Choosing surgery: patients' preferences within a trial of treatments for anterior cruciate ligament injury. A qualitative study.
BACKGROUND
The objective was to understand patients' views of treatment after acute anterior cruciate ligament (ACL) injury, and their reasons for deciding to request surgery despite consenting to participate in a randomised controlled trial (to 'cross-over').


METHODS
Thirty-four in-depth qualitative interviews were conducted with young (aged 18-35), physically active individuals with ACL rupture who were participating in a RCT comparing training and surgical reconstruction with training only. 22/34 were randomised to training only but crossed over to surgery. Of these, 11 were interviewed before surgery, and 11 were interviewed at least 6 months after surgery. To provide additional information, 12 patients were interviewed before randomisation. Interviews were audio-recorded, transcribed and analysed using the Framework approach.


RESULTS
Strong preference for surgery was commonplace and many patients said that they joined the RCT in order to bypass waiting lists. Patients who chose to cross-over described training as time consuming, boring and as unable to provide sufficient results within a reasonable timeframe. Some said their injured knees had given-way; others experienced new knee traumas; and many described their lack of trust in their knee. Patients believed that surgery would provide joint stability. Despite the ostensible satisfaction with surgery, more detailed exploration showed mixed views.


CONCLUSIONS
Participants in a trial of treatments for acute ACL injury express a variety of views and beliefs about those treatments, and trial participation happens in the absence of equipoise. Furthermore, opting for surgical reconstruction does not necessarily provide patients with satisfactory outcomes. Definition of successful outcome may require an individualised approach, incorporating patients' as well as surgeons' views before treatment decisions are made.
Thorstensson
Carina A
CA
Department of Research and Development, Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden. carina.thorstensson@spenshult.se
Lohmander
L Stefan
LS
Frobell
Richard B
RB
Roos
Ewa M
EM
Gooberman-Hill
Rachael
R
D000328:Adult; D016118:Anterior Cruciate Ligament / Q000503:physiopathology / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D001182:Arthroscopy; D002755:Choice Behavior; D018592:Cross-Over Studies; D005081:Exercise Therapy; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007593:Joint Instability / Q000503:physiopathology / Q000628:therapy; D007718:Knee Injuries / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D008297:Male; D017060:Patient Satisfaction; D036301:Qualitative Research; D020127:Recovery of Function; D012421:Rupture; D016896:Treatment Outcome; D014850:Waiting Lists; D055815:Young Adult