Purpose To translate the ACL-QOL from English to Swedish and evaluate measurement properties for use after surgical and non-surgical management of anterior cruciate ligament (ACL) injury. Methods The ACL-QOL was translated from English to Swedish and data were pooled from 13 cohorts to enable a comprehensive evaluation of measurement properties in line with COSMIN guidelines. We evaluated internal consistency, test-re-test reliability, measurement error, structural validity [confirmatory factor analysis (CFA)], construct validity and responsiveness (hypothesis testing), and floor/ceiling effects. Results were stratified by time since injury (<= 1.5 years; 2-10 years, 15-25 years; > 30 years) and ACL management strategy [surgical (n = 1163), non-surgical (n = 570)]. Results The Swedish ACL-QOL had sufficient internal consistency (total and domain scores) for use in surgically managed (Cronbachs alpha >= 0.744) and non-surgically managed (>= 0.770) ACL-injured individuals at all time-points. Test-re-test reliability was sufficient [intraclass correlation coefficients: all domains > 0.80, total score 0.93 (95% CI 0.86-0.96)]. The standard error of measurement was 5.6 for the total score and ranged from 7.0 to 10.3 for each domain. CFA indicated sufficient SRMR values when using the total score or five domains; however, CFI and RMSEA values did not meet cut-offs for good model fit. Hypothesis testing indicated sufficient construct validity and responsiveness. Floor effects were negligible and ceiling effects were negligible or minor. Conclusion The Swedish version of the ACL-QOL has sufficient internal consistency, test-re-test reliability, construct validity and responsiveness, for use in people with ACL injury managed with or without ACL surgery. Model fit could be improved and investigation into the source of misfit is warranted.

Objective To investigate the treatment decision-making process after an anterior cruciate ligament (ACL) injury from patients, orthopaedic surgeons and physiotherapists perspectives. Methods The study is a part of the NACOX study, which is designed to describe the natural corollaries after ACL injury. For the present study, a subgroup 101 patients were included. Patients, their orthopaedic surgeons and their physiotherapists, answered a Shared Decision-Making Process (SDMP) questionnaire, when treatment decision for ACL reconstruction surgery (ACLR) or non-reconstruction (non-ACLR) was taken. The SDMP questionnaire covers four topics: " informed patient", " to be heard", " involvement" and " agreement". Results Most (75-98%) patients considered their needs met in terms of being heard and agreement with the treatment decision. However, fewer in the non-ACLR group compared to the ACLR group reported satisfaction with information from the orthopaedic surgeon (67% and 79%), or for their own involvement in the treatment decision process (67% and 97%). Conclusion and practice implications Most patients and caregivers considered that patients needs to be informed, heard and involved, and to agree with the decision about the treatment process, were fulfilled to a high extent. However, patients where a non-ACLR decision was taken experienced being involved in the treatment decision to a lower extent. This implies that the non-ACLR treatment decision process needs further clarification, especially from the patient involvement perspective.

Background: In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made. Purpose: To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate. Results: The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older (P = .031) and had a lower preinjury activity level than did those in the acute-phase (P < .01) and subacute-phase (P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury. Conclusion: Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management.

Background: When deciding medical treatment, patients perspectives are important. There is limited knowledge about patients views when choosing non-operative treatment or anterior cruciate ligament (ACL) reconstruction (ACLR) after ACL injury. Purpose: To describe reasons that influenced patients decisions for non-operative treatment or ACLR after ACL injury. Study Design: Cross-sectional study. Methods: This study recruited a total of 223 patients (50% men), aged 28 +/- 8 years who had sustained ACL injury, either unilateral or bilateral. Subjects were, at different time points after injury, asked to fill out a questionnaire about their choice of treatment, where an ACLR treatment decision was made, some responded before and some after the ACLR treatment. A rating of the strength of 10 predetermined reasons in their choice of treatment graded as 0 (no reason) to 3 (very strong reason), was done. Results: Patients with unilateral ACL injury treated with ACLR (110 patients) rated "inability to perform physical activity at the same level as before the injury due to impaired knee function" (96%), "fear of increased symptoms during activity" (87%) and "giving way episodes" (83%) as strong or very strong reasons in their treatment decision. Patients with bilateral ACL injury treated with ACLR (109 knees) rated similar reasons as patients with unilateral ACLR and also "low confidence in the ability to perform at the preinjury activity level without ACLR" (80%) as strong or very strong reasons. Patients with unilateral ACL injury treated non-operatively (96 patients) rated "advice from clinician" (69%) as a strong or very strong reason. Patients with bilateral ACL injury treated non-operatively (25 knees) rated "absence of giving way episodes" (62%), and "no feeling of instability" (62%) as strong or very strong reasons. Conclusion: Inability to perform physical activity, fear of increased symptoms, and giving way episodes were reasons that patients with ACL injury considered when making decisions about ACLR. When choosing non-operative treatment, patients considered the absence of instability or giving way symptoms, being able to perform physical activity, and advice from clinicians.

Bakgrund: Efter en främre korsbandsskada syftar behandlingen att återställa knäfunktionen. Utvärdering av framstegen är av vikt, och adekvata mätmetoder för detta är nödvändigt. International Knee Documentation Committtee Subjective Knee Form (IKDC-SKF) är ett patientskattningsformulär som är välanvänt över hela världen vid främre korsbandsskador. Det utvärderar symptom, funktion och fysisk aktivitet. Det har inte funnits tillgängligt på svenska tidigare och det har heller inte funnits någon sammanställning över formulärets mätegenskaper.

Efter en främre korsbandsskada måste förr eller senare beslut om behandling fattas, om patienten ska genomgå en rekonstruktionsoperation för främre korsbandet, med efterföljande rehabilitering, eller enbart rehabilitering. Det finns riktlinjer som gör gällande att en korsbandsrekonstruktion kan vara ett adekvat alternativ när patienten har höga aktivitetskrav eller lider av instabilitet i knäleden. Det är dock ej fastställt vilka faktorer ortopedläkare och fysioterapeuter anser viktiga för att rekommendera rekonstruktionsoperation. Det är inte heller klargjort när efter skada och på vilka grunder faktiska behandlingsbeslut fattas, och hur orsaken till beslutet hänger samman med patientens självrapporterade symptom och funktion.

Syfte: Det övergripande syftet med avhandlingen var att utvärdera mätegenskaper för ett patientskattningsformulär som utvärderar funktion efter en främre korsbandsskada, samt att överblicka beslutsprocessen för behandling efter en främre korsbandsskada.

Metod: En systematisk genomgång utfördes av studier som utvärderat mätegenskaper för IKDC-SKF. Studierna värderades avseende metodologi och resultat. IKDC-SKF översattes till svenska, och den svenska versionens mätegenskaper prövades.

En enkätstudie utfördes där 98 svenska ortopedläkare och 391 svenska fysioterapeuter fick skatta 21 faktorers betydelse för valet att rekommendera rekonstruktionsoperation av främre korsbandet. Ortopedläkare och fysioterapeuter fick även skatta vikten av sin egen och motpartens bedömning samt patientens önskan, i valet av behandling.

I en prospektiv kohortstudie följdes 219 patienter med en främre korsbandsskada, från 6 veckor och upp till 12 månader efter skadan. Data om vilken behandling patienten genomgått, när behandling valdes och grunder för behandling samlades in från patient och ortopedläkare och jämfördes med patientskattad aktivitetsnivå innan skada, instabilitet och funktion.

Resultat: Den systematiska genomgången av IKDC-SKF och prövningen av den svenska versionens mätegenskaper visade att IKDC-SKF uppvisar goda mätegenskaper och går att tolka i kliniken?

Svenska ortopedläkare och fysioterapeuter anser att ung ålder, höga aktivitetskrav, knäkrävande arbete och instabilitet trots adekvat rehabilitering är faktorer som indicerar behov av rekonstruktionsoperation av främre korsbandet. 

Ett tidigt beslut för rekonstruktionsoperation efter främre korsbandsskada fattas i hög grad på grund av höga aktivitetskrav, och dessa patienter har även högre aktivitetsnivå innan skada. Ett senare beslut för rekonstruktionsoperation fattas i hög grad på grund av instabilitet och höga aktivitetskrav, medan ett sent beslut fattas i hög grad på grund av instabilitet. Ett beslut att enbart behandla med rehabilitering fattas i hög grad på grund av att patienten har tillräckligt god funktion eller inte har några besvär från instabilitet. Det var inga skillnader i patientskattad funktion och instabilitet mellan de patienter där rekonstruktionsoperation valdes och de som valde att behandla med enbart rehabilitering.

Sammanfattning: IKDC-SKF visar goda mätegenskaper och kan rekommenderas för användning hos patienter med en främre korsbandsskada och andra knärelaterade diagnoser.

Efter en främre korsbandsskada fattas ett tidigt beslut för rekonstruktionsoperation på grund av höga aktivitetskrav. Ett senare beslut för rekonstruktionsoperation fattas när patienten lider av instabilitet och nedsatt knäfunktion, medan ett beslut för enbart rehabilitering valdes när funktion och knästabilitet var god. Det var inga skillnader mellan patienter där man valt rekonstruktionsoperation och enbart rehabilitering, avseende skattad funktion och instabilitet. Både ortopedläkarens och fysioterapeutens bedömning samt patientens önskan är viktig i valet av behandling.

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients, roles are in the treatment decision. A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients preferences. Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patients wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patients wishes as important for the decision to recommend ACL reconstruction. Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. Diagnostic study: Level III.

Introduction Anterior cruciate ligament (ACL) injury can result in joint instability, decreased functional performance, reduced physical activity and quality of life and an increased risk for post-traumatic osteoarthritis. Despite the development of new treatment techniques and extensive research, the complex and multifaceted nature of ACL injury and its consequences are yet to be fully understood. The overall aim of the NACOX study is to evaluate the natural corollaries and recovery after an ACL injury. Methods and analysis The NACOX study is a multicentre prospective prognostic cohort study of patients with acute ACL injury. At seven sites in Sweden, we will include patients aged 15-40 years, within 6 weeks after primary ACL injury. Patients will complete questionnaires at multiple occasions over the 3 years following injury or the 3 years following ACL reconstruction (for participants who have surgical treatment). In addition, a subgroup of 130 patients will be followed with clinical examinations, several imaging modalities and biological samples. Data analyses will he specific to each aim. Ethics and dissemination This study has been approved by the regional Ethical committee in Linkoping, Sweden (Dnr 2016/44-31 and 2017/221-32). We plan to present the results at national and international conferences and in peer-reviewed scientific journals. Participants will receive a short summary of the results following completion of the study.

To translate to Swedish language and cross-culturally adapt the IKDC-SKF and to test the measurement properties of the Swedish version of IKDC-SKF in ACL-injured patients undergoing reconstruction surgery.The translation and cross-cultural adaption was performed according to guidelines. Seventy-six patients with an ACL injury filled out the IKDC-SKF and other questionnaires before ACL reconstruction and at 4, 6, and 12months after surgery. A total of 203 patients from the Swedish ACL Registry participated at 8months post-operative. Measurement properties were tested according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.The Swedish IKDC-SKF had high internal consistency (Cronbachs alpha=0.90) and test-retest reliability (ICC2,1=0.92, CI 95%: 0.81-0.97, Pamp;lt;.001). A single factor solution accounted for 46.1% of the variance in IKDC-SKF scores. Criterion validity was moderate to high. All ten predefined hypotheses for hypothesis testing were confirmed. The six hypotheses for responsiveness testing were confirmed. The effect size was 1.8, the standardized response mean was 1.9, the and minimal clinically important difference was 13.9 points.The Swedish version of the IKDC-SKF had good measurement properties and can be recommended for use in a population of ACL-deficient patients undergoing ACL reconstruction.

PURPOSE: To evaluate the methodological quality of studies reporting on the measurement properties of the International Knee Documentation Committee subjective knee form (IKDC-SKF) and to evaluate their results following the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines.

METHODS: Systematic search of articles published about the measurement properties of the IKDC-SKF, review of the studies' methodological quality, and synthesis of the results using the COSMIN guidelines.

RESULTS: Twenty-six studies were identified and reviewed. There was strong evidence for good internal consistency, test-retest reliability, and responsiveness. There was moderate evidence for good content and structural validity. With the SF36 as a gold standard, the level of evidence for criterion validity was indeterminate. There was conflicting evidence for hypothesis testing and not enough evidence to evaluate measurement error and cross-cultural validity. There were no floor or ceiling effects.

CONCLUSIONS: This review shows that the IKDC-SKF is a measurement instrument with good internal consistency, test-retest reliability, content and structural validity, and responsiveness and interpretability (no floor and ceiling effects). Further evaluation of measurement error, minimal important change, and hypotheses testing is recommended. The IKDC-SKF seems to be useful as a general instrument for all kinds of knee injuries, which might facilitate its clinical use in situations in which time is a factor.

LEVEL OF EVIDENCE: Systematic review, Level III.