Study Design and Participants
Institutional review board approval was granted for this study (institutional review board number COS-RGDS-2021-07-005). All participants gave valid consent to participate. We conducted a retrospective analysis of prospectively collected data from consecutive patients who underwent ACLR performed by the senior author between September 1, 2017, and December 31, 2020.
Patients were considered for study eligibility if they had experienced symptomatic instability after ACL injury and subsequently underwent ACLR with hamstring tendon autograft either with or without a concomitant ALLR. The decision to perform ALLR in addition to isolated ACLR was based on published indications
- Getgood A.
- Brown C.
- et al.
ALC Consensus Group
The anterolateral complex of the knee: Results from the International ALC Consensus Group Meeting.
and patient and/or surgeon preference. Patients were excluded if they had a history of ipsilateral knee surgery, if they underwent other concomitant procedures at the time of ACLR (e.g., multiligament reconstruction, LEAP other than ALLR, osteotomy, or cartilage restoration procedure), or if they did not undergo the K-STARTS test at 6 months postoperatively.
Postoperative Rehabilitation Protocol
All patients underwent the same rehabilitation protocol regardless of whether they received an isolated ACLR or a combined procedure. This included immediate brace-free, full weight bearing using crutches, cold pneumatic compression therapy, and progressive range-of-motion exercises. Only patients who underwent a meniscal repair were recommended to restrict range of motion from 0° to 90° for 6 weeks postoperatively. Return to sport was allowed at 4 months for non-pivoting sports, at 6 months for pivoting non-contact sports, and at 9 months for pivoting contact sports if patients achieved satisfactory results on the K-STARTS test.
Clinical Evaluation and K-STARTS Test
Patients were reviewed at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. At 6 months postoperatively, all patients underwent the K-STARTS test at Reathletic, Lyon, France provided that they were able to show a less than 40% deficit in isokinetic strength testing compared with the contralateral limb.
The K-STARTS test aims to evaluate the functional and psychological status of patients after ACLR. It is composed of 4 domains: The first section of the K-STARTS test appraises the psychological readiness to return to sport and is determined by the outcome of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) questionnaire. On this K-STARTS assessment, 3 points are given for ACL-RSI scores of 76% or more; 2 points, scores between 64% and 75%; 1 point, scores between 56% and 63%; and 0 points, scores of 55% or less.
The second section of the K-STARTS test evaluates neuromuscular control, determined by the outcome of the Qualitative Assessment of Single-Leg Landing (QASLS) tool. This tool provides an analysis of movement occurring in the arms, trunk, pelvis, thighs, knees, and feet during single-leg loading tasks.
- Herrington L.
- Myer G.
- Horsley I.
Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: A clinical commentary.
The QASLS score ranges between 0 points (best) and 10 points (worst), with the number of points increasing for inappropriate movement strategies. Patients with QASLS scores of 0 points, 1 points, 2 points, and 3 or more points receive scores of 3 points, 2 points, 1 point, and 0 points, respectively, on the K-STARTS test. Furthermore, 3 points are deducted if a patient is judged to have dynamic valgus of the limb during the single-leg loading task.
The third section of the K-STARTS test is an estimation of the limb symmetry index. Four categories of hop test (single, triple, side, and crossover) are carried out, and the percentage deficit of the distance hopped on the involved leg compared with the uninvolved, contralateral leg is computed.
- Franck F.
- Saithna A.
- Vieira T.D.
- et al.
Return to sport composite test after anterior cruciate ligament reconstruction (K-STARTS): Factors affecting return to sport test score in a retrospective analysis of 676 patients.
- Almangoush A.
- Herrington L.
Functional performance testing and patient reported outcomes following ACL reconstruction: A systematic scoping review.
- Munro A.G.
- Herrington L.C.
Between-session reliability of four hop tests and the agility T-test.
For each of the hop tests, a limb symmetry index of 90% or more corresponds to 3 points on the K-STARTS test, between 80% and 89% corresponds to 2 points, and 79% or less corresponds to 1 point, and if pain occurs during the test, no points are attributed.
The fourth section of the K-STARTS test evaluates the ability to change direction using the Modified Illinois Change of Direction Test (MICODT).
- Hachana Y.
- Chaabène H.
- Ben Rajeb G.
- et al.
Validity and reliability of new agility test among elite and subelite under 14-soccer players.
An average MICODT time of 12.5 seconds or less scores 3 points on the K-STARTS test. If the time ranges from 12.51 to 13.5 seconds, it scores 2 points, and if the time is greater than 13.5 seconds, it scores 1 point. Moreover, if pain prevents the test, no points are given.
The final score was calculated as a percentage of the maximum available points. If the final score was less than 50 points, return to sport was discouraged. If the score ranged between 66 and 80 points, pivoting non-contact sports were allowed. If the score ranged between 65 and 80 points, pivoting non-contact sports were allowed. If the score was higher than 80 points, the patient was allowed to return to contact sports. A review of medical notes was used to extract data regarding patient characteristics and technical details of surgery.
A matched-pair analysis was conducted to minimize the impact of extraneous factors and any potential treatment selection bias. A propensity score was calculated for each patient using the following parameters: age at the time of surgery (<30 years or ≥30 years), time interval between injury and reconstruction (<12 weeks or ≥12 weeks), body mass index (World Health Organization categories),
Preventing and managing the global epidemic. Report of a WHO consultation.
sex (male or female), and preoperative Tegner Activity Scale score (<7 or ≥7). Then, each patient who received isolated ACLR was matched with a patient who underwent ACLR-ALLR, according to the nearest corresponding propensity score.
- Mitchell A.F.S.
- Krzanowski W.J.
The Mahalanobis distance and elliptic distributions.
In the evaluation of covariates, a threshold of absolute standardized differences lower than 0.25 was defined a priori to reach enough similarity between groups to allow for comparisons to be drawn.
- Stuart E.A.
- Lee B.K.
- Leacy F.P.
Prognostic score-based balance measures can be a useful diagnostic for propensity score methods in comparative effectiveness research.