Title: Are Patient-Reported Outcome Measures for Anterior Cruciate Ligament Injuries Validated for Spanish Language and Culture? A Systematic Review

Introduction: Patient reported outcome measures (PROMs) have been adopted as a way to measure patient self-rated physical function and health status for those with anterior cruciate ligament (ACL) injuries. Although multiple PROMs exist and have been translated into various languages, the cross-cultural adaptation and validity of these PROMs for Spanish-speaking patients with ACL injuries is unknown.

Hypothesis/Purpose: We hypothesize that PROMs for ACL injuries in Spanish-speaking patients will exhibit inadequate adaptation quality and psychometric properties.

Aim: The aim of this study is to evaluate the adaptation quality of PROMs for ACL injuries in the Spanish language and to assess the psychometric properties of PROMs for ACL injuries in the Spanish language.

Methods: Under Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines, we conducted a systematic review to identify published studies related to adaptation quality and psychometric properties of Spanish PROMs in patients with ACL injuries. The methodological quality of the included studies was assessed using the Guidelines for the Process of Cross-Cultural Adaptation of Self-Reported Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaires, COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklists. Finally, the level of evidence for each PROM was determined based on the number of studies, methodological quality, consistency of results, and sample size.

Results: The initial search strategy identified 5,687 articles. Following removal of duplicates, 1,882 titles were screened, and 114 articles were assessed for eligibility. Six articles were selected for final review, comprising 4 PROMs – The Lysholm Knee Score, anterior cruciate ligamentreturn to sport after injury (ACL-RSI), lower extremity functional scale (LEFS), and lower limb functional index (LLFI). Three studies followed all 6 processes for cross-cultural adaptation. None of the studies demonstrated all 14 domains (e.g. description of translator expertise) required for cross-cultural validity. The ACL-RSI achieved the highest level of evidence, with three of nine domains demonstrating moderate evidence.

Conclusion: This review identified four instruments that have been translated for Spanishspeaking patients with ACL injuries, none of which demonstrated appropriate adaptation nor robust psychometric properties. The study highlights the need for improvement in PROMs for Spanish-speaking patients and the potential for mismeasurement and inappropriate application of PROM results in patients with ACL injuries.