Understanding the Factors that Influence Decision-Making Regarding Management of ACL Injuries: A UK, Australian and Canadian-Based Delphi Study

Aims: As public health systems change and engagement in sport competition grows, this study aims to build on previous research to establish expert consensus on aspects of ACL injury management, focussing on elite athletes and those impacted by lengthening surgical waiting lists. The study also aims to explore key factors that experts consider when determining ACL injury management. Methods: 22 specialist knee surgeons completed a 3-round Delphi Study consisting of 20 questions - consensus was set at 75% agreement. Round I was created based on an evidence review. Rounds II and III were identical and based on expert feedback from Round I. Wilcoxon signed rank test and Kendall’s W assessed the level of agreement between rounds and among participants, respectively. Key results: 32% believe rehabilitation-only is a viable option for elite athletes. 100% agreed rehabilitation has a greater re-injury risk than ACL-R. 86% agreed the decision for surgery can change if successful rehabilitation is completed whilst on the waiting list. Concomitant injuries was considered the most important factor. Only 50% of experts feel confident referring for rehabilitation-only management. Consensus was not reached on inclusion of lateral extra-articular procedures and secondary complications. Kendall’s W indicated moderate agreement in Round II (W = 0.532, p < 0.001) and stronger agreement in Round III (W = 0.672, p < 0.001), confirming convergence of expert consensus. Most items showed stable responses between rounds using. The Wilcoxon ranked test indicated individual participant’s responses were consistent across rounds (p = 0.16 to 1.00). Conclusions: Rehabilitation-only is not recommended for elite athletes or athletes in twisting / pivoting sports. For non-elite athletes who are on a waiting list for surgery, extensive rehabilitation should be prioritised, and re-assessment prior to their surgery is crucial, as successful rehabilitation can alter the decision for surgery. The presence of concomitant injuries is the most important factor when determining ACL injury management. Further research is required on the graft choice, lateral extra-articular procedures and impact of secondary complications.