"The only way you're ever going to play sport again is if you go through surgery": A mixed methods study exploring anterior cruciate ligament (ACL) injury treatment decisions from the perspective of 734 patients.

Abstract

Objectives: In patients with anterior cruciate ligament injury, i) describe beliefs about treatment options and the information received from clinicians in different disciplines and ii) explore treatment decision-making experiences, including factors that influenced their treatment decisions.

Design: Mixed-methods convergent parallel design, using an Australia-wide survey of 734 adults with anterior cruciate ligament injury, and 12 semi-structured interviews.

Methods: Survey responses were reported descriptively. A phenomenological approach and inductive thematic analysis were used for qualitative analysis. Quantitative and qualitative data were analysed concurrently. An integration stage involved comparison and collation of findings.

Results: Of 734 participants (70 % women), 540 (74 %) had anterior cruciate ligament reconstruction and 119 (16 %) were managed with rehabilitation alone. Participants consulted surgeons (94 %), physiotherapists (91 %), general practitioners (65 %), emergency department clinicians (22 %) and sports physicians (19 %). Most clinicians presented anterior cruciate ligament reconstruction as the best treatment [surgeons (85 %), physiotherapists (61 %)], and the best treatment to enable return to sport [surgeons (84 %), physiotherapists (62 %)]. Few clinicians informed patients that outcomes were similar on average between treatment strategies [surgeons (10 %), physiotherapists (29 %)]. Qualitative themes describe decision-making experiences: i) surgeons promoted surgery as the best/only option; ii) surgeon consults were rushed and patients felt poorly informed; iii) clinicians downplayed surgery risks and impacts; iv) general practitioners were utilised for referrals, not management advice; and v) mixed advice from physiotherapists. Quantitative and qualitative findings were closely aligned, with qualitative findings providing deeper insights into patients' treatment decision-making experience.

Conclusions: Australians with anterior cruciate ligament rupture received mixed treatment advice from clinicians, who often portrayed surgery as the best treatment option. Some patients received an unbalanced overview of treatment options that did not reflect the best-available research evidence, inhibiting an informed treatment decision.