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Commentary and Perspective

Can We Improve the Value of ACL Reconstruction by Studying the Rates of Return to Play and Satisfaction?

Commentary on an article by Benedict U. Nwachukwu, MD, MBA, et al.: “Return to Play and Patient Satisfaction After ACL Reconstruction. Study with Minimum 2-Year Follow-up”

Matzkin, Elizabeth MD*

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The Journal of Bone and Joint Surgery: May 3, 2017 - Volume 99 - Issue 9 - p e46
doi: 10.2106/JBJS.16.01561
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With estimates of over 2 billion dollars1 spent annually on anterior cruciate ligament reconstruction (ACLR), it is important to understand the societal value of this procedure. Value can be defined as patient-focused outcomes per dollar spent2. Many ACL studies utilize patient-reported outcome scores such as the Tegner, IKDC (International Knee Documentation Committee), and Lysholm scales. Rates of return to play and patient satisfaction after ACLR are less commonly reported.

Return to play is defined as a return, after an injury, to a sport at the same level as was possible before the injury. Satisfaction is more difficult to define as it involves the process of care, outcomes, and expectations3. For the purpose of this commentary, satisfaction can be simply defined as the fulfillment of one’s expectations. Are return to play and satisfaction equivalent? Can a patient return to play and be unsatisfied, and vice versa?

Nwachukwu et al. performed a Level-IV retrospective review of 232 active patients in an ACL database to determine (1) the rates and predictors of return to play after ACLR, (2) satisfaction after ACLR, and (3) the relationship between return to play and satisfaction. The overarching conclusion of the paper, supported by the data, was that ACLR in an active population results in a high rate of return to play and satisfaction. But what does this really mean? How do we use this information to improve ACLR for our patients? This article, rather than answering all of the questions, has left us with more good questions to be answered.

The authors conclude that both the rate of return to play and patient satisfaction are high after ACLR. The rate of return to play was 87% at a mean of 10 months postoperatively, and 89% of the patients who were eligible to return to their preinjury level of play had done so. The rate of satisfaction was reported to be 85%. The authors also state that “patellar tendon autograft increased the likelihood of returning to play whereas preinjury participation in soccer and lacrosse decreased these odds.” I would interpret this statement carefully as the heterogeneous nature of the study population and the limitations of the study design bring its validity into question. To improve our ability to make such a claim, we need to design better prospective, homogeneous studies to assess its reliability.

This is an important study, but it should be interpreted cautiously as it lacks many details and has the inherent limitations of a retrospective review of a heterogeneous database without a control group. Recall bias and 24 different surgeons performing multiple techniques of ACLR with different graft types and different postoperative rehabilitation protocols are also limitations of the study. Could residual postoperative knee laxity, meniscal pathology, surgical technique, or the postoperative rehabilitation program affect return-to-play or satisfaction results? Could return to play be affected by patient age, contact versus non-contact sport, competitive versus recreational sport, or male versus female? One may wonder whether return to play and satisfaction are the same for a young competitive female soccer player and a middle-aged male recreational basketball player. As much as we know, there is still much to learn.

The authors conclude that patients returning to play after ACLR are likely to be very satisfied with the result of surgery. This is important information and, although the study has substantial limitations, it forces us to look at the big picture: What can we do to make ACLR better for our patients? As surgeon scientists, we need to start thinking about the broader view and not just siloed outcome measures. We need to continue to improve rates of return to play to optimize patient satisfaction and in turn the value of ACLR.

*The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (


1. Spindler KP, Wright RW. Clinical practice. Anterior cruciate ligament tear. N Engl J Med. 2008 Nov 13;359(20):2135-42.
2. Nwachukwu BU, Hamid KS, Bozic KJ. Measuring value in orthopaedic surgery. JBJS Rev. 2013 Nov 19;1(1):01874474-201311000-00003.
3. Graham B, Green A, James M, Katz J, Swiontkowski M. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015 Jan 7;97(1):80-4.

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