The Impact of Preoperative Anxiety on the Incidence of Arthrogenic Muscle Inhibition After Anterior Cruciate Ligament Reconstruction.

Abstract

Background: A patient's psychological state plays an important role in the functional outcome of anterior cruciate ligament (ACL) reconstruction. The outcome can be impaired by arthrogenic muscle inhibition (AMI), which is a potentially severe complication after ACL reconstruction. It is better to identify patients at risk of AMI to provide appropriate management.

Purpose/hypothesis: The goal of this study was to evaluate the impact of preoperative anxiety on the incidence of AMI at 21 days after ACL reconstruction. It was hypothesized that patients with high preoperative anxiety would more frequently have AMI on day 21 (D21) after ACL reconstruction than less anxious patients. The secondary goal of this study was to evaluate the rate of AMI on D21 after ACL reconstruction in the high and low anxiety groups.

Study design: Cohort study; Level of evidence, 2.

Methods: A prospective cohort study was performed on 143 patients who underwent ACL reconstruction between May and June 2024 at a sports surgery center. The Surgical Fear Questionnaire (SFQ), assessing surgery-related anxiety, was completed by patients before surgery. The incidence of AMI (grade ≥1a) on D21 was the main outcome measure. Patients were divided into 2 groups according to their median SFQ score (≥30 = high anxiety; <30 = low anxiety) and paired for age, sex, and Tegner score. Analysis of the receiver operating characteristic curve and logistic regression analysis were performed to identify the optimal SFQ score to predict the presence of AMI on D21. The rate of secondary arthrolysis was also retrospectively recorded at 6 months after surgery in all patients.

Results: After pairing, 55 patients were included in the high anxiety group (mean age, 31.0 ± 11.7 years; mean SFQ score, 43.7 ± 10.8) and 45 in the low anxiety group (mean age, 33.5 ± 11.6 years [P = .281]; mean SFQ score, 13.7 ± 8.7 [P < .001]). The groups were comparable, except for the preoperative International Knee Documentation Committee score (55.9 ± 18.2 vs 65.7 ± 15.8, respectively; P = .007). The rate of AMI was higher (80.0%) in the high anxiety group on D21 than in the low anxiety group (55.6%) (P = .010). Patients with an SFQ score ≥27 had a 3.17-fold higher risk (95% CI, 1.33-7.81; P = .010) of developing AMI on D21. Receiver operating characteristic curve analysis showed an area under the curve of 0.77 (95% CI, 0.65-0.88). The Youden index reached a maximum value of 0.521 at the optimal SFQ score threshold of 27, corresponding to a sensitivity of 84.2% and a specificity of 67.9%. The distribution of AMI grades on D21 showed that severe forms (grade 2b) were more frequent in the high anxiety group than in the low anxiety group (58.2% vs 37.8%, respectively). Additionally, 2 cases of grade 3 AMI required secondary arthrolysis, with one in each group.

Conclusion: This prospective study showed that preoperative anxiety was associated with early AMI after ACL reconstruction. However, preoperative anxiety had no effect on the need for arthrolysis. Clinically, these findings suggest that the preoperative identification of anxious patients using the SFQ may help guide targeted perioperative interventions and rehabilitation strategies to reduce the risk of AMI and improve early functional recovery.

Registration: NCT02511158 (ClinicalTrials.gov).