Outcomes of Anterior Cruciate Ligament Reconstructionin Patients With Workers’ Compensation Claims

Gary Wexler, M.D., Bernard R. Bach, Jr., M.D., Charles A. Bush-Joseph, M.D.,David Smink, M.D., James D. Ferrari, M.D., and John Bojchuk, ATC

Summary: A general perception exists that outcomes of orthopaedic procedures in patient’swith Workers’ Compensation claims fare worse than those of patients without such claims. Weretrospectively reviewed the outcomes of anterior cruciate ligament (ACL) reconstruction inpatients who have Workers’ Compensation claims. This minimum 2-year follow-up studyanalyzed the occupational, functional, and objective results of patients who underwentarthroscopic-assisted anterior cruciate ligament (ACL) reconstruction. Twenty-two patientswith Workers’ Compensation claims representing 5% of patients who underwent ACLreconstruction at our institution between 1987 and 1995 were included in the current study. Allreconstructions were performed by the senior author (B.R.B.) using arthroscopic-assistedtechniques (single and double-incision) with bone–patellar tendon–bone autografts followedby an accelerated rehabilitation protocol. Postoperative follow-up physical examinationsrevealed a negative anterior drawer in 19 patients (91%), a negative Lachman in 15 patients(68%), and a negative pivot shift in 21 patients (96%). The KT-1000 arthrometric evaluationat follow-up showed a mean maximum manual difference of 1.9 mm with 15 patients (68%)having a maximum manual difference of#3 mm and 7 patients (32%) from 3 to 5 mm. Themean postoperative scores for the Hospital for Special Surgery scoring scale was 86, NoyesSports activity scale 81, Noyes ADL score 36, Noyes Problem with Sports 75, Noyes SportsFunction score 87, Lysholm score 82, and the Tegner score 5.9. The Noyes Occupationalrating system increased from preoperative 48 to 60 postoperatively and the Noyes Job Titlerating system score remained at 5 after surgery. Functional testing revealed mean deficits of nomore than 9% between the reconstructed and normal knees. SF-36 testing revealedsignificantly higher scores in theRole Physical and General Health categories and a significantlylower score in the Mental Health category when compared with United States norms. Subjectiveevaluation revealed that 95% of the patients would undergo a similar procedure if faced with asimilar injury to the contralateral knee in the future. The results of the current study show that ACLreconstruction leads to predictable functional and occupational results in those patients withwork-related injuries. All of our patients were able to return to work. The hypothesis that Workers’Compensation compromises the results of ACL reconstruction was not observed in this study.KeyWords: ACL reconstruction—Workers’Compensation claims.

‘‘The employer shall provide and pay for all thenecessary first aid, medical and surgical services, andall the necessary medical, surgical, and hospital ser-vices thereafter incurred, limited, however, to thatwhich is reasonably required to cure or relieve from the

effects of the accidental injury. . .’’ [The General andPermanent Laws of Illinois 305/8 Amount of Compen-sation-Nonfatal Cases.]

The sports medicine literature is replete with infor-mation documenting the success of anterior cruci-

ate ligament (ACL) reconstruction with respect tostabilization of the ACL-deficient knee, the return topreinjury levels of athletic activity, and patient satisfac-tion.1-16 Most of the studies analyze the young, activepatient who typically is injured during an athleticevent. Previous work from our own institution has had

From the Department of Orthopedic Surgery, Section of SportsMedicine, Rush Medical College, Chicago, Illinois, U.S.A.

Address correspondence and reprint requests to Bernard R.Bach, Jr., M.D., Rush-Presbyterian-St. Luke’s Medical Center, 1725W Harrison St, Suite 1063, Chicago, IL 60612, U.S.A.

r 2000 by the Arthroscopy Association of North America0749-8063/00/1601-1984$3.00/0

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 1 (January-February), 2000: pp 49–58 49

predictable results following ACL reconstruction forboth double-incision (DI) and endoscopic ACL recon-struction using patellar tendon autograft at short-termand intermediate follow-up evaluations, as well asmiddle aged patients who undergo ACL reconstruc-tion.2-5,12

There is a subpopulation of ACL-deficient patientswho are injured during work activities. Evidence in theliterature on spine and upper extremity injuries showsthat patients with Workers’ Compensation claims havea much slower rehabilitative period with less predict-able results.17-26 We have previously reviewed theresults of open distal clavicle resection and noted asignificant difference in the subjective results, but notobjective results in comparison Workers’ Compensa-tion versus non–Workers’ Compensation patients.27

Unfortunately, these patients often have secondaryissues that cloud the orthopaedic management andeventual outcomes from their initial work-relatedinjury. There is little information in the literatureconcerning the outcome for patients who undergo ACLreconstruction secondary to work-related injuries.

The purpose of the current study was to investigatethe results of ACL reconstruction in patients withWorkers’ Compensation claims. Our perception beforethis study was that the Workers’Compensation popula-tion appeared to respond well to ACL reconstructivesurgery in contrast to our observations of surgeryabout the shoulder region. Our goal was to challengethe notion that Workers’ Compensation in itself com-prises the results of ACL reconstruction. Clinical,functional, and objective analyses were performed aswell as occupational scoring to test our hypothesis.

MATERIALS AND METHODS

The study group included patients with Workers’Compensation claims who underwent endoscopic orarthroscopic-assisted ACL reconstruction using patel-lar tendon autograft performed by the senior author(B.R.B.) between January 1987 and December 1995.Patients were selected for ACL reconstruction basedon their preinjury activity level, desire to return to thatlevel, and postinjury symptoms of instability. Nopatients were excluded from having anACL reconstruc-tion based upon their Workers’ Compensation status.The patients were identified from a computerized database maintained by the senior author at Rush-Presbyterian-St. Luke’s Medical Center. During thistime period, a total of 449 ACL reconstructions wereperformed. Twenty-two reconstructions were per-formed in 22 patients with Workers’ Compensation

claims. Inclusionary criteria for the current studyincluded patients who underwent ACL reconstructionand who had a Workers’ Compensation claim. Exclu-sionary criteria for the current study included patientswith less than 2 years of minimal follow-up, bilateralreconstructions, multiligament reconstruction, allo-graft ACL reconstruction or revision ACL reconstruc-tion. All 22 patients comprising the study group werepersonally evaluated and none were lost to follow-up.Historical controls based on our previously reportedresults of DI and single-incision ACL reconstructionswere used for comparison.

Surgical Technique and RehabilitationBefore October 1991, patients underwent a DI

arthroscopic-assisted technique without extra-articularaugmentation as described by Bach et al.2 Thereafter, asingle-incision endoscopic procedure as described byHardin et al. was performed.28 Regardless of theoperative technique employed, the principles of graftharvesting, adequate notch preparation, tunnel place-ment, graft orientation, and rigid interference screwfixation with the knee in extension were used for allpatients. Surgery was delayed until patients had re-gained near normal range of motion and had minimalor no knee effusion. This study group included bothtypes of procedures as our previously reported studiesshowed no significant differences between the tech-niques.3-5

Postoperative physical therapy was started immedi-ately after surgery with gait training, straight legraising, prone heel hangs, and range of motion exer-cises. The DI group patients were progressed to fullweight bearing by 6 weeks, whereas the endoscopicgroup patients were allowed immediate full weightbearing following surgery. Both groups used a hingedknee brace for 6 weeks after surgery. A formalrehabilitation program was instituted during the firstpostoperative week. This program allowed stationarybicycling by week 2, stairsteppers by weeks 4 to 6,straight ahead jogging by weeks 12 to 16, and gradualreturn to sports by 4 to 6 months. A custom orthosiswas used from 6 weeks to 6 months for activities ofdaily living and was used for sports from 6 months to 1year postoperatively.

QuestionnaireA detailed questionnaire was developed so that the

modified Tegner, Lysholm, Hospital for Special Sur-gery, Noyes Sports Activity, Noyes Sports Function,Noyes Cincinnati, Noyes Occupational rating (Table1), and Noyes Job Title (Tables 2 and 3) rating scalescould subsequently be determined.29-33 All question-

50 G. WEXLER ET AL.

naires were completed by the patient to eliminateinterviewer or surgeon bias. These were completed atfinal follow-up.

Subjective AssessmentSubjective patient satisfaction was evaluated using

several methods. They were asked to categorize theirsatisfaction level as ‘‘completely,’’ ‘‘mostly,’’or ‘‘some-what’’ satisfied, or ‘‘dissatisfied.’’ Patients were alsoasked to respond with a simple yes or no if they wouldconsider having the procedure repeated on the oppo-site knee if faced with similar circumstances. Finally,patients were asked to graphically diagram their levelof satisfaction using a visual analog scale on a ruled10-cm scale.

Physical ExaminationPhysical examination of the both knees was per-

formed by the sports medicine fellow independently ofthe treating physician. This included supine range-of-motion measured with a goniometer, prone heel heightdifferences measured to the nearest centimeter, thighcircumference measurements and evaluation of patel-lofemoral compartment crepitation. Patellofemoralcrepitation was graded as 0 (absent), 11(mild), 21(moderate), or 31(severe). Varus/valgus stability at 0°and 30°, Lachman, anterior and posterior drawer, andpivot shift tests were performed. Ligamentous laxity asgraded as 11, 21, or 31 (0 to 5 mm, 6 mm to 10 mm,.10 mm). The pivot shift phenomenon was graded as11 (slip), 21 (jump), and 31(transient lock) in theposition of thigh abduction and external rotation,which maximizes the pivot shift phenomenon.

Functional ExaminationBilateral functional knee testing, which included

timed single-leg 6-m hop, measured single-leg hop,and single-leg vertical jump, was performed by an

experienced athletic trainer (J.B.). All patients under-went 3 trials of each functional test on each leg, whichwere then averaged and reported as side-to-side percent-age differences.

Arthrometric ExaminationEach knee was tested preoperatively and postopera-

tively with the KT-1000 arthrometer by an experiencedindependent examiner (J.B.). Testing was performedas described by Daniel et al.7 Anterior maximummanual and maximum manual side-to-side differences

TABLE 1. Cincinnati Job Title OccupationalRating System

Work Level Points Job Title

Disabled 0 Sick leave/disabilityVery light 1 Receptionist, data entry, telephone operatorVery light 2 SecretaryLight 3 Student, file clerkLight 4 Salesman, inspectorModerate 5 Mail carrierModerate 6 Police officer, stock person, nurseHeavy 7 Truck driver, firemanHeavy 8 Dock worker, plumber, carpenterVery Heavy 9 Farmer, garbage collectorsVery Heavy 10 Construction, miner, logger

TABLE 2. Cincinnati Occupational Rating Scale FactorOccupational Rating System Scale

Factor PointsIntensity,

Frequency Duration

Sitting 0 8-10 hr/d2 6-7 hr/d4 4-5 hr/d6 2-3 hr/d8 1 hr/d

10 0 hr/dStanding/walking 0 0 hr/d

2 1 hr/d4 2-3 hr/d6 4-5 hr/d8 6-7 hr/d

10 8-10 hr/dWalking on uneven ground 0 0 hr/d

2 1 hr/dTurning/twisting 4 2-3 hr/d

6 4-5 hr/d8 6-7 hr/d

10 8-10 hr/d0 0 times/d

Climbing 2 1 flight, 2 times/d4 3 flights, 2 times/d6 10 flights/ladders8 Ladders with weight 2-3 d/wk

10 Ladders daily with weight0 0 times/d

Lifting/carrying 2 1-5 times/d4 6-10 times/d6 11-15 times/d8 16-20 times/d

10 .20 times/d0 0 times/d

Squatting 1 1-5 times/d2 6-10 times/d3 11-15 times/d4 16-20 times/d5 .20 times/d0 0-5 lb

Pounds carried 1 6-10 lb2 11-20 lb3 21-25 lb4 26-30 lb5 .30 lb

51WORKERS’ COMPENSATION ACL OUTCOMES

(MMD) were calculated. An arthrometric failure wasdescribed as MMD.5 mm.

StatisticsAll data were recorded on computerized scantron

sheets to allow automatic input into a computerprogram. Descriptive statistics, analysis of variancetesting (ANOVA),x-square analysis, and linear regres-sion analysis were employed using the EXCEL soft-ware package (Microsoft, Redmond, WA). Signifi-cance was reported atP , .05.

RESULTS

Patient DemographicsThe Workers’ Compensation ACL reconstruction

study group was comprised of 22 patients (17 men, 5women) whose average age was 33 years (range, 23 to51 years; SD, 8.3). The left knee was involved in 9patients and the right knee in 13. The mean timeinterval from injury to reconstruction was 50 months(range, 4 weeks to 240 months; median, 29 months;SD, 64). There were 3 acutely reconstructed knees(defined as less than 6 weeks following injury) and 19chronic knees (.6 weeks). The mean interval fromsurgery to follow-up was 55 months (range, 24 monthsto 98 months; SD, 23). Eleven patients (50%) had aprevious surgical procedure performed on the affectedknee with 1 patient (4.5%) having more than 1 prioradditional procedure. The injury occurred acutely onthe job in 9 patients (41%) and represented an aggrava-tion of a pre-existing condition in 13 patients (59%).

Surgical Findings and Associated ProceduresTen knees (45%) had reconstructions performed

using an arthroscopic-assisted DI technique and 12knees (55%) were reconstructed using a single-incision arthroscopic technique. At the time of ACLreconstruction, 6 patients underwent meniscal repair(3 medial, 3 lateral) and there were 10 partial meniscec-tomies (7 medial, 3 lateral). At surgery, chondromala-

cia patella was noted in 8 patients (36%) with varyinggrades of chondromalacia found on the medial femoralcondyle (32%), on the lateral femoral condyle (23%),on the lateral tibia plateau (45%), and on the medialtibia plateau (32%).

Physical ExaminationResults of physical examination findings are listed

in Table 4. Preoperatively, the Lachman test wasgraded as negative in 1 patient (5%), as 11 in 4patients (20%), as 21in 9 patients (45%), and as 31in 6 patients (30%). Two patients had abnormalLachman tests, but were not specifically graded. Thepreoperative anterior drawer test was graded as nega-tive in 3 patients (17%), 11in 13 patients (72%), andas 21in 2 patients (11%). Four patients did not have apreoperative anterior drawer grade recorded. Thepreoperative pivot shift was graded as negative in 5patients (26%), 11in 6 patients (32%), 21in 7patients (37%), and as 31in 1 patient (5%). Threepatients did not have a preoperative pivot shift scorerecorded. The pivot shift test performed under anesthe-sia was abnormal in all patients. Varus laxity waspresent in 1 patient, grade 1 valgus laxity was presentin 2 patients, and grade 2 valgus laxity was present in 1patient.

At follow-up evaluation, 15 patients (68%) had anegative Lachman. Seven patients (32%) had a grade 1Lachman with a firm end point, which we considernormal. Nineteen patients (91%) had a negative ante-rior drawer and 2 patients (9%) had a grade 1 anteriordrawer at follow-up. One patient did not have apostoperative anterior drawer recorded. The postopera-tive pivot shift test, performed in the office setting, waspositive in only 1 patient (4%) who had a grade 1 pivot

TABLE 3. Factor Occupational Rating System Work Level

Work Level Scale Points*

Disabled 0Very light 1-20Light 21-40Moderate 41-60Heavy 61-80Very Heavy .80

*Based on the total points multiplied times 2 from the FactorOccupational Rating System Scale (Table 3).

TABLE 4. Physical Examination Findings

TestPreoperative

No. of Pts (%)PostoperativeNo. of Pts (%)

Anterior Drawer0 3 (17%) 19 (91%)11 13 (72%) 2 (9%)21 2 (11%) 0 (0%)

Lachman0 1 (5%) 15 (68%)11 4 (20%) 7 (32%)21 9 (45%) 0 (0%)31 6 (30%) 0 (0%)

Pivot Shift0 5 (26%) 21 (96%)11 6 (32%) 1 (4%)21 7 (37%) 0 (0%)31 1 (5%) 0 (0%)

52 G. WEXLER ET AL.

whereas the remainder of the 21 patients (96%) had anegative pivot shift. The postreconstruction reductionsin the Lachman, anterior drawer, and pivot shift gradesat follow-up were statistically significant (P , .0002).

The postoperative mean range of motion measured1° of hyperextension (range, 10° of hyperextension to10°; SD, 3.9) to 136° of flexion (range, 120° to 150°;SD, 7.4). The mean postoperative prone heel heightdifference was 1.8 cm with 10 patients having less than1 cm, 17 patients less than 2 cm, and 5 patients greaterthan 3 cm. Thigh girth atrophy was noted in 50% of thepatients (mean, 1 cm; range, 0 to 3 cm; SD, 1.1). Sevenpatients (32%) had patellofemoral crepitation on ac-tive flexion-extension, 6 of whom had minimal to mildcrepitation.

Subjective ResultsTwenty-one patients (95%) indicated that they would

undergo the procedure again given similar circum-stances or recommend the procedure to a friend.Patient satisfaction was assessed on a scale of 1 to 4 (1,completely satisfied; 2, mostly satisfied; 3, somewhatsatisfied; 4, dissatisfied). The mean score was 1.6 with91% of the patients being completely or mostlysatisfied. A visual analog scale was used to assessoverall satisfaction. The average score for this scalewas 7.5 (range, 5 to 10; SD, 1.4). Eleven patients(50%) ranked their knee from 8 to 10 whereas theremaining patients rated their knee from 5 to 7. Allpatients returned to work: 19 patients (86%) returnedto work at the same activity level, 2 patients (9%)returned to work at a lower activity level, and 1 patient(5%) returned at an increased activity level.

KT-1000 ArthrometryArthrometric results are in Table 5. Preoperatively,

the mean maximum manual translation of the affectedleg was 12.5 mm (range, 5 to 21 mm; SD, 4.4) Themean maximum manual difference (MMD) was 6.9mm (range, 1.5 to 13 mm; SD, 3.4), and the MMD wasgreater than 3 mm in 95% of the patients. The

preoperative maximum manual translations betweeninjured and uninjured knees were found to be statisti-cally significant (P, .0001).

At postoperative follow-up, the mean maximummanual translation was 6.7 mm (range, 2.5 to 11 mm;SD, 2.3). The mean MMD was 1.9 mm (range21.5 to5 mm; SD, 2.1). Fifteen patients (68%) had a meanMMD less than 3 mm, and 7 patients (32%) had aMMD greater than 3 mm and less than 5 mm.Significant reductions in maximum manual values inthe affected knee from preoperative to postoperativelevels (P, .0001) were noted. There were no signifi-cant differences between the postoperative recon-structed knee and the normal contralateral knee. Thereduction in the MMD from preoperative to postopera-tive evaluation was significant (P, .0001).

Rating ScalesAverage rating scale scores are listed in Table 6. The

mean retrospective Tegner preinjury rating was 7.1(range, 5 to 9; SD, 0.9). The mean Tegner postinjuryrating was 3.9 (range, 1 to 7; SD, 1.8). The meanTegner rating at follow-up evaluation was 5.9 (range, 2to 9; SD, 1.7). The Tegner rating changes frompreinjury to postinjury, and postinjury to postopera-tively were statistically significant (P, .0001).

The mean postoperative Lysholm score was 82(range, 43 to 100; SD, 14). The mean postoperativemodified HSS score at follow-up was 86 (range, 72 to100; SD, 7.5). This scoring system defines an excellentresult as 90 to 100, good as 80 to 89, fair as 70 to 79,and poor as,70. There were 82% good and excellentresults with 18% fair results and no poor results.

The mean postoperative Noyes Sports Activity scale

TABLE 5. KT-1000 Arthrometric Data

Test Preoperative Postoperative

Mean Max ManualTranslation 12.5 mm (SD 4.4) 6.7 (SD 2.3)

Mean MMD* 6.9 mm (SD 3.4) 1.9 mm (SD 2.1)MMD

#3 mm 2 patients 15 patients3.5 to 5 mm 3 7.5 mm 11 0

*MMD, maximum manual difference.

TABLE 6. Rating Scales of Workers’Compensation Patients

Test Score

Tegner (preinjury) 7.1 (range 5 to 9, SD 0.9)Tegner (postinjury) 3.9 (range 1 to 7, SD 1.8)Tegner (postoperative) 5.9 (range 2 to 9, SD 1.7)HSS 86 (range 72 to 100, SD 7.5)Lysholm 82 (range 43 to 100, SD 14)Noyes Sports Activity 81 (range 0 to 99, SD 22)Noyes ADL 36 (range 30 to 40, SD 4.0)Noyes Sports Function 87 (range 67 to 100, SD 9.7)Noyes Problems with Sports 75 (range 30 to 100, SD 11.2)Noyes Occupational (preoperative) 48 (range 22 to 96, SD 24)Noyes Occupational (postoperative) 60 (range 30 to 96, SD 21)Noyes Job Title Rating (pre-

operative) 5.14 (range 1 to 8, SD 2)Noyes Job Title Rating (post-

operative) 5.18 (range 1 to 8, SD 2)

53WORKERS’ COMPENSATION ACL OUTCOMES

at follow-up was 81 (range, 0 to 99; SD, 22). The meanpostoperative Noyes ADL score was 36 (range, 30 to40; SD, 4.0). The mean postoperative Noyes SportsFunction score was 87 (range, 67 to 100; SD, 9.7). Themean postoperative Noyes Problems with Sports scorewas 75 (range, 30 to 100; SD, 12.0). The meanretrospective Noyes Occupational Factor score was 48(range, 22 to 96; SD, 24), while the postoperativemean Occupational Factor score was 60 (range, 30 to96; SD, 21). The changes in the Occupational scorerevealed a statistical improvement following surgery(P , .05). The mean retrospective Noyes Job Titlerating score was 5.14 (range, 1 to 8; SD, 2) beforeinjury and 5.18 (range, 1 to 8; SD, 2) after surgery(P 5 .94). The following are the number of patients ateach title rating score: 1 at level 1, 1 at level 2, 4 atlevel 3, 3 at level 4, 2 at level 5, 6 at level 6, and 5 atlevel 8. One patient at level 3 decreased to level 1, 1patient at level 5 decreased to level 4, and 1 patient atlevel 2 increased to level 6. The average time to returnto work was 17.36 weeks (SD, 13.09). Although theaverage time to return to work in patients with NoyesJob Title Rating levels of 1-5 was significantly lessthan those patients with level of 6-8 (9.7 weeksv 25weeks,P 5 .013), linear regression analysis did notshow a positive correlation (r5 .46,r2 5 .21).

The SF-36 Questionnaire scores are shown in Table7. These values were compared with the norms for thegeneral United States population.34 Compared with thenorms, the Workers’ Compensation group had signifi-cantly higher scores in the Role Physical and GeneralHealth categories, but a significantly lower score in theMental Health category.

Functional TestingThe functional parameters that were measured in-

cluded the timed single-leg 6-m hop, the single-leghop for distance, and the vertical jump. The recon-structed knee showed a mean 7% deficit (range,19 to56; SD, 14) compared with the contralateral knee onthe timed single-leg hop, a mean 6% deficit (range,

129 to 23; SD, 11) for the single-leg hop for distance,and a mean 9% deficit (range,142 to 19; SD, 15) forthe vertical jump.

ComplicationsThere were 3 patients (14%) who required reopera-

tion. One patient slipped on ice while walking andsustained a patellar tendon rupture that required adirect repair with hamstring augmentation; however,he still was able to return to work at 6 months as apolice officer.35 A second patient suffered a twistinginjury and subsequent locked knee that required anarthroscopic subtotal lateral meniscectomy. A thirdpatient had complaints of painful hardware, which wasremoved.

DISCUSSION

The results of the current study show that ACLreconstruction patients with Workers’ Compensationclaims in our practice had objective, functional, subjec-tive, and occupational results that exceeded our expec-tations.

The shoulder and spine subspecialties literature hasshown that patients with Workers’Compensation claimshave a higher likelihood of poorer outcomes regardingthe orthopaedic management of the injury and theeventual return of the patient to work.17-26,36Friemanand Fenlin18 reported that patients with Workers’Compensation claims who underwent anterior acromio-plasties had a statistically longer time to return to workthan the ‘‘standard’’patient (7 times as long to return towork). Hawkins et al.21 reviewed the treatment ofpatients after failed acromioplasties for impingementsyndrome. They noted that the lack of improvement inthe Workers’ Compensation patients with any form oftreatment was striking and that future surgery in thispopulation of patients should be approached cau-tiously.

Weisel et al.26 performed a prospective investigation

TABLE 7. SF-36 Results

Category Work Comp Group Mean Score, Range, SD US Norms Mean Score, Range, SD P Value

Physical Function 88.33, 35-100,614.6 84.15, 0-100,623.3 .41Role Physical 96.42, 50-100,611.9 80.96, 0-100,634.0 .037Body Pain 74.86, 41-100,615.0 75.15, 0-100,623.7 .95General Health 82.62, 45-95,616.1 71.95, 5-100,620.3 .016Vitality 64.76, 45-90,613.7 60.86, 0-100,621.0 .39Social Function 89.88, 37.5-100,618.8 83.28, 0-100,622.7 .18Role Emotional 93.65, 0-100,622.6 81.26, 0-100,633.0 .085Mental Health 66.40, 16-80,616.6 74.74, 0-100,618.1 .039

54 G. WEXLER ET AL.

of more than 5,300 workers over a 10-year period.They found excessive time off from work and anunacceptably high operation rate with poorer out-comes compared with national averages in regard tospine surgery. Frymoyer19 reported that psychosocialfactors and work environment factors are better prog-nostic indicators of low back pain than are physicalfindings. Similarly, Waddell et al.25 have reported onthe need to approach the patient with occupational lowback pain from a biopsychosocial model.

Katz et al.37 reported that a Workers’ Compensationclaim was the strongest predictor of poor outcome inpatients following arthroscopic partial medial menis-cectomy. Patients with Workers’ Compensation whoundergo ACL reconstruction represent a unique popu-lation in that there is minimal literature reporting onthis relationship. Noyes and Barber-Westin38 reviewedtheir experience with ACL reconstruction and Work-ers’ Compensation. Their series of 19 Workers’ Com-pensation patients had no significant difference frommatched controls with respect to knee stability, subjec-tive variables, complications, overall rating, and pa-tient perceived outcome. However, the Workers’ Com-pensation patients had statistically more time lost fromemployment, both before and after reconstruction.Noyes and Barber-Westin surmised that many factorscontributed to this time lost from work, such asinadequate diagnosis and lack of timely treatment, andadversarial issues at the workplace.

In our study group, the objective and subjectiveresults were not significantly different from our previ-ously reported results of DI and single-incision ACLreconstruction evaluated at 2 to 4 year follow-upevaluations, of DI ACL reconstruction data evaluatedat 4 to 9 year follow-up, or of a similar sized cohort of‘‘middle aged’’ (.35 years old) patients (Tables 8, 9,and 10). In each study, objective stability (Lachman,pivot shift, KT-1000), functional testing, scoring scales(Tegner, Lysholm, Noyes, HSS), and subjective satis-faction did not differ to any great degree.

Most of the rating systems that are currently used toevaluate knee ligament reconstruction are based on theyoung active individual and analyze the type and

intensity of sports activities in which they partici-pate.29 These scoring systems often neglect occupa-tional factors and fail to show the effect of treatmenton work activities. The current article includes manyof the standard reporting methods for the athleticindividual but also includes an occupational scoringsystem, and reports on the return to work activities.This methodology allows for comparison of the cur-rent series with our historical controls.

All patients in this study returned to work. Ouraggressive approach to rehabilitation following sur-gery may help to motivate patients during their postop-erative rehabilitation. The team approach of the treat-ing medical staff, including physicians, athletic trainers,physical therapists, and nurses (including the Workers’Compensation nurse case manager), emphasizes andencourages patients to return to their preinjury condi-tion. This philosophy begins with our preoperativeteaching program, which clearly emphasizes that thegoal of surgery is to return the worker back to the workforce. This positive framework in which the patientsinteract may play a role in developing the properpsychosocial environment for patients to return towork. Our protocol for returning patients to work issimilar to our athletic activity protocol. We allowpatients to return to full athletic activity between 4 and6 months after surgery, and similarly, patients withheavily demanding work activities (category I) areallowed to return to work without restriction between 4to 6 months after surgery.

The average age of our Workers’ Compensation

TABLE 8. Patient Demographic Comparisons Between Current Study and Previous Studies

TechniqueNo.Pt

Mean Ageat Surgery

Interval toReconstruction

PostopFollow-up

PreviousSurgery

PostreconstructionReoperation

Bach3 DI 62 27 (16-45) 24 (0.1-156) 37 (27-51) 26 (40%) 6 (10%)Bach4 Endo 103 25 (10-53) 34 (0.2-249) 36 (24-55) 45 (44%) 15 (15%)Bach5 DI 97 26 (12-53) 32 (0.2-232) 79 (66-113) 46 (47%) 25 (26%)Current study DI/Endo 22 33 (23-51) 50 (1-240) 55 (24-98) 11 (50%) 3 (14%)

TABLE 9. Postoperative Physical Examination andKT-1000 Comparisons

Study0/11

LachmanNegative

PivotKT

MMD

KT#3mm

KT3-5

KT.3mm

Bach3 60 (96%) 57 (92%) 0.3 (26-16) 92% 4% 4%Bach4 101 (98%) 94 (91%) 1.1 (26-7) 83% 14% 3%Bach5 95 (98%) 81 (84%) 1.0 (211.5-7) 70% 26% 4%Current

study 22 (100%) 21 (96%) 1.9 (21.5-5) 68% 32% 0%

55WORKERS’ COMPENSATION ACL OUTCOMES

population (mean age, 33 years) was slightly higherthan most reported series on ACL reconstruction.However, the results of the postoperative physical andarthrometric examination in this series compare favor-ably with most series reported in the literature. All but1 of our patients had a negative pivot shift (95%), allpatients had a negative or 11Lachman test, and 91%of the patients had a negative anterior drawer test. TheKT-1000 arthrometer provides another objective param-eter of knee stability. There were no arthrometricfailures (MMD.5 mm) in this series.

The results of the knee scoring systems com-pare favorably with series reported in the litera-ture.1,3-6,9,11,16,39The postoperative Tegner activity scorein this series was slightly less than the mean retrospec-tive preinjury Tegner score, although not significant.This may be attributable to the fact that our patientpopulation is an older one and that patients may havedecreased their activity level for reasons other thanthose related to knee stability (e.g., time consider-ations, family responsibilities, work responsibilities).This observation has been noted in our other ACLfollow-up studies.3-5

The Noyes Occupational score allows for compari-son of the patients’ ability to function in the work-place.32 The mean improvement in this score frompreoperative to postoperative of 12 points indicatesthat patients were able to return to the workplace atincreased levels of work activity. The fact that allpatients were able to return to work (1 patient with anincrease in work activity level and 2 patients with adecreased work activity level) suggests that ACLreconstruction in the Workers’ Compensation popula-tion is effective from an occupational viewpoint.Although we did not see a significant correlationbetween the Job Level rating and return to work, atrend was seen that patients with more strenuous jobstended to take longer to return to work.

The SF-36 is a self-administered questionnaire thatqueries patients concerning their health in 8 differentdimensions: physical functioning, role limitations dueto physical problems, bodily pain, general health

perception, energy/fatigue, social functioning, rolelimitations due to emotional problems, and mentalhealth.34 Health status measurements like the SF-36have potential value in evaluating the complex issuesof work-related disability.17,23,40 In our study, theSF-36 scores of our Workers’ Compensation patientswere similar to the general population of the UnitedStates and in fact were significantly higher in the RolePhysical and General Health categories. Interestingly,the Workers’Compensation patients also scored signifi-cantly lower in the Mental Health category. Psychologi-cal distress from job difficulties contributes greatly tolower Mental Health scores.34 As Noyes and Barber-Westin38 alluded to in their study on ACL reconstruc-tion in the Workers’ Compensation population, muchof the subjective dissatisfaction seen in the Workers’Compensation population may be secondary to theadversarial mechanisms inherent in the process as wellas the oftentimes delayed and poor initial treatment.38

This would certainly be reflected in lower MentalHealth scores.

The patients’ subjective satisfaction with the ACLreconstruction treatment protocol was extremely high.Ninety-five percent of the patients stated that theywould undergo a similar procedure if faced withidentical circumstances and 91% of the patients weremostly or completely satisfied. This high satisfactionlevel is comparable with that of our other reportedstudies, and clearly different than what has beenreported in the spine and shoulder Workers’Compensa-tion literature. One major difference between thesepopulations is that ACL reconstruction is generallyperformed for instability and mechanical symptomsrather than pain. In the spine and shoulder Workers’Compensation literature, the operations that have beenevaluated, such as spinal fusion and rotator cuff repair,are generally performed to relieve pain. It is quitepossible that this pain issue is what contributes tofavorable results in ACL reconstruction. In this study,the Workers’ Compensation patients’ scores in theBodily Pain category of the SF-36 was not signifi-cantly different than those of the general United States

TABLE 10. Postoperative Rating Scale Comparisons

Study

Tegner Lysholm Modified HSSNoyes KneeSport Act

Noyes KneeSport Act

Preinjury Prereconst Postop

Bach3 7.6 (6-10) 2.1 (0-10) 6.3 (1-9) 88 (52-100) 88 (65-99) 86 (30-100) 90 (50-100)Bach4 7.3 (4-9) 3.5 (0-7) 6.5 (2-9) 89 (43-100) 90 (72-100) 88 (0-100) 90 (33-100)Bach5 7.1 (4-9) 3.5 (0-9) 6.3 (2-9) 87 (34-100) 87 (72-100) 87 (20-100) 89 (27-100)Current study 7.1 (5-9) 3.9 (1-7) 5.9 (2-9) 82 (43-100) 86 (72-100) 81 (0-99) 87 (67-100)

56 G. WEXLER ET AL.

population, and in the Role Physical category, thepatients actually scored significantly higher. This sug-gests that pain was not a factor in the patients’ abilitiesto carry out their work and activities of daily living.

The limitations of the current study are several. Thisis a retrospective study with historical controls. How-ever, using our previously reported studies, whichincluded patients who underwent reconstruction usingthe same techniques during the same time frames,strengthens our observations.3-5 One could argue that aprospective design that included a nonoperative con-trol group might yield better insight. This studyrepresents a small group of patients and perhaps alarger study group may have resulted in differentobservations. It is problematic to include a nonopera-tive control group in this type of study because of thedemands of the workplace environment. These typesof patients need a stable knee in order to function onthe job (e.g., climbing ladders, carrying heavy ob-jects). The magnitude of our patients were construc-tion workers, fire fighters, police officers, and heavylaborers. One could also argue that age-matchedpatients who underwent ACL reconstruction could beused as a control group; however, the analysis mightbe confusing due to the comparison of athletes andworkers. The benefit of a prospective study is that itwould allow for the determination of pretreatment andposttreatment scores for the various knee rating scales.

The results reported here contradict the generaltrend of outcomes from the Workers’ Compensationspine and upper extremity population and refute thenotion that Workers’ Compensation claims in patientsundergoing ACL reconstruction are doomed to lessthan optimal outcomes. Unfortunately the label ofWorkers’ Compensation may influence the treatingorthopaedic surgeon’s decision-making process. Thisseries presents the general orthopaedic practitionerwith information that may prove helpful in evaluatingand treating the Workers’ Compensation patient whohas an ACL-deficient knee.

These results raise an important question—why didthese patients do well postoperatively, particularly incontrast with the studies of other orthopaedic condi-tions? There may be a selection bias based on thesurgeon; unfortunately, we do not have accurate data toindicate what percentage of our ACL-deficient Work-ers’ Compensation patients undergo reconstructionversus being treated nonoperatively. Perhaps there is aselection bias based on the preoperative types ofpatients who were either self-referred or referred by arehabilitation nurse or employer. In the state of Illinois,‘‘aggravation of a pre-existent’’ condition constitutes

Workers’ Compensation coverage. For example, anindividual who sustained a high school football-relatedinjury, but reinjured the knee several years later as alaborer was covered under the Workers’ Compensationstatute. As many of our patients wished to return torecreational athletics after reconstruction, the seniorauthor believes that there was a unique motivationalfactor that positively affected our patients’ outcomesand consistent ability to return to work. Additionally,we clearly educated our patients that they would not bereleased to return to athletics until they had beenreleased to return to the workplace. Unfortunately, thesize of the study group did not allow comparison of theresults of those patients who sustained their initialinjury at work (n5 9) versus those who sustained an‘‘aggravation of their pre-existent condition’’ (n5 13).

In summary, our retrospective review of ACL surgi-cal results using a high-strength, anatomically placed,securely fixated graft treated with an acceleratedrehabilitation program yielded predictable results thatwere similar to our historical controls using identicaltechniques. Subsequent to this study, we have contin-ued to observe the predictable return to the work forcein a larger group of work-injured ACL patients. Basedon these observations, we recommend ACL reconstruc-tion for those patients with moderate, heavy, or veryheavy occupational job level ratings.

Acknowledgment: The authors acknowledge the assis-tance of former sports medicine fellows Drs. Matthew Levyand Steven Tradonsky who participated in the clinicalevaluations of these patients. We would also like to acknowl-edge Sue Leurgans, Ph.D., Director of the Section ofBiostatistics, Department of Preventive Medicine, RushMedical College, and Rema Raman, who assisted in thestatistical analysis of the data.

REFERENCES

1. Arciero RA, Scoville CR, Snyder RJ, Uhorchak JM, TaylorDC, Huggard DJ. Single versus two-incision arthroscopicanterior cruciate ligament reconstruction.Arthroscopy1996;12:462-469.

2. Bach BR Jr. Arthroscopy assisted patellar tendon substation foranterior cruciate ligament reconstruction.Am J Knee Surg1989;2:3-20.

3. Bach BR Jr, Jones GT, Sweet FA, Hager CA. Arthroscopy-assisted anterior cruciate ligament reconstruction using patellartendon substitution. Two to four year follow-up results.Am JSports Med1994;22:758-767.

4. Bach BR Jr, Levy ME, Bojchuck J, Tradonsky S, Bush-JosephCA, Khan NH. Single incision endoscopic anterior cruciateligament reconstruction using patellar tendon autograft—Minimum two year follow up evaluation.Am J Sports Med1998;26:30-40.

5. Bach BR Jr, Tradonsky S, Bojchuck J, Levy ME, Bush-JosephCA, Khan NH. Arthroscopy assisted anterior cruciate ligament

57WORKERS’ COMPENSATION ACL OUTCOMES

reconstruction using patellar tendon autograft—Five to nineyear follow-up evaluation.Am J Sports Med1998;26:20-29.

6. Buss DD, Warren RF, Wickiewicz TJ, Galinat BJ, Panariello R.Arthroscopically assisted reconstruction of the anterior cruci-ate ligament with the use of autogenous patellar-ligamentgrafts. Results after twenty-four to forty-two months.J BoneJoint Surg Am1993;75:1346-1355.

7. Daniel DM, Stone ML, Fithian DC, Rossman DJ, KaufmanKR. Fate of the ACL-injured patient: a prospective outcomestudy.Am J Sports Med1994;22:632-644.

8. Giove TP, Miller SJ III, Kent BE, Sanford TL, Garrick JG.Non-operative treatment of the torn anterior cruciate ligament.J Bone Joint Surg1983;65:184-192.

9. Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, MengatoR. Anterior cruciate ligament reconstruction: Endoscopic ver-sus two-incision technique.Arthroscopy1994;10:502-512.

10. Hawkins RJ, Misamore GW, Merritt TR. Follow-up of theacute nonoperated isolated anterior cruciate ligament tear.Am JSports Med1986;14:205-210.

11. Marder RA, Raskind JR, Carroll M. Prospective evaluation ofarthroscopically assisted anterior cruciate ligament reconstruc-tion. Patellar tendon versus semitendinosus and gracilis ten-dons.Am J Sports Med1991;19:478-484.

12. Novak PJ, Bach BR Jr, Hager CA. Clinical and functionaloutcome of anterior cruciate ligament reconstruction in therecreational athlete over the age of 35.Am J Knee Surg1996;9:111-116.

13. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptom-atic anterior cruciate deficient knee. Part I: The long-termfunctional disability in athletically active individuals.J BoneJoint Surg Am1983;65:154-162.

14. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptom-atic anterior cruciate deficient knee. Part II: The results ofrehabilitation, activity modification, and counseling on func-tional disability.J Bone Joint Surg Am1983;65:163-174.

15. O’Neill DB. Arthroscopically assisted reconstruction of theanterior cruciate ligament.J Bone Joint Surg Am1996;78:803-813.

16. Shelbourne KD, Klootwyk TE, Wilckens JH, DeCarlo MS.Ligament stability two to six years after anterior cruciateligament reconstruction with autogenous patellar tendon graftand participation in accelerated rehabilitation program.Am JSports Med1995;23:575-579.

17. Beaton DE, Bombardier C, Hogg-Johnson SA. Measuringhealth in injured workers: A cross-sectional comparison of fivegeneric health status instruments in workers with musculoskel-etal injuries.Am J Industrial Med1996;29:618-631.

18. Frieman BG, Fenlin JM Jr. Anterior acromioplasty: Effect oflitigation and workers’ compensation.J Shoulder Elbow Surg1995;4:175-181.

19. Frymoyer JW. Predicting disability from low back pain.ClinOrthop1992;279:101-109.

20. Hawkins RJ, Brock RM. Anterior acromioplasty: Early resultsfor impingement with intact rotator cuff.Orthop Trans1979;3:274.

21. Hawkins RJ, Chris T, Bokor D, Kiefer G. Failed anterioracromioplasty:A review of 51 cases.Clin Orthop1989;243:106-111.

22. Himmelstein JS, Feuerstein M, Stanek EJ. Work-related upperextremity disorders and work disability.J Occup Environ Med1995;11:1278-1286.

23. Jette DU, Jette AM. Health status assessment in the occupa-tional health setting.Orthop Clin North Am1996;27:891-902.

24. Sanderson PL, Todd BD, Holt GR, Getty CJ. Compensation,work status, and disability in low back pain patients.Spine,20:554-556, 1995.

25. Waddell G, Main CJ, Morris EW, DiPaola M, Gray ICM.Chronic low back pain, psychological distress and illnessbehaviour.Spine1984;9:209.

26. Wiesel SW, Boden SD, Feffer HL. A quality-based protocol formanagement of musculoskeletal injuries: A ten-year prospec-tive outcome study.Clin Orthop1994;301:164-176.

27. Novak PJ, Bach BR Jr, Romeo AR, Hager CA. Surgicalresection of the distal clavicle.J Shoulder Elbow Surg1995;4:35-40.

28. Hardin GT, Bach BR Jr, Bush-Joseph CA, Farr J. Endoscopicsingle-incision anterior cruciate ligament reconstruction usingpatellar tendon autograft.Am J Knee Surg1992;5:144-55.

29. Anderson AF. Rating scales, in Fu FH, Harner CD, Vince KG,eds.Knee surgery. Baltimore: Williams & Wilkins, 1994;275-295.

30. Lysholm J, Gillquist J. Evaluation of knee ligament surgeryresults with special emphasis on use of scoring scale.Am JSports Med1982;10:150-153.

31. Noyes FR, ed.The Noyes knee rating system. Cincinnati:Cincinnati Sports Medicine and Research and EducationFoundation, 1995.

32. Noyes FR, Mooar LA, Barber SD. The assessment of work-related activities and limitations in knee disorders.Am J SportsMed1991;19:178-188.

33. Tegner Y, Lysholm J. Rating systems in the evaluation of kneeligament injuries.Clin Orthop1985;198:43-49.

34. Ware JE Jr. SF-36Health survey. Manual and interpretationguide.Boston: Nimrod, 1997.

35. Bach BR Jr, Hardin GT. Distal rupture of the infrapatellartendon after use of its central third for anterior cruciateligament reconstruction.Am J Knee Surg1992;5:140-143.

36. Greenough CG. Recovery for low back pain; 1-5 year fol-low-up of 287 injury related cases.Acta Orthop Scand1993;64:1-34 (suppl 254).

37. Katz JN, Harris TN, Larson MG, Krushell RJ, Brown CH,Fossel AH, Liang MH. Predictors of functional outcomes afterarthroscopic partial meniscectomy.J Rheumatol1992;19:1938-1942.

38. Noyes FR, Barber-Westin SD. A comparison of results ofarthroscopic assisted anterior cruciate ligament reconstructionbetween Workers’ Compensation and noncompensation pa-tients.Arthroscopy1997;13:474-484.

39. O’Brien SJ, Warren RF, Pavlov H, Panariello R WickiewiczTL. Reconstruction of the chronically insufficient anteriorcruciate ligament with the central third of the patellar ligament.J Bone Joint Surg Am1991;73:278-286.

40. Mohtadi NG. Quality of life assessment as an outcome inanterior cruciate ligament reconstructive surgery, in JacksonDW, Arnoczsky SP, Frank CB, Woo SLY, Simon TM, eds.Theanterior cruciate ligament. Current and future concepts.NewYork: Raven, 1993;439-444.

58 G. WEXLER ET AL.