Most adolescents, parents and adults rated all aspects of the decision aid as good-excellent (eg, presentation, comprehensibility, length, graphics, formatting and amount of information). Following interviews, we identified seven main themes with subthemes (online supplemental file 16). The interviews highlighted agreement with most of the decision aid content (eg, management options, questions to ask health professionals, summary of benefits and harms). Most health professionals selected ‘strongly agree’ or ‘agree’ when asked to rate statements about the decision aid but some health professionals had opposing views on components of the decision aid (eg, using statistics from studies including participants over 18 years old, potential risks and return to sport).

Analysis of the interviews revealed that most aspects of the decision aid were agreed on by participants despite suggestions for refinement. However, some health professionals had divided opinions on the evidence used to inform content and rehabilitation time frames. Feedback from all participant groups consistently highlighted the importance of positive messaging, social and psychological support and considering long-term goals. Most participant groups also gave positive feedback on ‘questions to consider asking health professionals’.

Most participants agreed the decision aid clearly outlines its intended users and treatment options but there were mixed views on deciding optimal management. Some participants suggested bringing more attention to the impact of additional injury (eg, meniscus damage) to decision-making or adding other treatment options (eg, bracing, ACL healing and ‘prehabilitation’). We decided to present only two management options side by side for ease of comparison, which is similar to other decision aids for musculoskeletal conditions.21 22 Opinions of the optimal management for children and adolescents who have additional injuries to their ACL rupture were mixed and evidence remains uncertain.13 16 The decision aid prompts patients to confirm their diagnosis with a team of health professionals to gain a balanced opinion on their individual circumstance and discuss multiple factors that may influence their choice (eg, presence of ‘repairable’ injuries, if their knee gives way and activity levels9).

Some physiotherapists and orthopaedic surgeons had conflicting views on using evidence from research that included participants over 18 years old. Given the decision aid is not for adults with an ACL rupture, we decided not to present data from studies on people over 18 years to avoid children and adolescents having to consider multiple data sources and potentially becoming confused.36 The decision aid is designed for children and adolescents and includes prompts to encourage management that considers individual circumstances and different rates of child development (eg, questions to consider when talking to a health professional and key points).

Although children and adolescents should be encouraged to take an active role in the decision-making process, interviews with parents suggested that individual circumstances may dictate how the decision aid is best used. Some parents suggested the decision aid would save them time when researching information to help with making treatment choices (eg, getting this handout instead of me having to go home and Google, I Googled many, many nights trying to find you know, something like this’ (F, 41–50 years old, parent)). One parent withdrew their adolescent child before the interview due to concerns that discussion of potential harms could disrupt their child’s focus on rehabilitation. This adolescent recently had ACL reconstruction and was not given the option to have non-surgical management based on their injuries. Overall, parents and health professionals should consider encouraging children and adolescents to be involved in shared decision-making9 37 38 and consider that the decision aid is designed to be used before making the management decision. Once a decision is made, particularly an irreversible decision, parents and health professionals may have an important role in guiding focus and promoting optimism.

The decision aid can facilitate parents discussing their child’s treatment preference, sport choice and potential harms of participation. Parents and health professionals should acknowledge their supporting role in treatment decisions (eg, ‘it’s important that we listen to the kids and what they have to say, it’s their body’ (F, 41–50 years old, parent)). Discussions of sporting choice may solidify a decision or lead to diversifying sporting participation that has been shown to encourage the development of resilient self-identities.36 Parental anxiety or pain catastrophising has been shown to negatively influence children’s anxiety, postoperative pain and ability to perform rehabilitation.39 While potential harms and uncertainty of returning to sport can be a sensitive topic, their acknowledgement could also provide reassurance to children and adolescences if something goes wrong (eg, ‘as a parent you’re trying to make sure they understand the decision they’re making’ (F, 41–50 years old, parent)).

Avoiding unrealistic expectations and including children and adolescents in decision-making was frequently mentioned by all participant groups. Using the decision aid could prevent decisions being made based on unrealistic expectations and help improve treatment satisfaction. It is accepted that patient satisfaction has been closely linked to expectations,40 the decision aid may help improve the mismatch between expectations and evidence. Many young athletes (86%) expect to return to sport following ACL reconstruction by 6 months which is much sooner than is recommended in accepted professional guidelines.41 42 While return to sport rates may be higher in children who have ACL reconstruction followed by rehabilitation compared with rehabilitation only,13 subsequent ipsilateral or contralateral ACL rupture following ACL reconstruction followed by rehabilitation can be as high as 32% in paediatric athletes.39 The reality is that despite anatomical surgical success or well-designed rehabilitation programmes, many athletes may never return to their preinjury athletic performance level or their primary sport.43

Interviews frequently highlighted that information regarding psychological and social support should be included in the decision aid. Sudden changes to sport participation can affect self-identity in children and adolescents who particularly mentioned the mental struggle of recovering post ACL rupture (eg, ‘the point that stands out to me, that was probably the stay positive one. Because the other year, it was hard. But the mental part of it is the hardest part, like getting past that’ (M, 15–17 years old, adolescent)). Children and adolescent self-identities can be fragile and absence from participating in a sport they depend on can be psychologically traumatising.39 Therefore, we decided to include messages to encourage the discussion and planning for psychological support. Health professionals should give early recognition to psychosocial factors that have been shown to affect mental well-being and ability to recover from injury.43 The decision aid incorporates reassurance and encourages monitoring physical and psychological recovery.

Our development process (online supplemental file 17) had several strengths. The steering group includes people who experienced an ACL rupture and one who was 18 years old when they ruptured their ACL, the manuscript is transparent about the authors’ professional backgrounds, the design, conduct and reporting of this study were guided by the IPDAS criteria, we conducted one-on-one interviews with participants which allowed for in-depth feedback to be gathered on the decision aid, and used mixed methods to evaluate acceptability of the decision aid. The readability of our tool measured higher (grades 9–11) than recommendations (grade 8) but contains multiple features to support understanding and readability that align with best practice44 including bullet points, white space, images and subheaders. The tool, therefore, performs well relative to existing decision aids in terms of its attention to health literacy.44 We also included justification of the evidence used to inform numeric estimates of benefits and harms in the decision aid and used the highest quality evidence available comparing rehabilitation only and ACL reconstruction followed by rehabilitation for children and adolescents.13

Our patient decision aid was limited by the lack of high-quality evidence comparing rehabilitation only to ACL reconstruction followed by rehabilitation in children and adolescents. Emergence of future studies related to this topic will likely warrant an update of the evidence used in the decision aid. Another limitation is that evidence from older studies did not always report details of rehabilitation or consider advances in treatment to know if they reflect current recommended practice. We were unable to recruit any children participants to interview and adolescent participants were aged between 15 and 17 years old. We did interview health professionals who treat children and younger adolescents, but not being able to recruit children participants means the decision aid was not directly influenced by children’s feedback. Most authors are physiotherapists, and most health professional participants were physiotherapists (75%), trained in Australia (69%) and worked in private practice (63%) which may impact the themes that emerged from interviews (eg, views on costs and waiting time for ACL reconstruction). Recruitment of participants was difficult which was expected without offering incentives for their time. We did not directly involve children or adolescents in all stages of the study as consumers, and stakeholder involvement heavily influenced the design of the decision aid via feedback during online interviews and questionnaires on the acceptability of the decision aid. Our aim was to interview participants until we achieved data saturation, but we acknowledged that the majority of participants were Australian (60%). Including participants from several different countries may have made the decision aid more globally acceptable (eg, feedback was influenced by different cultures and healthcare systems) but the sample size of participants from each country may limit the usability of the decision aid for use in different countries. Future work includes adapting this decision aid for culturally and linguistically diverse populations as it is only presented in English.