BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 1

SUPPLEMENTAL MATERIAL: A Knowledge Translation Plan for the STABILITY 1

Trial

Ethics approval was obtained from the Western University Health Sciences Research Ethics

Board and the local research ethics board for each participating site. The STABILITY 1 trial was

registered on ClinicalTrials.gov (NCT02018354).

1. Background/Formulating an Actionable Message:

 Methodology: STABILITY 1 was a large, international, prospective RCT designed to

investigate how the addition of an anterolateral stabilizing procedure, lateral extra-

articular tenodesis (LET), to ACLR would affect clinical outcomes in young active

patients1.

 Main finding: The addition of LET to a single bundle hamstring autograft ACLR results

in a statistically significant and clinically relevant reductions in rotational laxity and graft

failure in high risk patients1.

 Support: This study adds to a strong message within the larger body of literature, as

cadaver studies have provided proof of concept that LET is beneficial for restoring

normal knee kinematics and stability2–4, while meta-analyses favour the use of LET over

isolated ACLR to reduce rotational laxity5 and anterolateral translation6, without an

increased risk of developing osteoarthritis7.

 Benefits: Use of LET to augment ACLR can reduce rates of graft failure and revision

surgeries. This may increase patient quality of life and reduce healthcare costs.

 Actionable message: LET should be considered in addition to ACLR with hamstring

tendon autografts in young, active patients at high risk of graft failure.

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 2

2. Target Audience:

 Orthopaedic surgeons who regularly perform ACLR, especially on high-risk patients.

Research-oriented surgeons will be targeted first8,9.

 Young, active patients with the goal of returning to high-risk sports/activities.

3. Barriers and Facilitators:

 Potential barriers and facilitators identified for translation of the STABILITY 1 trial

results have been identified in Table 1 and 2, respectively.

Table 1. Potential Barriers to Disseminating and Implementing the STABILITY 1 Results

Category Barrier Example from STABILITY 1
Innovation Complexity10 The addition of LET to ACLR inherently increases surgical
complexity. Training, practice, and extra steps in surgery are
required.
Trialability10 Testing the intervention requires training and observation by
an expert. Applicable patients will need to consent to the
procedure.
Observability10 Benefits to patients (lack of re-rupture) cannot be observed
immediately, requiring a long follow-up period before being
confident in outcomes.
Change in The addition of LET will change surgeons’ discussion with
Routine patients, surgery preparation, and surgical process.
Clinicians Competence If not part of their usual practice, surgeons will not be
competent at performing LET. There will be a learning curve
to achieve the desired level of competence.
Motivation to Most surgeons likely think they have high success and low
Change complication rates with their usual ACLR technique, reducing
their motivation to change.
Attitudes and Surgeons may believe their approach is adequate and
opinions produces the best possible outcomes or may not trust trial
results. Older age, ego, rigidity, and insecurity are
characteristics which may contribute to a lack of interest in
changing practice11.
Practice Patient Patients may be nervous about a new, longer, or more
Setting Characteristics complex surgery. This will be largely influenced by surgeon-
patient communication.
Organization Resources Adding LET will require more operating room time and

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 3

surgical materials, increasing costs versus ACLR alone. The

time, travel and technology involved in training will also
utilize resources.
Adapted from Castiglione & Ritchie12

Table 2. Potential Facilitators for Disseminating and Implementing the STABILITY 1 Results
Category Facilitator Example from STABILITY 1
Innovation Relative Use of LET may reduce rotational laxity and graft failure1,5.
10
Advantage This is beneficial to patients by improving outcomes, and
beneficial to surgeons and organizations by reducing revision
surgeries.
Evidence13 Orthopaedic surgeons are more likely to rely on evidence when
study sample size is > 100, and when results are significant,
clinically relevant and appear in reputable journals14.
Clinicians Individual Research-oriented surgeons and/or those who work in an
Characteristics academic setting are more likely to be open to new evidence
and practice changes8,9. These surgeons should be targeted
first with KT strategies.
Motivation to The magnitude of the intervention’s effect and high quality of
Change the evidence may increase surgeons’ motivation to change.
Surgeons whose patients the research is applicable to and who
recognize a need for improvement may be more motivated to
adopt new practices.
Practice Patient Patients are likely to welcome the idea of LET if they
Setting Characteristics understand its benefits. Patients who hope to return to high-
risk sports will be especially motivated.
Champions Early adopters of a new technique can act as champions of the
procedure and mentor new adopters10. Clinical champions
understand the local context of their setting and can help tailor
strategies to facilitate acceptance within a specific
organization12.
Organization Philosophy Organizations whose mission statement or values include a
and Mission commitment to EBM and innovation will be more likely to
support practice changes. These may be promising locations to
start the KT process.
Resources Lower rates of graft failure will decrease the number of
revision ACLR surgeries done, in turn reducing the overall
cost to the healthcare system and associated costs for patients
(rehabilitation, time off work, etc.).
Adapted from Castiglione & Ritchie12

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 4

4. Knowledge Translation Strategies

 Opinion Leaders: Identifying credible messengers called “opinion leaders” can expedite

the KT process by concentrating promotional efforts, encouraging casual communication

amongst colleagues regarding new research, and modelling within their own practice10.

Successful opinion leaders are credible, trustworthy, and influential in their field15.

Opinion leaders have had variable effectiveness on clinician practice change in the

literature15.

o Barriers Targeted: Negative attitudes/opinions, low motivation to change

o Facilitators Used: Motivation to change, philosophy/mission, champions

 Interactive Workshops: Training should be a top KT priority in orthopaedic surgery.

Hands-on workshops include demonstrations, presentations, and skills labs, overseen by

experts. Workshops can increase competence and should lessen the fear of a slow

learning curve. Workshops may include a didactic component to review synthesized

supporting evidence, as well as hands on saw bones, cadaveric skills labs and with the

innovation of current and future technology, simulation and virtual reality training.

Educational meetings and workshops are shown to improve professional practice and

assist in achieving treatment goals when used alone or with other KT strategies16.

o Barriers Targeted: Complexity, low trialability, change in routine, low

competence, low perceived capabilities

o Facilitators Used: Relative advantage, strong evidence, philosophy/mission,

opinion leaders

 Surgical Telementoring: Through telemedicine and virtual reality technology, mentors

can remotely observe and advise surgeons learning a new technique. Mentees can

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 5

observe mentors operate through the same medium. Telementoring can help combat the

fear of the learning curve, as well as expand the number of surgeons who can be trained

by removing geographical barriers. Surgeries using telementoring have reported a

positive impact on surgical education, with similar complication rates to on-site

mentoring17 and reduced travel costs.18

o Barriers Targeted: Geographical distance, complexity, low trialability, change in

routine, low competence, low perceived capabilities

o Facilitators Used: Relative advantage, evidence, philosophy/mission, opinion

leaders

 Social Media: Social media has become a primary channel for communicating new ideas

in academic research (e.g. #orthotwitter). Social media can be used for “reducing the

knowledge translation gap, creating communities of practice, and reducing traditional

hierarchal decisions”19. Social media is a relatively cheap method of KT, with the

potential to reach audiences worldwide. Little formal research has been conducted on the

efficacy of social media as a KT strategy, however a recent scoping review indicated

widespread and increased use of social media for knowledge translation and education

amongst clinicians and mentees20. Social media and technology communication strategies

such as infographics, podcasts, YouTube videos, blogs, etc. can play a substantial role in

KT as accessible, time efficient, comprehensive strategies which broaden impact and

increase two way communication between researchers and end users21,22. These

strategies also help combat the barriers of knowledge translation in article publication

such as limited access, lack of reader engagement, and time commitment required to

consume research21. Social media strategies can be utilized at minimal cost (most

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 6

platforms are free), but the time/effort/expertise needed to create impactful resources may

add costs21.

o Barriers Targeted: Negative attitudes/opinions, low motivation to change,

geographical distance, accessibility issues

o Facilitators Used: Individual characteristics, motivation to change, opinion

leaders, limited resources required

 Patient Education & Advocacy: External pressure for clinical change can be applied

effectively by patients, especially in private healthcare systems whereby access to

surgeons and treatments are patient driven. It is therefore critical that resources available

to patients are up to date and reflect best evidence. These resources must be easily

accessible and targeted to patients’ level of knowledge. Patient education strategies

should be multi-faceted including in-person conversations with surgeons, written

materials, and online resources23. A systematic review of patient targeted KT

interventions reported that these strategies achieve positive outcomes and were effective

when used before, during or just after patient encounters with clinicians23. Many

institutions and societies have begun to synthesize evidence into patient resources and

community outreach tools.

o Barriers Targeted: Low motivation to change, negative attitudes/opinions

o Facilitators Used: Relative advantage, patient characteristics, external pressure

5. Primary Outcomes:

 Increased awareness of LET.

 Increased use of LET for appropriate patients by orthopaedic surgeons.

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 7

We believe that many components of this plan represent communal challenges and opportunities

for knowledge translation within the field of orthopaedic surgery. We found this process

extremely helpful for creating a plan of action that moves beyond traditional dissemination

routes and is specific to our research and goals.

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 8

References

1. Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces

Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-

Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports

Med. 2020;48(2):285-297. doi:10.1177/0363546519896333

2. Geeslin AG, Moatshe G, Chahla J, et al. Anterolateral Knee Extra-articular Stabilizers: A

Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire

Lateral Extra-articular Tenodesis. Am J Sports Med. 2018;46(3):607-616.

doi:10.1177/0363546517745268

3. Inderhaug E, Stephen JM, Williams A, Amis AA. Biomechanical Comparison of

Anterolateral Procedures Combined with Anterior Cruciate Ligament Reconstruction. Am

J Sports Med. 2017;45(2):347-354. doi:10.1177/0363546516681555

4. Inderhaug E, Stephen JM, Williams A, Amis AA. Anterolateral Tenodesis or

Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft

Fixation When Combined With ACL Reconstruction. Am J Sports Med.

2017;45(13):3089-3097. doi:10.1177/0363546517724422

5. Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM. Lateral Extra-

articular Tenodesis Reduces Rotational Laxity When Combined with Anterior Cruciate

Ligament Reconstruction: A Systematic Review of the Literature. Arthrosc - J Arthrosc

Relat Surg. 2015;31(10):2022-2034. doi:10.1016/j.arthro.2015.04.089

6. Devitt BM, Bell SW, Ardern CL, et al. The role of lateral extra-articular tenodesis in

primary anterior cruciate ligament reconstruction: A systematic review with meta-analysis

and best-evidence synthesis. Orthop J Sport Med. 2017;5(10):1-12.

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 9

doi:10.1177/2325967117731767

7. Devitt BM, Bouguennec N, Barfod KW, Porter T, Webster KE, Feller JA. Combined

anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not

result in an increased rate of osteoarthritis: a systematic review and best evidence

synthesis. Knee Surgery, Sport Traumatol Arthrosc. 2017;25(4):1149-1160.

doi:10.1007/s00167-017-4510-1

8. Schneider P, Bransford R, Harvey E, Agel J. Operative treatment of displaced midshaft

clavicle fractures: Has randomised control trial evidence changed practice patterns? BMJ

Open. 2019;9(9):1-5. doi:10.1136/bmjopen-2019-031118

9. Dijkman BG, Kooistra BW, Pemberton J, Sprague S, Hanson BP, Bhandari M. Can

orthopedic trials change practice?: A survey of 796 orthopedic surgeons on the possible

findings of a hip fracture trial. Acta Orthop. 2010;81(1):122-125.

doi:10.3109/17453671003587093

10. Rogers E. Lessons for guidelines from the diffusion of innovation. Jt Comm J Qual

Improv. 1995;21(7):324-328. doi:10.1016/s1070-3241(16)30155-9

11. Bhandari M, Montori V, Devereaux PJ, Dosanjh S, Sprague S, Guyatt GH. Challenges to

the Practice of Evidence-Based Medicine during Residents’ Surgical Training: A

Qualitative Study Using Grounded Theory. Acad Med. 2003;78(11):1183-1190.

doi:10.1097/00001888-200311000-00022

12. Castiglione SA, Ritchie JA. Moving into action-We know what practices we want to

change, now what? An implementation guide. Can Institutes Heal Res. Published online

2012:1-47. doi:http://www.cihr-irsc.gc.ca/e/45669.html

13. Grol R, Dalhuijsen J, Thomas S, Rutten G, Mokkink H. Attributes of clinical guidelines

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 10

that influence the use of guidelines in general practice: observational study. BMJ.

1998;317:858-861.

14. Thornley P, De Sa D, Evaniew N, Farrokhyar F, Bhandari M, Ghert M. An international

survey to identify the intrinsic and extrinsic factors of research studies most likely to

change orthopaedic practice. Bone Jt Res. 2016;5(4):130-136. doi:10.1302/2046-

3758.54.2000578

15. Flodgren G, O’brien MA, Parmelli E, Grimshaw JM. Local opinion leaders: Effects on

professional practice and healthcare outcomes. Cochrane Database Syst Rev.

2019;2019(6). doi:10.1002/14651858.CD000125.pub5

16. Forsetlund L, Bjørndal A, Rashidian A, et al. Continuing education meetings and

workshops: Effects on professional practice and health care outcomes. Cochrane

Database Syst Rev. 2009;(2). doi:10.1002/14651858.CD003030.pub2

17. Augestad KM, Bellika JG, Budrionis A, et al. Surgical telementoring in knowledge

translation - Clinical outcomes and educational benefits: A comprehensive review. Surg

Innov. 2013;20(3):273-281. doi:10.1177/1553350612465793

18. Anvari M. Telesurgery: Remote knowledge translation in clinical surgery. World J Surg.

2007;31(8):1545-1550. doi:10.1007/s00268-007-9076-5

19. Roland D. Social Media, Health Policy, and Knowledge Translation. J Am Coll Radiol.

2018;15(1):149-152. doi:10.1016/j.jacr.2017.09.009

20. Chan TM, Dzara K, Dimeo SP, Bhalerao A, Maggio LA. Social media in knowledge

translation and education for physicians and trainees: a scoping review. Perspect Med

Educ. 2020;9(1):20-30. doi:10.1007/s40037-019-00542-7

21. Barton CJ, Merolli MA. It is time to replace publish or perish with get visible or vanish :

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

A KT Plan for Stability 11

opportunities where digital and social media can reshape knowledge translation. Br J

Sports Med. 2019;53(10):594-598.

22. Chapman E, Haby MM, Toma TS, et al. Knowledge translation strategies for

dissemination with a focus on healthcare recipients: An overview of systematic reviews.

Implement Sci. 2020;15(1):1-14. doi:10.1186/s13012-020-0974-3

23. Gagliardi AR, Légaré F, Brouwers MC, Webster F, Badley E, Straus S. Patient-mediated

knowledge translation (PKT) interventions for clinical encounters: A systematic review.

Implement Sci. 2016;11(1):1-13. doi:10.1186/s13012-016-0389-3

Marmura H, et al. Br J Sports Med 2022; 56:363–365. doi: 10.1136/bjsports-2021-104406