Clinically Interpretable Modeling of ACL Reconstruction Outcomes Using Confidence-Aware Gait Analysis

Background/Objectives: Outcomes following Anterior Cruciate Ligament (ACL) reconstruction vary widely among patients, yet existing classification techniques often lack transparency and clinical interpretability. To address this gap, we developed a multi-modal framework that integrates gait dynamics with patient-specific characteristics to enhance personalized assessment of ACL reconstruction outcomes. Methods: Participants, both post-ACL reconstruction and healthy controls, were equipped with inertial measurement unit (IMU) sensors on bilateral wrists, ankles, and the sacrum during standardized locomotion tasks. Using the Phase Slope Index (PSI), we quantified causal relationships between sensor pairs, hypothesizing that (1) PSI-derived metrics capture discriminative biomechanical interactions; (2) task-specific differences in segment coordination patterns influence model performance; and (3) recovery duration modulates classifier confidence and the structure of high-dimensional data distributions. Classification models were trained using PSI features, and permutation-based sensor importance analyses were conducted to interpret task-specific biomechanical contributions. Results: PSI-based classifiers achieved 96.37% accuracy in distinguishing ACL reconstruction outcomes, validating the first hypothesis. Permutation importance revealed that jogging tasks produced more focused importance distributions across fewer sensor pairs while improving accuracy, confirming task-specific coordination effects (hypothesis two). Visualization via t-SNE demonstrated that longer recovery durations corresponded to reduced model confidence but more coherent feature clusters, supporting the third hypothesis. Conclusions: By integrating causal gait metrics and patient recovery profiles, this approach enables interpretable and high-performing ACL outcome prediction. Quantitative evaluation measures—including model confidence and t-SNE cluster coherence—offer clinicians objective tools for personalized rehabilitation monitoring and data-driven return-to-sport decisions.