the subjective function at follow-up demonstrated that patients were significantly less satisfied (p < 0.05) with the outcome if they had a lower level of activity, sports activity, strenuous work, activities of daily living, overall knee function, sports participation, or symptom-free activity; if they were unemployed; or if they had difficulty with walking, squatting, ascending or descending stairs, running, jumping, cutting, or twisting. Patient satisfaction was significantly associated (p < 0.05) with the Lysholm knee score, overall International Knee Documentation Committee (IKDC) knee score, IKDC subjective subscore, IKDC symptoms subscore, and IKDC range-of-motion subscore. The seven independent multivariate determinants (adjusted R 2 = 0.83, p < 0.001) of patient satisfaction included the Lysholm score, overall subjective knee function, IKDC range-of-motion subscale, patellar tenderness, full giving-way, flexion contracture, and swelling.
Conclusions: Univariate and multivariate determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament were established. Although some specific surgical and objective variables were important, subjective variables of symptoms and function had the most robust associations with patient satisfaction. In assessing the outcome of reconstruction from the perspective of patient satisfaction with the outcome, we should emphasize patient-derived subjective assessment of symptoms and function, particularly those involving issues of stiffness, giving-way, swelling, and patellofemoral symptoms.
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