Positive impact of patient participation in arthroscopic anterior cruciate ligament reconstruction surgery on clinical and functional outcomes, rehabilitation and patient satisfaction

Abstract

Background

This study aimed to evaluate the effect of patient participation on clinical and functional outcomes, satisfaction, and compliance with postoperative rehabilitation in patients undergoing surgery for anterior cruciate ligament (ACL) injury.

Methods

Sixty-one patients who underwent isolated ACL reconstruction (ACLR) were included. Thirty patients in the participation group were shown the arthroscopy screen and allowed to communicate with the surgeon during surgery. For clinical and functional evaluation, knee joint range of motion (ROM), International Knee Documentation Committee Subjective Knee Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale (LKSS), Short Form-36 (SF-36) score, and Tegner Activity Scale (TAS), were used. The Pain Quality Assessment Scale was used to assess pain. Additionally, the patient’s satisfaction and exercise compliance were evaluated using a 5-point Likert scale and percentage of exercise participation, respectively.

Results

At 3rd week, the ROM, SF-36, LKSS values, and pain scores were better in the participation group compared to the control group(p <.05). At 6th month, the IKDC, KOOS, SF-36 values and pain scores were also better in the participation group compared to the control group (p <.05). However, the ROM, LKSS, and TAS values were similar between groups at the 6th month(p >.05). Postop satisfaction at 3rd week and 6th month and exercise compliance postoperatively were significantly better in the participation group compared to the control group(p <.05).

Conclusion

Patient participation during ACLR surgery by communicating with the surgeon positively affects clinical and functional outcomes. It also contributes to patient satisfaction and compliance with the rehabilitation program postoperatively.

Clinical trial number

Not Applicable.

Background

The anterior cruciate ligament (ACL) is one of the most frequently damaged structures in falls and sports injuries, which impairs the quality of life, can lead to chronic instability, and is often managed using surgical reconstruction as a gold standard treatment in active patients [1, 2]. The diagnosis of ACL injuries has increased in frequency over the years [3].

The development of surgical and rehabilitation methods over the last 20 years has contributed to patients with ACL injuries returning to sports activities at some levels after surgery. However, the recovery process imposes mental, physiological, and economic burdens on patients [4]. Rehabilitation following ACL reconstruction (ACLR) aims to help the patient safely resume their pre-injury level of physical activity while ensuring the knee adequately supports function [5]. Patients with exercise compliance had better outcomes than those who did not comply [6]. Poor compliance adversely affects treatment costs and effectiveness [7]. Although the benefits of postoperative exercise are known, patient compliance with exercise remains a concern for postoperative rehabilitation, and the proportion of non-adherent patients is approximately 50-70% [8]. Patients’ compliance and adherence to postoperative exercises play an important role in their confidence that exercise can reduce pain and promote functional recovery [8, 9]. Certain reviews illustrated a beneficial link between increased adherence to rehabilitation and enhanced outcomes after ACL reconstruction [10].

Surgical procedures are traditionally explained during consultations between the surgeon and the patient. These consultations inform patients about the preoperative phase, procedure details, benefits, risks, postoperative recovery, and possible alternatives. However, the effectiveness of this information transfer is often limited and may not be fully retained [11]. A lack of knowledge or education about the procedure and its potential outcomes has also been shown to heighten preoperative anxiety [12]. Providing patients with diverse information formats (videos, photos, etc.) about their disease and procedures enhances awareness. Studies show this is linked to better motor learning, self-assessment, and improved patient satisfaction and quality of life [13,14,15]. Pre- and postoperative education are well-documented strategies for improving patient outcomes. In orthopedic surgery, there are few studies on the participation of patients during surgery and their effects on the results [6]. Moreover, there are no studies on the effectiveness of patient participation during ACLR in terms of postoperative clinical and functional outcomes, patient satisfaction, and rehabilitation compliance.

This study focuses on intraoperative participation because it creates a unique opportunity for real-time patient engagement. By observing the surgical procedure and receiving immediate feedback from the surgeon, patients can better understand their condition and the surgical process, which may positively influence their motivation, adherence to rehabilitation, and ultimately, their clinical outcomes.

We aimed to evaluate the effect of patient participation by communicating with the surgeon during surgery on clinical and functional outcomes, satisfaction, and compliance with postoperative rehabilitation, in patients undergoing ACLR. We hypothesized that patient participation would improve their clinical and functional outcomes, satisfaction, and compliance with postoperative rehabilitation.

Methods

Patient selection

The university ethics committee approved this study on January 18, 2023, under the number 2023/51. This study was conducted as a retrospective observational analysis. Between January 2020 and January 2023, 188 patients underwent ACLR at our hospital. Clinical data, including preoperative and postoperative evaluations, were routinely collected prospectively during outpatient follow-ups. After receiving ethical approval for this study in 2023, these prospectively collected data were retrospectively analyzed using the hospital’s electronic medical record system. The inclusion criteria were as follows: patients aged 18 to 45 years, a history of acute knee injury, and ACL rupture confirmed both on magnetic resonance imagining and during arthroscopy. Patients with another ligament injury, meniscus injury, history of surgery on the same side lower extremity, any side of the knee with cartilage damage and history of trauma to the same side of the lower extremity were excluded from the study. 61 patients who underwent surgery for isolated ACL rupture were included in the study. The included patients are shown in the flowchart. (Fig. 1)

Informed consent was obtained from all patients. Patient demographics, time from trauma to surgery and sports participation were recorded preoperatively. All patients were informed in advance about the surgery to be performed. Information about the method of surgery, postoperative expectations, the graft material to be used and the rehabilitation process was shared with all patients. The group of patients who communicated with the surgeon during surgery was called the “participation group” (Group 1). The group that included patients who did not participate was called the “control group” (Group 2). Patients were allocated to the groups based on the order of their surgeries. The surgical technician arranged the allocation according to the sequence of surgeries, ensuring an unbiased distribution. Of the 61 patients, 30 were included in the participation group and 31 were included in the control group. Before the study, we calculated the sample size using G*Power to ensure adequate power to detect differences between participation and control groups. We set the alpha level at 0.05, statistical power at 0.80, and effect size (Cohen’s d) at 0.50, indicating a medium effect size in similar studies. Results indicated at least 54 patients were necessary.

Fig. 1

Flowchart of the included patients

Surgical technique

An orthopedic surgeon skilled in arthroscopic surgery performed all procedures under regional anesthesia, either spinal or epidural. Anterolateral and anteromedial portals were used routinely for arthroscopic examination of all knee compartments and treatment for meniscal tears, and other intra-articular abnormalities. Patients in the participation group were allowed to see the arthroscopy screen during the examination of the ruptured stump of the ACL using the probe and were informed about the procedure. They could also watch the screen during the surgical procedure. No videos were shown to the control group. Single-bundle ACLR was performed with semitendinosus and gracilis tendons using a 4-strand technique with at least 8 mm final graft size thickness. A standard guide was used to measure the graft diameter. The ACL remnant fibers were carefully debrided, and the femoral and tibial footprints were verified by probing. A 6-mm femoral guide (Smith & Nephew, Andover, MA, USA) was utilized for femoral tunnel drilling at 120° of knee flexion. The femoral tunnel was created via the anteromedial portal in all cases. The tibial tunnel was drilled at the anatomical center of the remnant tissue using an Acufex tip-to-tip drilling guide (Smith & Nephew, Andover, MA, USA) set at a 55° angle. Both tunnels were prepared based on the graft diameter. After advancing the graft from the tibial to the femoral tunnel, femoral fixation was achieved using an Endobutton suspensory system (Aleda; Aleda Machinery, Ankara, Turkey), and tibial fixation was performed using an interference screw (Artroline; Artrotek, Adana, Turkey). Finally, arthroscopic evaluation confirmed the absence of graft impingement in the intercondylar notch. After the procedure, the reconstructed ligament was shown to the participation group that it was functional and had adequate stability on the arthroscopy screen during knee flexion and extension range, anterior drawing test and while probing the reconstructed ligament. The knee laxity of the patients was evaluated before the surgery was completed. Evaluations were made with the lachman test, anterior drawer test and pivot shift test. No laxity was observed in any patient. The same surgical procedure was performed for all the patients, and the same language was used for communication in the participation group.

Rehabilitation

On the first day post-surgery, we began isometric quadriceps, patellar mobilization, and hamstring exercises. Additionally, range of motion (ROM) exercises began on postoperative day 1, utilizing a continuous passive motion machine for 10 min, 4 to 6 times a day, aiming to achieve a 0–90 degree knee range of motion (ROM) by the end of the first week. After pain and swelling control, patients were allowed to bear partial weight with a hinged knee brace at 0 degrees. Patients were discharged when they were able to raise their legs straight. Muscle conditioning, closed chain exercises, and balance training commenced at week 2 post-surgery. Quadriceps exercises with weights began at week 3. Full weight-bearing was permitted once the ROM reached 0 to 100 with adequate muscle control throughout the motion. Before discharge, all patients were provided health education and rehabilitation advice by the same sports physiotherapist. After discharge, the rehabilitation program was applied to all patients by the same blind sports physician in the sports medicine clinic.

Evaluation

Among the 61 patients included in the study, 52 were male and 9 were female, with a mean age of 26.46 ± 5.98 years and a mean body mass index (BMI) of 23.70 ± 3,19 kg/m². The interval from injury to surgery was less than 3 months in 21 patients. Except for one individual, all patients had an education level of high school or higher. Additionally, 35 patients were engaged in amateur sports, while 17 participated in recreational sports activities. Clinical and functional evaluations were performed and recorded in all patients before the operation and at three weeks and six months after surgery. Clinical evaluation was performed by an orthopedic physician blinded to surgical treatment and groups. ROM of the operated knee, International Knee Documentation Committee Subjective Knee Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale (LKSS), and Tegner Activity Scale (TAS), were used for evaluating clinical and functional outcomes [16,17,18]. The Short Form-36 (SF-36) score, which is a general measure of health-related quality of life and is sensitive to ACLR, was also evaluated [19]. Pain Quality Assessment Scale, which helps evaluate the severity of pain, as well as other qualities, was used for assessing pain [20]. In order to evaluate the patient satisfaction, the patients were asked “Are you satisfied with your knee after the surgery?” and they were asked to respond based on a 5-point Likert scale as follows: “very satisfied,” “satisfied,” “neither satisfied nor dissatisfied,” “not satisfied,” and “not at all satisfied” [6]. We classified “very satisfied” or “satisfied” as satisfied, and “neither satisfied nor dissatisfied,” “dissatisfied,” and “very dissatisfied” as dissatisfied. According to recent studies, in the evaluation of patients’ compliance with exercise, those who went to the sports medicine clinic at the time and duration determined by the sports physician and participated in more than half of the recommended postoperative exercise program were considered compliant. In comparison, those who participated in less than half were considered non-compliant [6, 9].

Statistical analysis

Data analysis utilized SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). To assess data distribution, the Shapiro-Wilk test was applied. Continuous data are reported as means, standard deviations, and 95% confidence intervals (CIs), whereas categorical data are shown as frequencies and percentages. A χ2 test was employed to compare categorical variables. An a priori power analysis using G Power 3.1.9.7 was conducted to determine the necessary sample size, verifying that 30 patients per group were adequate for a statistical power of 0.8. A two-sample t-test was performed to analyze continuous variables across groups, with a significance level set at p <.05.

Results

The mean age of patients included in the study was 26.5 ± 5.9 years. Fifty-two (85.2%) patients were male, and nine (14.8%) were female. The mean BMI of the patients was 23.85 ± 2.36 kg/m2. Thirty-six patients had a high school education, and 24 had a university-level education. Time to operation (< 3 vs. ≥ 3 months) was similar between the groups. When the patients’ demographic data were analyzed according to the group, there was no significant difference in age, sex, BMI, sports participation and time to operation. Demographic data of the patients are shown in Table 1.

Table 1 Patient demographics

Outcome measures were recorded at three different time points: preoperatively, at the 3rd week, at the 6th month. In the clinical and functional evaluations of the patients, there were no differences between the groups preoperatively. At 3rd week, the ROM, SF-36, LKSS values, and pain scores were better in the participation group compared to the control group (p =.04, 0.001, 0.015, 0.02, respectively). However, there were no significant differences between groups in terms of IKDC, KOOS, and TAS values at 3rd week postoperatively (p >.05). At 6th month, the IKDC, KOOS, SF-36 values and pain scores were also better in the participation group compared to the control group (p =.001, 0.001, 0.008, 0.001, respectively). However, the ROM, LKSS, and TAS values were similar between groups at 6th month (p >.05). Postop satisfaction at 3rd week and 6th month, and exercise compliance postoperatively were significantly better in the participation group compared to control group (p =.011, 0.003, 0.006, respectively). The clinical and functional outcome scores of the patients are shown in Table 2.

Table 2 Clinical and functional outcome scores at follow-up

Discussion

The most important findings of this study were that patients who participated during ACLR surgery and communicated with the surgeon showed better clinical and functional scores, patient satisfaction, and exercise compliance compared to the controls at different time points during the follow-ups. SF-36 and pain scores were found to be better in the participation group at 3rd week and 6th month postoperatively. In addition, ROM, IKDC, KOOS, and LKSS scores were better in the participant group compared to the control in some different time points. Postop patient satisfaction and exercise compliance were also significantly higher in the postoperative par.

Currently, ACLR is the gold standard treatment for ACL rupture [1, 2]. In addition, physical rehabilitation treatment is essential to regain former function, improve quality of life, participate in daily activities, and return to sports safely after surgery as soon as possible [21, 22].

Better adherence to rehabilitation programs is widely recognized as a critical factor in improving return-to-sport outcomes and patient satisfaction [22,23,24,25,26]. Our findings demonstrate that intraoperative participation positively influences rehabilitation adherence, clinical outcomes, and satisfaction. However, the relationship between return-to-sport motivation and patient satisfaction is likely influenced by factors beyond intraoperative participation, such as motivation and patient education, as highlighted in previous studies [26, 27]. Previous research has shown that low adherence to rehabilitation programs may stem from a lack of knowledge about the importance of rehabilitation [28]. In this context, our study emphasizes the potential benefits of providing detailed information about the injury and demonstrating the pathology during surgery. Such engagement appears to foster a sense of trust and motivation in patients, potentially enhancing adherence to rehabilitation protocols. Motivation has been identified as a key factor for adherence and is essential for ensuring successful rehabilitation outcomes [6]. This aligns with the improvements in satisfaction and adherence observed in our study. The effects of intraoperative participation extend beyond merely sharing information. It provides patients with a sense of involvement in their treatment process, creating a psychological connection to the surgical outcomes. This approach may increase patient confidence and commitment to rehabilitation programs [29]. However, further studies are needed to evaluate the direct impact of these interventions on long-term outcomes, including return-to-sport rates. Future research should also explore controlled variables, such as the type of anesthesia, to better understand their combined impact on clinical outcomes and patient satisfaction.

Strong motivation to return to sports during the rehabilitation program is a key in ensuring a return to preinjury sports activities [30]. Motivation is likely essential for patients to engage with the rehabilitation program, yet despite its significance, some patients fail to comply fully with the requirements program [8, 9, 25]. We conducted this study, thinking that giving the patient more detailed information about his/her injury during ACLR surgery, showing the pathology, participation during intraoperative screening and communicating, and encouraging and motivating his/her by showing that a stable reconstruction has been performed would increase her clinical and functional scores, satisfaction, and exercise compliance.

Studies on active participation during treatment in orthopedic surgery are limited [6]. However, several recent studies have shown that showing pre- and post-operative photographs and video recordings to patients can increase motor learning, help self-assessment, and improve patient satisfaction and quality of life [13,14,15, 31]. Misir et al. [14] showed preoperative and postoperative knee radiographs and posture images to patients who underwent total knee arthroplasty. SF-36, KOOS, Knee Society Score (KSS), Oxford Knee Score, and Western Ontario and McMaster Universities Osteoarthritis Index scores used in clinical and functional evaluations significantly improved in the group in which the photographs were shown. There was no difference in the control group. Ozcamdalli et al. [15], on the other hand, conducted a randomized controlled study in which they demonstrated preoperative and postoperative shoulder joint range of motion in patients who underwent arthroscopic rotator cuff repair. When the patients watched preoperative and postoperative video recordings of the shoulder range of motion after arthroscopic rotator cuff repair, they found that although the shoulder range of motion was not different from that of the control group, patients’ satisfaction and perception of well-being increased in the short term. Albayrak et al. [13] conducted a controlled study in which preoperative and postoperative photographs were shown to patients who had undergone kyphosis surgery. The results showed that pain score, mental health, self-image, and satisfaction were higher in the group where photos were shown. In a randomized controlled trial, Pinsornsak et al. [31] compared the use of knee joint motion pictures immediately after surgery with a control group without photography and found that the group in which photography was used showed improved early knee flexion and function at 6 weeks. Informing patients in detail about their disease and clinical course may be encouraging for patients to achieve good results. Higher expectations have also been shown to indicate better postoperative recovery. Some studies on lower extremity surgery have found an association between higher preoperative expectations and better outcomes [32]. For example, Henry et al. [33] reported that higher expectations after limb orthopedic surgery may be associated with better activity and less pain. Preoperative education reduces anxiety and aligns patient expectations, as shown in studies like Spalding et al. [11] found that well-informed patients have greater confidence and adhere better to postoperative protocols. Sonesson et al. [31] also noted that preoperative preparation enhances rehabilitation adherence, which is crucial for optimal outcomes after ACL reconstruction. Postoperative patient participation in pain management and rehabilitation is vital. Kaptain et al. [31] found that involving patients in pain assessment improves their management experience and clinical outcomes. Intraoperative participation enables real-time decision-making, fostering a psychological connection and immediate feedback that boosts self-efficacy and motivation. Studies on awake craniotomy show that patient involvement enhances trust in the surgical team and overall satisfaction [32]. Pre- and postoperative education address knowledge gaps and promote adherence through structured guidance. Intraoperative participation, however, offers experiential learning. This real-time interaction may explain the differences in early recovery observed in our study, where the intraoperative participation group showed better range of motion, functional scores, and satisfaction in early rehabilitation.

We believe that videos or photographs shown during or after surgery can increase patient compliance and encourage more attention to postoperative exercise to aid postoperative recovery. In our study, we realized that the participation of patients during ACLR surgery improved expectations and provided an incentive to actively engage in rehabilitation exercises. Thus, patients may show better results, such as less pain and return to previous activities. We believe that raising awareness in patients by showing videos or photographs is important in terms of postoperative results.

When we examined the clinical and functional scores of the patients in our study, SF-36 and the pain scores in the participation group were better at 3rd week and 6th month postoperatively. Moreover, in the participation group, the ROM and LKSS scores of patients were better at 3rd week, and IKDC and KOOS scores were better at 6th week postoperatively than that in the control group. Although the surgical procedure was the same, we attributed the better results recorded in the participation group to the fact that the patients were more self-confident after surgery and their participation in rehabilitation was higher. In concordant with our study, a recent study showed that active participation of patients during arthroscopic partial meniscectomy surgery can reduce pain, improve symptoms [6]. Despite notable differences in ROM and LKSS during the third week, no significant differences appeared at six months. This is due to standardized rehabilitation protocols ensuring comparable functional recovery levels. Previous studies reported similar findings showing convergence in long-term recovery after ACL reconstruction among various groups [34]. Therefore, while early participation may boost short-term gains, its long-term impact may diminish progresses.

Various studies have reported that patient satisfaction may vary subjectively. O’Toole et al. [35] demonstrated that patient satisfaction hinges on pain levels instead of the patient or injury’s characteristics after a lower-extremity injury. Similarly, Kocher et al. [36] found that patient satisfaction following ACLR is significantly linked to subjective symptoms. Ruan et al. [6] found that active participation of patients during arthroscopic surgery can increase patient satisfaction and quality of life. In line with this study patient satisfaction in the participation group was significantly higher on both evaluations compared to the control group in our study.

Rehabilitation is complex, comprehensive, and challenging for patients. Recently Ruan et al. [6] showed that active participation of patients during arthroscopic partial meniscectomy surgery can increase exercise compliance, and quality of life. In our study, the exercise compliance and rehabilitation adaptation process of the patients were evaluated. Exercise compliance was higher in the participation group. This is because, owing to participation in surgery, patients may have high recovery expectations, which could potentially affect rehabilitation compliance. Patient involvement during ACL surgery improves patient expectations and provides an incentive to actively engage in rehabilitation exercises. We believe that videos shown during surgery can improve patient compliance and allow more attention to be paid to post-operative exercises to aid postoperative recovery. Thus, patients can show better results, such as less pain and return to previous activities.

This study has several limitations. First, number of patients was small because patients with only isolated ACL ruptures were included in this study. Second, since soccer is common in our region and this is common among men; our patient population consisted mostly of men. The data from this study cannot be generalized to women. Third, return to sports could not be evaluated because of the short-term follow-up. Although 6 months seems to be insufficient for returning to play, we believe that a period of 6 months is sufficient for rehabilitation and return to daily activities. The other limitation of this study is that it did not directly investigate the effect of anesthesia type on clinical and functional outcomes. While our findings suggest that intraoperative participation plays a role in patient engagement and postoperative adherence, we cannot definitively conclude that general anesthesia leads to inferior outcomes. Future studies comparing different anesthesia techniques in a controlled setting would be valuable to better understand their potential impact. Lastly, a psychological evaluation of the effect of patient participation on clinical and functional outcomes could not be conducted in this study. While patient satisfaction was assessed and provides indirect insights into the psychological impact, it does not fully capture the broader psychological dynamics that may influence adherence to rehabilitation, motivation, or perceived recovery. This study provides a foundation for further investigation into the psychological dimensions of intraoperative patient participation. Multicenter studies with larger patient populations are required to validate these findings and explore the role of psychological factors more comprehensively. Furthermore, studies focusing on specific patient groups, such as professional athletes, may offer valuable insights into the psychological and functional outcomes related to return-to-sport scenarios.

Conclusion

Patient participation during ACLR by communicating with the surgeon positively affects some clinical and functional outcomes. It also contributes to patient satisfaction, and patients’ compliance with the rehabilitation program postoperatively.