Prognostic Factors for Patient-Reported Outcomes at 32 to 37 Years After Surgical or Nonsurgical Management of Anterior Cruciate Ligament Injury
Authors: Filbay Stephanie , Andersson Christer , Gauffin Håkan , Kvist Joanna 
Published: August 2021

Background: Knowledge to inform the identification of individuals with a poor long-term prognosis after anterior cruciate ligament (ACL) injury is limited. Identifying prognostic factors for long-term outcomes after ACL injury may inform targeted interventions to improve outcomes for those with a poor long-term prognosis. Purpose: To determine whether ACL treatment (early augmented or nonaugmented ACL repair plus rehabilitation, rehabilitation alone, or rehabilitation plus delayed ACL reconstruction [ACLR]) and 4-year measures (quadriceps and hamstrings strength, single-leg hop, knee laxity, flexion and extension deficit, self-reported knee function, activity level) are prognostic factors for patient-reported outcomes at 32 to 37 years after acute ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 251 patients aged 15 to 40 years with acute ACL rupture between 1980 and 1985 were allocated to early ACL repair (augmented or nonaugmented) plus rehabilitation or to rehabilitation alone, based on birth year. One hundred ninety of 234 completed 32- to 37-year follow-up questionnaires (response rate, 81%); 18 people were excluded, resulting in 172 patients available for analysis (mean age, 59 ± 6 years; 28% female). Potential prognostic factors assessed 4 years after ACL injury were ACL treatment (early ACL repair, rehabilitation alone, or delayed ACLR), isokinetic quadriceps and hamstrings strength, single-leg hop performance, knee flexion and extension deficit, knee laxity, Tegner activity scale, and Lysholm score. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the Anterior Cruciate Ligament Quality of Life (ACL-QOL) measure. Linear regression adjusted for age, sex, baseline meniscal injury, and contralateral ACL injury was used to assess potential prognostic factors for 32- to 37-year outcomes. Multiple imputation accounted for missing data. Results: A fair/poor Lysholm score (vs excellent/good) at 4 years was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −12 [95% confidence interval (CI), −19 to −4]), KOOS Symptoms (−15 [95% CI, −23 to −7]), KOOS Sport and Recreation (−19 [95% CI, −31 to −8]), and ACL QOL (−9 [95% CI, −18 to −1]) scores. A 4-year single-leg hop limb symmetry index <90% was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −9 [95% CI, −17 to −1]) and ACL QOL (−13 [95% CI, −22 to −3]) scores at long-term follow-up. A lower activity level, delayed ACLR, and increased knee laxity were prognostic factors in the crude analysis. Rehabilitation alone versus early repair, quadriceps and hamstring strength, and flexion and extension deficit were not related to 32- to 37-year outcomes. Conclusion: Reduced self-reported knee function and single-leg hop performance 4 years after ACL injury were prognostic factors for worse 32- to 37-year outcomes. Estimates exceeded clinically important thresholds, highlighting the importance of assessing these constructs when managing individuals with ACL injuries. Registration: NCT03182647 ( ClinicalTrials.gov identifier).