Treatment of Acute vs. Chronic ACL Injured/Deficient Knee

Part 1: Demographics

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* 1. What is your current age?

under 30

31-40

41-50

51-60

over 61

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* 2. Where do you currently practice?

United States

Canada

Central or South America

Europe

Asia

Africa

Middle East

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* 3. How long have you been in independent practice?

<5 years

5-10 years

11-20 years

>20 years

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* 4. Which best describes your current practice setting?

Community-based

Hospital-based

Non-operative

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* 5. Which best describes your current practice remuneration?

Private medicine

Public medicine

Mixed private/public

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* 6. Which best describes your practice type?

Academic

Non-academic

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* 7. Which of the following Orthopaedic Surgery accredited Fellowships have you completed:

Sports Medicine

Foot and ankle

Trauma

Arthroplasty/Adult reconstruction

Spine

Other (please specify)

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* 8. How many ACL reconstructions do you perform a year?

<10

10-25

26-50

51-100

>100

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* 9. Do you perform more than six of the following procedures per year?

	Yes	No
Cartilage repair not including microfracture (MACI, OATS – allograft or autograft, AMIC, ACI)	Cartilage repair not including microfracture (MACI, OATS – allograft or autograft, AMIC, ACI) Yes	Cartilage repair not including microfracture (MACI, OATS – allograft or autograft, AMIC, ACI) No
Knee joint replacement (including UKA, TKA)	Knee joint replacement (including UKA, TKA) Yes	Knee joint replacement (including UKA, TKA) No
Osteotomy around the knee (HTO, DFO)	Osteotomy around the knee (HTO, DFO) Yes	Osteotomy around the knee (HTO, DFO) No

PART 2: ACL INJURY DIAGNOSIS/CLASSIFICATION IN YOUR PRACTICE

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* 10. How long after an initial ACL injury would you consider the knee “chronically” ACL deficient?

After 6 weeks

After 3 months

After 6 months

More than 1 year

Non-time-based factor:

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* 11. For an isolated ACL Injury you intend to reconstruct, what is the ideal time period for surgery?

<3 weeks

3-6 weeks

6-12 weeks

>12 weeks

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* 12. What proportion of symptomatic acute ACL injuries (according to your definition of acuity) do you treat surgically?

<10%

10-25%

25-50%

50-75%

>75%

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* 13. What proportion of symptomatic chronic ACL injuries (according to your definition of chronic) that you assess for the 1st time do you treat surgically?

<10%

10-25%

25-50%

50-75%

>75%

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* 14. For what you consider an “ACUTE” ACL deficient/injured knee, which of the following investigations do you routinely obtain? Check all that apply.

Weight bearing knee X-rays

Non-weight bearing knee X-rays

Standing lower extremity alignment X-rays (whole leg)

MRI

Ultrasound

Other (please specify)

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* 15. For what you consider an “ACUTE” ACL deficient knee, how likely are you to perform the following calculation during the assessment?

	Never	Rarely	Sometimes	Often	Always
Posterior Tibial slope calculation	Posterior Tibial slope calculation Never	Posterior Tibial slope calculation Rarely	Posterior Tibial slope calculation Sometimes	Posterior Tibial slope calculation Often	Posterior Tibial slope calculation Always
Coronal plane alignment on full-length standing x-ray	Coronal plane alignment on full-length standing x-ray Never	Coronal plane alignment on full-length standing x-ray Rarely	Coronal plane alignment on full-length standing x-ray Sometimes	Coronal plane alignment on full-length standing x-ray Often	Coronal plane alignment on full-length standing x-ray Always
Kellgren-Lawrence OA grading on PA flexion weight bearing views	Kellgren-Lawrence OA grading on PA flexion weight bearing views Never	Kellgren-Lawrence OA grading on PA flexion weight bearing views Rarely	Kellgren-Lawrence OA grading on PA flexion weight bearing views Sometimes	Kellgren-Lawrence OA grading on PA flexion weight bearing views Often	Kellgren-Lawrence OA grading on PA flexion weight bearing views Always

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* 16. For what you consider a “CHRONIC” ACL deficient/injured knee, which of the following investigations do you routinely obtain? Check all that apply.

Weight bearing knee X-rays

Non-weight bearing knee X-rays

Standing lower extremity alignment X-rays (whole leg)

MRI

Ultrasound

Other (please specify)

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* 17. For what you consider a “CHRONIC” ACL deficient knee, how likely are you to perform the following calculation during the assessment?

	Never	Rarely	Sometimes	Often	Always
Posterior Tibial slope calculation	Posterior Tibial slope calculation Never	Posterior Tibial slope calculation Rarely	Posterior Tibial slope calculation Sometimes	Posterior Tibial slope calculation Often	Posterior Tibial slope calculation Always
Coronal plane alignment on full-length standing X-ray	Coronal plane alignment on full-length standing X-ray Never	Coronal plane alignment on full-length standing X-ray Rarely	Coronal plane alignment on full-length standing X-ray Sometimes	Coronal plane alignment on full-length standing X-ray Often	Coronal plane alignment on full-length standing X-ray Always
Kellgren-Lawrence OA grading on PA flexion weight bearing views	Kellgren-Lawrence OA grading on PA flexion weight bearing views Never	Kellgren-Lawrence OA grading on PA flexion weight bearing views Rarely	Kellgren-Lawrence OA grading on PA flexion weight bearing views Sometimes	Kellgren-Lawrence OA grading on PA flexion weight bearing views Often	Kellgren-Lawrence OA grading on PA flexion weight bearing views Always

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* 18. In selecting treatment for an "ACUTE" ACL injured/deficient knee how important are the following anatomic factors in determining whether you would perform ACL reconstruction?

	Very Important	Important	Moderately Important	Slightly Important	Not Important
Posterior Tibial slope	Posterior Tibial slope Very Important	Posterior Tibial slope Important	Posterior Tibial slope Moderately Important	Posterior Tibial slope Slightly Important	Posterior Tibial slope Not Important
Coronal plane alignment	Coronal plane alignment Very Important	Coronal plane alignment Important	Coronal plane alignment Moderately Important	Coronal plane alignment Slightly Important	Coronal plane alignment Not Important
Degree of arthritis by KL scale	Degree of arthritis by KL scale Very Important	Degree of arthritis by KL scale Important	Degree of arthritis by KL scale Moderately Important	Degree of arthritis by KL scale Slightly Important	Degree of arthritis by KL scale Not Important
Status of the medial meniscus -- i.e., torn vs intact	Status of the medial meniscus -- i.e., torn vs intact Very Important	Status of the medial meniscus -- i.e., torn vs intact Important	Status of the medial meniscus -- i.e., torn vs intact Moderately Important	Status of the medial meniscus -- i.e., torn vs intact Slightly Important	Status of the medial meniscus -- i.e., torn vs intact Not Important
High grade pivot-shift	High grade pivot-shift Very Important	High grade pivot-shift Important	High grade pivot-shift Moderately Important	High grade pivot-shift Slightly Important	High grade pivot-shift Not Important
Hyperextension >5 degrees	Hyperextension >5 degrees Very Important	Hyperextension >5 degrees Important	Hyperextension >5 degrees Moderately Important	Hyperextension >5 degrees Slightly Important	Hyperextension >5 degrees Not Important

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* 19. In selecting treatment for "CHRONIC" ACL deficient knee, how important are the following anatomic factors in determining whether you would perform ACL reconstruction?

	Very Important	Important	Moderately Important	Slightly Important	Not Important
Posterior Tibial slope	Posterior Tibial slope Very Important	Posterior Tibial slope Important	Posterior Tibial slope Moderately Important	Posterior Tibial slope Slightly Important	Posterior Tibial slope Not Important
Coronal plane alignment	Coronal plane alignment Very Important	Coronal plane alignment Important	Coronal plane alignment Moderately Important	Coronal plane alignment Slightly Important	Coronal plane alignment Not Important
Degree of arthritis by KL scale	Degree of arthritis by KL scale Very Important	Degree of arthritis by KL scale Important	Degree of arthritis by KL scale Moderately Important	Degree of arthritis by KL scale Slightly Important	Degree of arthritis by KL scale Not Important
Status of the medial meniscus -- i.e., torn vs intact	Status of the medial meniscus -- i.e., torn vs intact Very Important	Status of the medial meniscus -- i.e., torn vs intact Important	Status of the medial meniscus -- i.e., torn vs intact Moderately Important	Status of the medial meniscus -- i.e., torn vs intact Slightly Important	Status of the medial meniscus -- i.e., torn vs intact Not Important
High grade pivot-shift	High grade pivot-shift Very Important	High grade pivot-shift Important	High grade pivot-shift Moderately Important	High grade pivot-shift Slightly Important	High grade pivot-shift Not Important
Hyperextension >5 degrees	Hyperextension >5 degrees Very Important	Hyperextension >5 degrees Important	Hyperextension >5 degrees Moderately Important	Hyperextension >5 degrees Slightly Important	Hyperextension >5 degrees Not Important

PART 3: ACL TREATMENT

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* 20. Does the length of time from injury (i.e., how you have defined acute vs chronic) influence your graft choice in ACLR?

Yes

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* 21. If yes to previous question (#20), what is your preferred graft choice in "ACUTE" ACLR reconstruction?

Autograft hamstring

Autograft quads

Autograft btb

Allograft

Other (please specify)

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* 22. If yes to previous question (#20), what is your preferred graft choice in "CHRONIC" ACLR reconstruction?

Autograft hamstring

Autograft quads

Autograft btb

Allograft

Other (please specify)

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* 23. In an “ACUTE” ACL injured/deficient knee, which of the following augmentation procedures are you likely to perform in addition to ACLR?

	Very Unlikely	Unlikely	Neutral	Likely	Very Likely
AL reconstruction or LET	AL reconstruction or LET Very Unlikely	AL reconstruction or LET Unlikely	AL reconstruction or LET Neutral	AL reconstruction or LET Likely	AL reconstruction or LET Very Likely
Internal brace	Internal brace Very Unlikely	Internal brace Unlikely	Internal brace Neutral	Internal brace Likely	Internal brace Very Likely
Limb re-alignment in the coronal plane	Limb re-alignment in the coronal plane Very Unlikely	Limb re-alignment in the coronal plane Unlikely	Limb re-alignment in the coronal plane Neutral	Limb re-alignment in the coronal plane Likely	Limb re-alignment in the coronal plane Very Likely
Limb re-alignment in the sagittal plane	Limb re-alignment in the sagittal plane Very Unlikely	Limb re-alignment in the sagittal plane Unlikely	Limb re-alignment in the sagittal plane Neutral	Limb re-alignment in the sagittal plane Likely	Limb re-alignment in the sagittal plane Very Likely

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* 24. In a “CHRONIC” ACL deficient knee, which of the following augmentation procedures are you likely to perform in addition to ACLR?

	Very Unlikely	Unlikely	Neutral	Likely	Very Likely
ALL reconstruction or LET	ALL reconstruction or LET Very Unlikely	ALL reconstruction or LET Unlikely	ALL reconstruction or LET Neutral	ALL reconstruction or LET Likely	ALL reconstruction or LET Very Likely
Internal brace	Internal brace Very Unlikely	Internal brace Unlikely	Internal brace Neutral	Internal brace Likely	Internal brace Very Likely
Limb re-alignment in the coronal place	Limb re-alignment in the coronal place Very Unlikely	Limb re-alignment in the coronal place Unlikely	Limb re-alignment in the coronal place Neutral	Limb re-alignment in the coronal place Likely	Limb re-alignment in the coronal place Very Likely
Limb re-alignment in the sagittal plane	Limb re-alignment in the sagittal plane Very Unlikely	Limb re-alignment in the sagittal plane Unlikely	Limb re-alignment in the sagittal plane Neutral	Limb re-alignment in the sagittal plane Likely	Limb re-alignment in the sagittal plane Very Likely

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* 25. If you perform sagittal limb re-alignment surgery in a "CHRONIC" ACL deficient knee, what is your threshold requiring an osteotomy for slope correction?

I do not perform limb re-alignment in chronic ACL deficient knee

<12 degrees

>12 degrees

Other (please specify)

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* 26. How likely would you be to consider coronal plane re-alignment osteotomy in the "CHRONIC" ACL deficient knee with"

	Very Unlikely	Unlikely	Neutral	Likely	Very Likely
Kellgren-Lawrence grade <3 in the affected compartment	Kellgren-Lawrence grade <3 in the affected compartment Very Unlikely	Kellgren-Lawrence grade <3 in the affected compartment Unlikely	Kellgren-Lawrence grade <3 in the affected compartment Neutral	Kellgren-Lawrence grade <3 in the affected compartment Likely	Kellgren-Lawrence grade <3 in the affected compartment Very Likely
Kellgren-Lawrence grade ≥3 in the affected compartment	Kellgren-Lawrence grade ≥3 in the affected compartment Very Unlikely	Kellgren-Lawrence grade ≥3 in the affected compartment Unlikely	Kellgren-Lawrence grade ≥3 in the affected compartment Neutral	Kellgren-Lawrence grade ≥3 in the affected compartment Likely	Kellgren-Lawrence grade ≥3 in the affected compartment Very Likely
Mechanical Axis Deviation of >15mm	Mechanical Axis Deviation of >15mm Very Unlikely	Mechanical Axis Deviation of >15mm Unlikely	Mechanical Axis Deviation of >15mm Neutral	Mechanical Axis Deviation of >15mm Likely	Mechanical Axis Deviation of >15mm Very Likely

PART 4: PATIENT COUNSELLING

Question Title

* 27. Do you counsel patients differently on their expected surgical outcomes based on whether an ACL injury is "ACUTE" vs. "CHRONIC"?

Yes

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* 28. How confident are you in the following outcomes of ACLR for an "ACUTE" ACL injury?

	Very Confident	Confident	Moderately Confident	Slightly Confident	Not Confident
High patient satisfaction	High patient satisfaction Very Confident	High patient satisfaction Confident	High patient satisfaction Moderately Confident	High patient satisfaction Slightly Confident	High patient satisfaction Not Confident
Return to sport at pre-injury level	Return to sport at pre-injury level Very Confident	Return to sport at pre-injury level Confident	Return to sport at pre-injury level Moderately Confident	Return to sport at pre-injury level Slightly Confident	Return to sport at pre-injury level Not Confident
Graft rupture	Graft rupture Very Confident	Graft rupture Confident	Graft rupture Moderately Confident	Graft rupture Slightly Confident	Graft rupture Not Confident
Decreased risk of OA progression	Decreased risk of OA progression Very Confident	Decreased risk of OA progression Confident	Decreased risk of OA progression Moderately Confident	Decreased risk of OA progression Slightly Confident	Decreased risk of OA progression Not Confident

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* 29. How confident are you in the following outcomes of ACLR for a "CHRONIC" ACL injury?

	Very Confident	Confident	Moderately Confident	Slightly Confident	Not Confident
High patient satisfaction	High patient satisfaction Very Confident	High patient satisfaction Confident	High patient satisfaction Moderately Confident	High patient satisfaction Slightly Confident	High patient satisfaction Not Confident
Return to sport at pre-injury level	Return to sport at pre-injury level Very Confident	Return to sport at pre-injury level Confident	Return to sport at pre-injury level Moderately Confident	Return to sport at pre-injury level Slightly Confident	Return to sport at pre-injury level Not Confident
Graft rupture	Graft rupture Very Confident	Graft rupture Confident	Graft rupture Moderately Confident	Graft rupture Slightly Confident	Graft rupture Not Confident
Decreased risk of OA progression	Decreased risk of OA progression Very Confident	Decreased risk of OA progression Confident	Decreased risk of OA progression Moderately Confident	Decreased risk of OA progression Slightly Confident	Decreased risk of OA progression Not Confident

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* 30. Do you consider that an "ACUTE" vs "CHRONIC" ACL deficient knee as having unique anatomical differences?

Yes

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* 31. If yes to #27, which of the following anatomic factors do you recognize as important in considering the treatment of or prognosis of "CHRONIC" ACL deficiency?

	Very Important	Important	Moderately Important	Slightly Important	Not Important
Cartilage lesions	Cartilage lesions Very Important	Cartilage lesions Important	Cartilage lesions Moderately Important	Cartilage lesions Slightly Important	Cartilage lesions Not Important
Anterior translation of the tibia with respect to the femur on X-ray	Anterior translation of the tibia with respect to the femur on X-ray Very Important	Anterior translation of the tibia with respect to the femur on X-ray Important	Anterior translation of the tibia with respect to the femur on X-ray Moderately Important	Anterior translation of the tibia with respect to the femur on X-ray Slightly Important	Anterior translation of the tibia with respect to the femur on X-ray Not Important
Anterior translation of the tibia with respect to the femur on MRI	Anterior translation of the tibia with respect to the femur on MRI Very Important	Anterior translation of the tibia with respect to the femur on MRI Important	Anterior translation of the tibia with respect to the femur on MRI Moderately Important	Anterior translation of the tibia with respect to the femur on MRI Slightly Important	Anterior translation of the tibia with respect to the femur on MRI Not Important
Medial meniscal posterior horn tears	Medial meniscal posterior horn tears Very Important	Medial meniscal posterior horn tears Important	Medial meniscal posterior horn tears Moderately Important	Medial meniscal posterior horn tears Slightly Important	Medial meniscal posterior horn tears Not Important
Vertical oriented PCL on MRI	Vertical oriented PCL on MRI Very Important	Vertical oriented PCL on MRI Important	Vertical oriented PCL on MRI Moderately Important	Vertical oriented PCL on MRI Slightly Important	Vertical oriented PCL on MRI Not Important
Lateral meniscus posterior horn root tear	Lateral meniscus posterior horn root tear Very Important	Lateral meniscus posterior horn root tear Important	Lateral meniscus posterior horn root tear Moderately Important	Lateral meniscus posterior horn root tear Slightly Important	Lateral meniscus posterior horn root tear Not Important