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ORIGINAL ARTICLE

Anterior Cruciate Ligament Reconstruction Practices of South Asian Association of Regional Cooperation Knee Surgeons:  A Pilot Study

Zachary A Kanouse, John Aaron Nyland, Chakra R Pandey.

School of Medicine, University of Louisville
United States.

 

Address for Correspondence:
Zachary A Kanouse
School of Medicine, University of Louisville
United States.

Abstract:

Objective:  Determine the practices of South Asian Association of Regional Cooperation (SAARC) knee surgeons with at least 5 years of ACL reconstruction experience. 
Methods:  A 15-item survey was distributed at the Fourth SAARC Orthopaedic Association Conference. 
Results: 
Fourteen surgeons representing five SAARC countries (70% of eligible attendees) completed and returned the survey.  Most (42.9%) performed 10-25 ACL reconstructions/year.  The primary graft used was a bone-patellar tendon-bone (BPTB) autograft (57.1%).  Most (50%) used a BPTB autograft > 95% of the time and a hamstring autograft < 5%, while 43% used a hamstring autograft > 80% of the time and a BPTB autograft < 20%.  The primary tibial (85.7%) and femoral (57.1%) fixation was interference screws.  Most (62.5%) released BPTB autograft patients back to sports at six months post-surgery.  An equal percentage (50%) released hamstring autograft patients back to sports at six or nine months post-surgery.  Most (57.1%) did not perceive a benefit changing to an anatomical double bundle ACL reconstruction.  Concerns were expressed about patients presenting later following index ACL injury with more associated injuries, referring physicians providing incomplete information, fewer surgical options due to limited resources, the need to improvise techniques, more frequent post-surgery hospitalization, and the need for more educational and technology information exchanges.  Conclusions:  Most experienced SAARC surgeons performed < 50 ACL reconstructions/year with increasing hamstring autograft use.  Concerns were expressed regarding the need for additional resources, for improved educational and technology information exchanges, and for earlier referral with improved documentation.  Further study with greater subject numbers and representation from all SAARC countries is needed.

J.Orthopaedics 2010;7(2)e2

Keywords:

knee; arthroscopy; survey

Background:

The South Asian Association of Regional Cooperation (SAARC) was created in response to economic and societal adversities experienced by South Asian nations.1,2  The leaders of state from seven nations, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka adopted the original SAARC charter in 1985.  In 2007, Afghanistan was formally introduced as a full member.  Committees have been established by SAARC to facilitate seven areas of development:  Agriculture-rural issues, science technology-meteorology, health-population activities, transportation, women-youth-children issues, human resource development, and environment-forestry.1,2

Anterior cruciate ligament (ACL) injuries of the knee and their sequelae are a global healthcare concern among active individuals, particularly females.3,4  Additionally, surgical and rehabilitation management for this condition remain somewhat controversial.5  Compared to Western medical literature few reports have addressed issues related to the ACL reconstruction and rehabilitative practices specific to SAARC countries.  Our literature search revealed that all previously published reports come from one SAARC member nation, India.6-8

Clinical medicine as it relates to health-population activities and SAARC standard practices, surgical and patient outcomes following ACL injury, reconstruction, and rehabilitation have not been previously reported.  The purpose of this pilot descriptive study was to identify the ACL reconstruction and rehabilitation practices of experienced SAARC knee surgeons.  It is our intent that this work will help develop prospective multi-center studies.

Materials and Methods:

A 15-item survey was distributed at the Fourth SAARC Orthopaedic Association Conference held in Kathmandu, Nepal to surgeons that specialized in knee arthroscopy and who had been performing ACL reconstruction for a minimum of five years.  A departmental ethics review board approved this study.  After providing demographic data including country of residence and age, surgeons answered multiple choice questions regarding the number of ACL reconstructions performed annually, how long after the index injury ACL reconstruction was generally performed, the primary ACL reconstruction graft choice, how many months following ACL reconstruction the patient was allowed to return to sports, and if prescribed for what length of time functional knee braces were used. 

Fill in the blank type questions identified surgeon practices for current and historical ACL reconstruction graft use (bone-patellar tendon bone, doubled hamstring tendon, quadrupled hamstring tendon, quadriceps tendon, or allograft), preferred ACL graft fixation method, perceptions of how current ACL reconstruction and treatment practice differ from current Western country practices based on medical journals, web-based medium, or direct observations, and on what they deem to be important for Western country peers and companies to know about ACL reconstruction in their country.  Lastly, fill in the blank type questions were used to identify whether or not knee braces were routinely prescribed following ACL reconstruction, if they perceived any advantage in changing to an anatomical double bundle ACL reconstruction technique, and if so, to describe the ideal patient for this technique. 

Descriptive statistical analysis (SPSS version 11.0, Chicago, IL, USA) was performed using Chi-Square or Fisher’s Exact tests (when Chi-Square test assumptions were not met) for categorical data comparisons.  An alpha level of p < 0.05 was selected to indicate statistical significance.

Results:

From approximately 200 hundred conference attendees, 35 surgeons were identified that primarily performed knee arthroscopy.  Of these attendees 20 had been performing arthroscopic ACL reconstruction for a minimum of five years prior to survey completion.  Fourteen surgeons from five SAARC countries (India = 5, Nepal = 4, Bangladesh = 2, Pakistan = 2, and Bhutan = 1) completed the survey for a 70% (14/20) return rate from eligible conference attendees.  Surgeon age (mean ± standard deviation) was 43.4 ± 10.4 years (range = 30-71 years).  Most (42.9%) performed 10-25 ACL reconstructions/year (Fig. 1).

Fig.1. Number of ACL reconstructions performed/year by experienced SAARC knee surgeons.

Most performed ACL reconstruction surgery at more than six weeks post-injury (64.3%) (Fig. 2). 

Fig. 2.  Time period between index ACL injury and surgery.

The primary graft selected for ACL reconstruction was a bone-patellar tendon-bone (BPTB) autograft (57.1%), with 42.9% choosing hamstring autografts.  Slightly more respondents used a BPTB autograft > 95% of the time and a hamstring autograft < 5% (50%) than used a hamstring autograft > 80% of the time and a BPTB autograft < 20% (43%)(Fig. 3). 

Fig. 3.  Current ACL reconstruction graft preference (BPTB = bone-patella tendon-bone autograft; HS = hamstring autograft) of experienced SAARC knee surgeons.

Two experienced surgeons that had recently changed their primary ACL reconstruction graft preference switched from either 100% BPTB autograft or 75% BPTB autograft and 25% double strand hamstring graft use to greater use of two or four strand hamstring autografts.  The primary method of tibial (85.7%) and femoral (57.1%) graft fixation was interference screws.  The second most frequent femoral fixation method was endo-buttons (35.7%) and the second most frequent tibial fixation method was a screw-post combination (7.1%).  The most frequent time of release to unrestricted activities of daily living for BPTB autograft patients was 5-6 months (37.5%) followed by 10-12 months (25%), 3-4 months (25%), and 1-2 months (12.5%).  The most frequent time of release to unrestricted activities for hamstring autograft patients was 7-9 months (66.7%), 5-6 months (16.7%) and 1-2 months (16.7%).  The time of release to unrestricted activities of daily living between graft types did not display statistically significant differences (Fisher’s Exact Test = 3.2, p = 0.61).  Most surgeons released patients with a BPTB autograft (62.5%) back to sports at six months post-surgery followed by nine months post-surgery (25%) and > 12 months post-surgery (12.5%).  Surgeons were equally divided (50%) for releasing patients with a hamstring autograft back to sports either at six or nine months post-surgery.  The timing of release back to sports did not display statistically significant differences between graft types (Fisher’s Exact Test  = 1.4, P = 0.77).  Most surgeons (57.1%) did not routinely prescribe a functional knee brace post-surgery.  Of those who prescribed knee braces, most (60%) recommended use for less than six months post-surgery while 40% recommended their use for six months – one year.  Experienced knee surgeons from India were more likely to prescribe a functional knee brace post-surgery (80%, 4 of 5 surgeons) than experienced knee surgeons from the other SAARC countries (22.2%, 2 of 9 surgeons).  Most surgeons (57.1%) did not perceive a substantial benefit in changing from their current ACL reconstruction method to use of an anatomical double bundle ACL reconstruction technique.  Surgeons who believed that a benefit would exist believed that it would be most advantageous for high re-injury risk athletes such as competitive soccer players and revision cases.

Perceived ACL reconstruction practice differences compared to Western countries based on what surgeons had observed in Western journals, web-based medium, or travels, included, fewer surgical options due to limited facility, equipment and implant availability (Bangladesh), a widespread need to improvise surgical techniques (Pakistan), a higher percentage of male cases (India), fewer opportunities for revision surgery with the athlete remaining active in sports (India), the need for 2-3 day post-surgery hospitalization (Nepal), and patients tending to present for treatment later following the index ACL injury with a greater number of associated injuries (India, Nepal). 

Surgeons who provided comments as to what they believed their peers and companies in Western countries should know about ACL reconstruction in their country suggested that many patients present to them a considerable time period following the index ACL injury (Pakistan), there is often poor or inaccurate documentation from the referring general care physician regarding the patient’s injury history (India), limited facility, equipment, and implant resource availability (Nepal), the belief that comparable patient outcomes can be achieved despite existing facility and other patient care difficulties (Nepal), the effectiveness of simple, inexpensive knee braces (India) and the need for more arthroscopic and sports medicine education and technology information transfer and fellowship experiences (India).

Discussion :

A similar percentage of SAARC knee surgeons selected BPTB and hamstring autografts for ACL reconstruction.  This is not surprising given the history of similar patient outcome effectiveness between these graft types9 and the growing trend toward greater hamstring autograft use.10  Additionally, the majority of respondents performed < 50 ACL reconstructions/ year, which also is comparable to Western country practices.11,12  Knee surgeons in Western countries often prescribe functional knee braces following ACL reconstruction to prevent graft strain, decrease pain, improve knee extension range of motion and restrict end range movements to facilitate graft healing.  In a systematic review that assessed knee joint range of motion, ACL graft laxity, knee pain level, and re-injury risk however, Wright et al13 reported that none of these variables were influenced by knee brace use following ACL reconstruction.  The more restricted use of functional knee braces by experienced SAARC knee surgeons suggests a better use of limited resources, particularly given the limited evidence supporting the efficacy of regular functional knee brace use.  Perhaps knee surgeons in Western countries should re-examine their routine prescription of expensive custom or “off the shelf” knee braces following ACL reconstruction given this limited evidence.  Two experienced SAARC knee surgeons (India, Pakistan) recommended that short-term use of simple, inexpensive knee braces was sufficient. 

A growing number of knee surgeons are attempting to more closely replicate native ACL function via the use of anatomical double bundle ACL reconstruction techniques.   This trend is occurring despite the considerable body of evidence that supports conventional ACL reconstruction methods and the limited evidence for improved patient outcomes that exist supporting anatomical double bundle ACL reconstruction.   Most experienced SAARC knee surgeons did not believe that anatomical double bundle ACL reconstruction would provide a significant advantage over conventional single bundle ACL reconstruction methods.  Those who did suggested that sportsmen such as competitive soccer athletes and revision cases would benefit most.

Surgeon perceptions regarding what they deemed important that Western country knee surgeons and companies should know about ACL reconstruction in their country differed somewhat based on the SAARC country of origin.  For example, experienced knee surgeons from Nepal, Pakistan, Bangladesh, and Bhutan expressed greater concerns related to limited medical resource availability, the need to more frequently improvise or modify surgical techniques, and the more common need for post-surgery hospitalization.  In contrast, experienced knee surgeons from India more commonly expressed concerns related to the need for arthroscopy and sports medicine educational information and technology exchanges.  In contrast to knee surgeons in India who seek technique refinement and updates, knee surgeons in other SAARC countries were more interested in obtaining basic assistance at the immediate patient care level.

A recurrent theme from most experienced SAARC knee surgeons was a concern regarding low public health awareness as to the significance of the index ACL injury and how delayed treatment is associated with injury to adjacent knee tissues, progressive lower extremity dysfunction, and decreased general health (India, Nepal, Pakistan).  This finding is similar to rural healthcare issues experienced in many Western countries where limited medical personnel and facility resources, increased travel distances, and decreased public awareness combine to lead patients to only seek healthcare after their condition or disease has progressed to being chronic, extremely painful, and highly debilitating. 

Optimized use of available equipment and personnel resources is essential to the development of improved public health education and awareness regarding the seriousness of ACL injury.  These initiatives may help to identify currently untapped resources, to better distribute existing resources, and to facilitate better resource sharing between SAARC member nations.  Cooperative planning in the prescriptive development of arthroscopy and sports medicine educational and technology information exchange programs would help insure that the needs of all SAARC member countries are met (both basic necessities and technique refinement), better supporting the organization’s overall vision and mission. 

This study is limited in that it represents only a small sample of experienced SAARC knee surgeons that specialize in arthroscopic ACL reconstruction.  However, this is a very unique group of experienced knee surgeons whose ACL reconstruction practice experiences have not been previously reported.  Our literature search did not identify any previous reports that focused on ACL reconstruction practices solely in this region of the world.  Pilot studies such as this are important to collect preliminary data, refine prospective research questions and plans, and develop research instruments.  Based on our study findings, future research should focus on increasing the awareness of the general public regarding the potential impact of ACL injury on general health and quality of life and to increase the awareness of general practice physicians as to the need to improve examination documentation and/or to expedite referral to a knee arthroscopy specialist when indicated.  Further study needs to be performed recruiting a larger number of experienced knee surgeons including representatives from other SAARC countries such as the Maldives, Sri Lanka, and Afghanistan. 

Given the other important healthcare problems that exist in the region served by SAARC14-15 issues related to arthroscopic ACL reconstruction may not initially seem to be of particular importance.  However, untreated or inappropriately treated lower extremity musculoskeletal injuries are a serious worldwide health concern that directly impacts general health status.  Information such as that provided by this study will better enable the SAARC medical community to establish arthroscopy and sports medicine education and technology information exchange program goals in addition to helping design multi-center, prospective research studies to improve patient healthcare and quality of life.

Conclusions:

Experienced SAARC knee surgeons displayed similar ACL reconstruction practices to surgeons from Western countries.  Most of the experienced SAARC knee surgeons that participated in this study perform < 50 ACL reconstructions per year.  There was trend toward increasing hamstring autograft use and did not routinely prescribe functional knee braces.  Most experienced SAARC knee surgeons also did not perceive a benefit to changing their current surgical procedure to an anatomical double bundle ACL reconstruction technique.  Many experienced SAARC knee surgeons expressed concerns regarding the need for additional medical and surgical resources, improved arthroscopy and sports medicine educational and technology information exchange and fellowship experiences, earlier patient referral with improved documentation, and improved public awareness regarding the impact of ACL injury on general health status.  Our findings can assist the SAARC sports medicine community in establishing realistic organizational goals and in designing prospective multi-center studies to better serve the needs of all member nations.

Reference :

1.     South Asian Association for Regional Cooperation.  [http://www.saarc-sec.org/] Wikipedia.  [http://en.wikipedia.org/w/index.php?title=South Asian Association for Regional Cooperation&olddid=23181920]

2.    Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K.  A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and knee injury-reduction regimen.  Arthroscopy 2007, 23(12):1320-25.e6  

3.    [http://download.journals.elsevierhealth.com/pdfs/journals/0749- 8063/PIIS074980630700686X.pdf]

4.     Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, et al.  Non-contact ACL injuries in female athletes:  An International Olympic Committee current concepts statement.  Br J Sports Med 2008;42(6):394-412. [http://bjsm.bmj.com/content/42/6/394.full.pdf]

5.     Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF.  Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury.  Arthroscopy  2003;19(7):762-70. [http://download.journals.elsevierhealth.com/pdfs/journals/0749-8063/PIIS0749806303003980.pdf]

6.     Chaudhary D, Monga P, Joshi D, Easwaran R, Bhatia N, Singh AK.  Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft:  Experience of the first 100 cases.  J Orthop Surg (Hong Kong) 2005;13(2):147-52. [http://www.josonline.org/pdf/v13i2p147.pdf]

7.     Nag HL, Neogi DS, Nataraj AR, Kumar VA, Yadav CS, Singh U.  Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.  Arthroscopy  2009;25(2):131-6. [http://download.journals.elsevierhealth.com/pdfs/journals/0749-8063/PIIS0749806308007263.pdf]

8.     Dhillon MS, Mohan P, Nagi ON.  Does harvesting the medial third of the patellar tendon cause lateral shift of the patella after ACL reconstruction?  Acta Orthop Belg  2003;69(4):334-40. [http://www.actaorthopaedica.be/acta/download/2003-4/06-dhillon-nagi-.pdf]

9.     Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R.  ACL reconstruction: A meta-analysis of functional scores.  Clin Orthop 2007;458:180-7.  [http://www.ncbi.nlm.nih.gov/pubmed/17308473]

10.  West RV, Harner CD.  Graft selection in anterior cruciate ligament reconstruction.  J Am Acad Orthop Surg  2005;13(3):197-207.  [http://www.jaaos.org/cgi/content/abstract/13/3/197]

11.  Duquin TR, Wind WM, Fineberg MS, Smolinski RJ, Buyea CM.  Current trends in anterior cruciate ligament reconstruction.  J Knee Surg  2009;22(1):7-12.  [http://www.ncbi.nlm.nih.gov/pubmed/19216345]

12.  Forssblad M, Valentin A, Engstrom B, Werner S.  ACL reconstruction:  Patellar tendon versus hamstring grafts-economical aspects.  Knee Surg Sports Traumatol Arthrosc  2006;14(6):536-41. [http://www.springerlink.com/content/r146507716477710/]

13.  Wright R, Fetzer GB, Spindler KP.  Bracing after ACL reconstruction: A systematic review.  Clin Orthop  2007:455:162-8.  [http://www.ncbi.nlm.nih.gov/pubmed/17279043]

14.  Nishtar S.  South Asian health:  What is to be done?  SAARC: Regional cooperation for sustainable health.  BMJ2004;328:837-9.[http://www.bmj.com/cgi/content/full/328/7443/837-a?view=long&pmid=15070648]

15.  Khan IM, Khan S, Chotani R, Laaser U.  SARS and SAARC:  Lessons for preparedness.  J Ayub Med Coll Abbottabad  2003;15(2):1-2. [http://www.ncbi.nlm.nih.gov/pubmed/14552237]

 

This is a peer reviewed paper 

Please cite as: Zachary A Kanouse: Anterior Cruciate Ligament Reconstruction Practices of South Asian Association of Regional Cooperation Knee Surgeons:  A Pilot Study

J.Orthopaedics 2010;7(2)e2

URL: http://www.jortho.org/2010/7/2/e2

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