The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement

Published:September 06, 2020DOI:


      To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement.


      A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement.


      A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker’s compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001).


      Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker’s compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mitchell J.
        • Graham W.
        • Best T.M.
        • et al.
        Epidemiology of meniscal injuries in US high school athletes between 2007 and 2013.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 715-722
        • Mall N.A.
        • Chalmers P.N.
        • Moric M.
        • et al.
        Incidence and trends of anterior cruciate ligament reconstruction in the United States.
        Am J Sports Med. 2014; 42: 2363-2370
        • Herzog M.M.
        • Marshall S.W.
        • Lund J.L.
        • Pate V.
        • Mack C.D.
        • Spang J.T.
        Trends in incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002-2014.
        Sports Health. 2018; 10: 523-531
        • Abram S.G.F.
        • Judge A.
        • Beard D.J.
        • Price A.J.
        Adverse outcomes after arthroscopic partial meniscectomy: A study of 700 000 procedures in the national Hospital Episode Statistics database for England.
        Lancet. 2018; 392: 2194-2202
        • Kawata M.
        • Sasabuchi Y.
        • Taketomi S.
        • et al.
        Annual trends in arthroscopic meniscus surgery: Analysis of a national database in Japan.
        PLoS One. 2018; 13e0194854
        • Vaishya R.
        • Agarwal A.K.
        • Ingole S.
        • Vijay V.
        Current trends in anterior cruciate ligament reconstruction: A review.
        Cureus. 2015; 7: e378
        • Maletis G.B.
        • Chen J.
        • Inacio M.C.S.
        • Love R.M.
        • Funahashi T.T.
        Increased risk of revision after anterior cruciate ligament reconstruction with bone-patellar tendon-bone allografts compared with autografts.
        Am J Sports Med. 2017; 45: 1333-1340
        • Dunn W.R.
        • Spindler K.P.
        • Consortium M.
        Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): A Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study.
        Am J Sports Med. 2010; 38: 2040-2050
        • Bisson L.J.
        • Kluczynski M.A.
        • Wind W.M.
        • et al.
        Patient outcomes after observation versus debridement of unstable chondral lesions during partial meniscectomy: The Chondral Lesions and Meniscus Procedures (ChAMP) randomized controlled trial.
        J Bone Joint Surg Am. 2017; 99: 1078-1085
        • Sihvonen R.
        • Paavola M.
        • Malmivaara A.
        • et al.
        Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.
        N Engl J Med. 2013; 369: 2515-2524
        • Collins N.J.
        • Misra D.
        • Felson D.T.
        • Crossley K.M.
        • Roos E.M.
        Measures of knee function: International Knee Documentation Committee (IKDC) subjective knee evaluation form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS).
        Arthritis Care Res (Hoboken). 2011; 63: S208-S228
        • Makhni E.C.
        • Padaki A.S.
        • Petridis P.D.
        • et al.
        High variability in outcome reporting patterns in high-impact ACL literature.
        J Bone Joint Surg Am. 2015; 97: 1529-1542
        • Atkinson T.M.
        • Schwartz C.E.
        • Goldstein L.
        • et al.
        Perceptions of response burden associated with completion of patient-reported outcome assessments in oncology.
        Value Health. 2019; 22: 225-230
        • Guattery J.M.
        • Dardas A.Z.
        • Kelly M.
        • Chamberlain A.
        • McAndrew C.
        • Calfee R.P.
        Floor effect of PROMIS depression CAT associated with hasty completion in orthopaedic surgery patients.
        Clin Orthop Relat Res. 2018; 476: 696-703
        • Dowdle S.B.
        • Glass N.
        • Anthony C.A.
        • Hettrich C.M.
        Use of PROMIS for patients undergoing primary total shoulder arthroplasty.
        Orthop J Sports Med. 2017; 5 (2325967117726044)
        • Hancock K.J.
        • Glass N.
        • Anthony C.A.
        • et al.
        Performance of PROMIS for healthy patients undergoing meniscal surgery.
        J Bone Joint Surg Am. 2017; 99: 954-958
        • Cook C.E.
        Clinimetrics Corner: The minimal clinically important change score (MCID): A necessary pretense.
        J Man Manip Ther. 2008; 16: E82-E83
        • Paulsen A.
        • Roos E.M.
        • Pedersen A.B.
        • Overgaard S.
        Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively.
        Acta Orthop. 2014; 85: 39-48
        • Harris J.D.
        • Brand J.C.
        • Cote M.P.
        • Faucett S.C.
        • Dhawan A.
        Research pearls: The significance of statistics and perils of pooling. Part 1: Clinical versus statistical significance.
        Arthroscopy. 2017; 33: 1102-1112
        • Cote M.P.
        Editorial commentary: Threshold values for treatment success-rotator cuff repair success lies in the eye of the beholder.
        Arthroscopy. 2019; 35: 312-313
        • Kivlan B.R.
        • Martin R.L.
        • Christoforetti J.J.
        • et al.
        The patient acceptable symptomatic state of the 12-item International Hip Outcome Tool at 1-year follow-up of hip-preservation surgery.
        Arthroscopy. 2019; 35: 1457-1462
        • Puzzitiello R.N.
        • Gowd A.K.
        • Liu J.N.
        • Agarwalla A.
        • Verma N.N.
        • Forsythe B.
        Establishing minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after biceps tenodesis.
        J Shoulder Elbow Surg. 2019; 28: 639-647
        • Cvetanovich G.L.
        • Gowd A.K.
        • Liu J.N.
        • et al.
        Establishing clinically significant outcome after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2019; 28: 939-948
        • Liu J.N.
        • Gowd A.K.
        • Redondo M.L.
        • et al.
        Establishing clinically significant outcomes after meniscal allograft transplantation.
        Orthop J Sports Med. 2019; 7 (2325967118818462)
        • Kurosaka K.
        • Tsukada S.
        • Nakayama H.
        • et al.
        Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction: A randomized controlled trial.
        Arthroscopy. 2018; 34: 182-188
        • Muller B.
        • Yabroudi M.A.
        • Lynch A.
        • et al.
        Defining thresholds for the patient acceptable symptom state for the IKDC Subjective Knee Form and KOOS for patients who underwent ACL reconstruction.
        Am J Sports Med. 2016; 44: 2820-2826
        • Chen R.E.
        • Papuga M.O.
        • Voloshin I.
        • et al.
        Preoperative PROMIS scores predict postoperative outcomes after primary ACL reconstruction.
        Orthop J Sports Med. 2018; 6 (2325967118771286)
        • Nwachukwu B.U.
        • Chang B.
        • Voleti P.B.
        • et al.
        Preoperative Short Form Health Survey score is predictive of return to play and minimal clinically important difference at a minimum 2-year follow-up after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2017; 45: 2784-2790
        • Gowd A.K.
        • Lalehzarian S.P.
        • Liu J.N.
        • et al.
        Factors associated with clinically significant patient-reported outcomes after primary arthroscopic partial meniscectomy.
        Arthroscopy. 2019; 35: 1567-1575.e1563
        • Puzzitiello R.N.
        • Agarwalla A.
        • Bush-Joseph C.A.
        • Forsythe B.
        Iliotibial band tenodesis with a tenodesis screw for augmentation of anterior cruciate ligament reconstruction.
        Arthrosc Tech. 2019; 8: e389-e393
        • Higgins L.D.
        • Taylor M.K.
        • Park D.
        • et al.
        Reliability and validity of the International Knee Documentation Committee (IKDC) subjective knee form.
        Joint Bone Spine. 2007; 74: 594-599
        • Magnuson J.A.
        • Strnad G.
        • Smith C.
        • et al.
        Comparison of Standard and Right/Left International Knee Documentation Committee subjective knee form scores.
        Am J Sports Med. 2019; 47: 1203-1208
        • Nguyen J.
        • Marx R.
        • Hidaka C.
        • Wilson S.
        • Lyman S.
        Validation of electronic administration of knee surveys among ACL-injured patients.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3116-3122
        • van Meer B.L.
        • Meuffels D.E.
        • Vissers M.M.
        • et al.
        Knee Injury and Osteoarthritis Outcome Score or International Knee Documentation Committee subjective knee form: Which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term?.
        Arthroscopy. 2013; 29: 701-715
        • Wright R.W.
        Knee injury outcomes measures.
        J Am Acad Orthop Surg. 2009; 17: 31-39
        • Hambly K.
        • Griva K.
        IKDC or KOOS: Which one captures symptoms and disabilities most important to patients who have undergone initial anterior cruciate ligament reconstruction?.
        Am J Sports Med. 2010; 38: 1395-1404
        • Copay A.G.
        • Subach B.R.
        • Glassman S.D.
        • Polly Jr., D.W.
        • Schuler T.C.
        Understanding the minimum clinically important difference: A review of concepts and methods.
        Spine J. 2007; 7: 541-546
        • Nwachukwu B.U.
        • Chang B.
        • Fields K.
        • et al.
        Defining the “substantial clinical benefit” after arthroscopic treatment of femoroacetabular impingement.
        Am J Sports Med. 2017; 45: 1297-1303
        • Nwachukwu B.U.
        • Chang B.
        • Kahlenberg C.A.
        • et al.
        Arthroscopic treatment of femoroacetabular impingement in adolescents provides clinically significant outcome improvement.
        Arthroscopy. 2017; 33: 1812-1818
        • Wright A.A.
        • Hensley C.P.
        • Gilbertson J.
        • Leland 3rd, J.M.
        • Jackson S.
        Defining patient acceptable symptom state thresholds for commonly used patient reported outcomes measures in general orthopedic practice.
        Man Ther. 2015; 20: 814-819
        • Alexopoulos E.C.
        Introduction to multivariate regression analysis.
        Hippokratia. 2010; 14: 23-28
        • Hohmann E.
        • Wetzler M.J.
        • D’Agostino Jr., R.B.
        Research pearls: The significance of statistics and perils of pooling. Part 2: Predictive modeling.
        Arthroscopy. 2017; 33: 1423-1432
        • Saltzman B.M.
        • Meyer M.A.
        • Weber A.E.
        • Poland S.G.
        • Yanke A.B.
        • Cole B.J.
        Prospective clinical and radiographic outcomes after concomitant anterior cruciate ligament reconstruction and meniscal allograft transplantation at a mean 5-year follow-up.
        Am J Sports Med. 2017; 45: 550-562
        • Levy D.M.
        • Kuhns B.D.
        • Chahal J.
        • Philippon M.J.
        • Kelly B.T.
        • Nho S.J.
        Hip arthroscopy outcomes with respect to patient acceptable symptomatic state and minimal clinically important difference.
        Arthroscopy. 2016; 32: 1877-1886
        • Logerstedt D.
        • Lynch A.
        • Axe M.J.
        • Snyder-Mackler L.
        Pre-operative quadriceps strength predicts IKDC2000 scores 6 months after anterior cruciate ligament reconstruction.
        Knee. 2013; 20: 208-212
        • de Jong S.N.
        • van Caspel D.R.
        • van Haeff M.J.
        • Saris D.B.
        Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions.
        Arthroscopy. 2007; 23: 21-28, 28.e21-23
        • Dunn W.R.
        • Wolf B.R.
        • Harrell Jr., F.E.
        • et al.
        Baseline predictors of health-related quality of life after anterior cruciate ligament reconstruction: A longitudinal analysis of a multicenter cohort at two and six years.
        J Bone Joint Surg Am. 2015; 97: 551-557
        • Eitzen I.
        • Holm I.
        • Risberg M.A.
        Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction.
        Br J Sports Med. 2009; 43: 371-376
        • Grindem H.
        • Granan L.P.
        • Risberg M.A.
        • Engebretsen L.
        • Snyder-Mackler L.
        • Eitzen I.
        How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry.
        Br J Sports Med. 2015; 49: 385-389
        • Uribe J.W.
        • Arango D.
        • Frank J.
        • Kiebzak G.M.
        Two-year outcome with the AperFix system for ACL reconstruction.
        Orthopedics. 2013; 36: e159-e164
        • Yasen S.K.
        • Borton Z.M.
        • Eyre-Brook A.I.
        • et al.
        Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
        Knee. 2017; 24: 55-62
        • Lubowitz J.H.
        • Schwartzberg R.
        • Smith P.
        Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
        Arthroscopy. 2013; 29: 1195-1200
        • Koga H.
        • Muneta T.
        • Yagishita K.
        • et al.
        Mid- to long-term results of single-bundle versus double-bundle anterior cruciate ligament reconstruction: Randomized controlled trial.
        Arthroscopy. 2015; 31: 69-76
        • Agarwalla A.
        • Puzzitiello R.N.
        • Liu J.N.
        • et al.
        Timeline for maximal subjective outcome improvement after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2018; (363546518803365)
        • Schmale G.A.
        • Kweon C.
        • Larson R.V.
        • Bompadre V.
        High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.
        Clin Orthop Relat Res. 2014; 472: 2168-2174
        • Nwachukwu B.U.
        • Voleti P.B.
        • Berkanish P.
        • et al.
        Return to play and patient satisfaction after ACL reconstruction: Study with minimum 2-year follow-up.
        J Bone Joint Surg Am. 2017; 99: 720-725
        • Steadman J.R.
        • Matheny L.M.
        • Briggs K.K.
        • Rodkey W.G.
        • Carreira D.S.
        Outcomes following healing response in older, active patients: A primary anterior cruciate ligament repair technique.
        J Knee Surg. 2012; 25: 255-260