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. 2025 Jan 28;13(1):23259671241298993.
doi: 10.1177/23259671241298993. eCollection 2025 Jan.

Ranking Surgeon Performance After ACL Reconstruction Using the Knee Injury and Osteoarthritis Outcome Score (KOOS) Subscales

Sarah B Floyd  1   2 , Briggs Ahearn  3 , Michael J Kissenberth  3 , John M Brooks  4   2 , Charles A Thigpen  2   5   6
Affiliations

Ranking Surgeon Performance After ACL Reconstruction Using the Knee Injury and Osteoarthritis Outcome Score (KOOS) Subscales

Sarah B Floyd et al. Orthop J Sports Med. .

Abstract

Background: Patient-reported outcomes (PROs) are considered the gold standard for evaluating value-based care in orthopaedics. However, there is little evidence to guide implementation of PROs for surgeon performance evaluation.

Purpose: To develop a risk-adjusted surgeon performance measure using the Knee injury and Osteoarthritis Outcome Score (KOOS) for patients undergoing anterior cruciate ligament reconstruction (ACLR).

Study design: Cross-sectional study; Level of evidence, 3.

Methods: Patients (N = 1248; 662 men; mean age, 30 ± 13 years) who underwent ACLR performed by 40 surgeons between 2010 and 2018 were identified from a large, nationally representative sports medicine clinical data registry. Linear regression was used to predict change scores for each KOOS subscale (Pain, Symptoms, Activities of Daily Living [ADL], Function in Sports and Recreation, and Knee-Related Quality of Life) while adjusting for patient baseline characteristics. A risk-adjusted performance measure was calculated for each KOOS subscale as the difference between the unadjusted and the risk-adjusted predicted change score across all patients treated by a single surgeon. Surgeon-relative quartile ranking was compared across outcome subscale scores.

Results: One-third of the patients (34%) displayed acute cartilage damage, and 56% had a meniscal injury. In the risk adjustment models, older age, presence of diabetes, current smoking status, acute cartilage damage, concurrent cartilage treatment, lower baseline Veterans RAND 12-Item Health Survey mental and physical component scores, and lower baseline Marx and KOOS subscale values all had a significant negative influence on the predicted KOOS subscale change values (P < .05 for all). Surgeon performance, ranked in quartile groups, was the same for 10 surgeons but varied by 1 to 2 quartiles for the other 30 surgeons across the different KOOS subscales.

Conclusion: These results showed that surgeon performance varies widely when evaluated using different KOOS subscales for patients undergoing ACLR. Based on the preliminary results and clinical perspective, the authors recommend the ADL and Symptoms subscales as the best options to differentiate surgeon performance for these patients. However, evaluation of surgeon performance may require consideration or use of a set of PROs or the development of a single index PRO that is sensitive to the range of outcome dimensions important to patients.

Keywords: ACL; KOOS; PRO; knee; outcomes; performance measures.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: B.A. has received grant support from Arthrex and DJO and education payments from Smith & Nephew and Peerless Surgical. M.K. has received education payments from Arthrex, consulting fees from Arthrex, nonconsulting fees from Arthrex, and hospitality payments from Exactech. C.A.T. has received consulting fees from Breg and has stock/stock options in Players Health and Trex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flowchart of patient inclusion. ACL, anterior cruciate ligament; KOOS, Knee injury and Osteoarthritis Outcome Score; SOS, Surgical Outcomes System.
Figure 2.
Figure 2.
Anterior cruciate ligament reconstruction surgeon performance measure scores and rankings across Knee injury and Osteoarthritis Outcome Score (KOOS) subscales. Error bars represent 95% confidence intervals. ADL, Activities of Daily Living; QOL, Knee-Related Quality of Life; Sports/Rec, Function in Sports and Recreation.
Figure 3.
Figure 3.
Surgeon rank score and quartile group score across Knee injury and Osteoarthritis Outcome Score (KOOS) subscales. Red indicates surgeons who changed ≥2 quartile rankings across KOOS subscale dimensions (n = 13). Yellow indicates surgeons who changed 1 quartile ranking across dimensions (n = 17). Green indicates surgeons who did not change quartile rankings across dimensions (n = 10). ADL, Activities of Daily Living; QOL, Knee-Related Quality of Life; Sports/Rec, Function in Sports and Recreation.
See this image and copyright information in PMC

References

    1. American Academy of Orthpaedic Surgeons. Appropriate use criteria for the treatment of anterior cruciate ligament injuries. American Academy of Orthpaedic Surgeons; 2015. Accessed October 25.2024. https://www.aaos.org/globalassets/quality-and-practice-resources/auc-tre...
    1. American Academy of Orthopaedic Surgeons. Principles for musculoskeletal based patient reported outcome-performance measurement development [position statement 1188]. American Academy of Orthopaedic Surgeons; 2018. Accessed October 25, 2024. https://www.aaos.org/contentassets/1cd7f41417ec4dd4b5c4c48532183b96/1188...
    1. Antosh IJ, Svoboda SJ, Peck KY, Garcia EJ, Cameron KL. Change in KOOS and WOMAC scores in a young athletic population with and without anterior cruciate ligament injury. Am J Sports Med. 2018;46(7):1606-1616. - PubMed
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