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The survey aimed to assess trends and beliefs in the management of anterior cruciate ligament reconstruction (ACLR) amongst orthopaedic surgeons in India.
Methods
A survey was created and distributed among the various orthopaedic surgeons from India. The questionnaire included brief details of surgeons and their experience, clinical assessment, management strategies and the rehabilitation protocol.
Results
135 surgeons completed the survey. 35% of them were having experience of more than 12 years. A large number of surgeons were from government academic institutes (35.5%). The most common criteria for deciding about surgery was Clinical evaluation (94.8%). The most common graft choice was hamstring tendon (94%), and suspensory fixation on the femur side and interference screw on the tibial side (80%) is the most common fixation method. Almost two-thirds of surgeons in this survey use bracing to protect ACL graft in the initial phase.
Conclusion
We presented the preferences amongst the group of surgeons on the management of ACL injuries. Hamstring tendon graft remains the most preferred graft for ACL reconstruction. Further, the suspensory loop on the femoral side and interference screw on the tibial side are the preferred fixation method. This group of surgeons is conservative in terms of the timing of surgeries and post-operative bracing. Level of evidence Level V, Expert Opinion.
ACL injuries in men's professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture.
Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.
). In the past decade, there have been significant improvements in ACL reconstruction techniques and altered rehabilitation protocols to achieve the pre-injury level of activity
Original report: transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: a comparative study conducted at an armed forces hospital.
Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.
Original report: transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: a comparative study conducted at an armed forces hospital.
) Even rehabilitation protocols are still evolving. With the advent of accelerated rehabilitation protocol, the return to sports and functionality may be possible much earlier.
Clinical and functional outcomes and proprioception after a modified accelerated rehabilitation program following anterior cruciate ligament reconstruction with patellar tendon autograft.
) However, there is no such survey available from the Asian population regarding indications, management and the rehabilitation protocol. A web-based survey was conducted to assess the practices followed in respect of the management of ACL injuries amongst orthopaedic surgeons of India. This survey aimed to report the preference in relation to ACL reconstruction technique and rehabilitation protocol among Indian surgeons and to compare it with other published surveys. Further, the survey would compare the options of this group of surgeons on graft type, tunnel placement and fixation options.
2. Material and methods
A team of four experienced surgeons who are regularly managing ACL injuries each with more than two decades of experience surveyed between June 2021 and Oct 2021. The survey form was created after carrying out discussion with each of the surgeons. The questionnaire was made to bring out the prevalent practices, the gap in knowledge and surgical options utilized. The survey included a questionnaire regarding pre-operative diagnosis, clinico-radiological examination, management strategies and rehabilitation protocols followed. The survey included twenty-five questions which included brief details of surgeons professional role and their experience, clinical assessment, management and the rehabilitation protocol. It was prepared on google forms and the link of the same was distributed via email and various social media platforms like WhatsApp and telegram to as many Orthopaedics surgeons managing sports injuries as possible. Consent of willingness to participate was obtained from all the surgeons informing them about the use of received data.
In the survey, Surgeons were asked about their professional backgrounds like Orthopaedics surgeons and fellowship trained sports medicine surgeons. Fellowship trained surgeons were defined as surgeons who underwent minimum one year formal training. Surgeons were also asked about their work institute like government academic institutes, private multispecialty hospital, private orthopaedics hospital, academic private sector, and non-academic government sector. Private multispecialty hospital was a referral tertiary care hospital which had all faculties of medical, surgical and allied subjects including specialties under one roof. Whereas specialized Orthopaedic centres were standalone surgical centres with visiting consultants of other specialty on need basis.
2.1 Statistical analysis
Data was collected on a Microsoft excel sheet and analysis was done using Stata Version 12 (StataCorp LP, Texas, USA) response to the survey were documented frequency or percentage of the total. Part of the survey was reported using descriptive methods. As the analysis was of respondents, therefore no a priori sample size calculation or power of the study was obtained. For certain questions, participants were given the option of choosing multiple questions, and for those questions, the total percentage may be more than 100% on addition.
3. Results
3.1 Demographics
A total of 135 orthopaedic surgeons with varying experience responded to the survey. All were male and more than 65% of them were between 35 and 50 years of age, and approximately 20% were more than 50 years of age. 32% of them were fellowship-trained sports medicine surgeons, while the rest were Orthopaedics surgeons. More than 35% of them were doing these surgeries for more than 12 years (Fig. 1). Most surgeons were from government academic institutes (35.5%). The remaining were from the private multispecialty hospital (22.2%), private orthopaedics hospital (19.3%), academic private sector (14%), and rest (9%) were from the non-academic government sector. Approximately 30% of the surgeons were performing more than 100 ACL reconstruction surgeries in a year while the rest were performing less than 100 surgeries in a year (Fig. 2).
Fig. 1Number of years of Practice in Arthroscopy of surgeons as per this survey.
The criteria for deciding about the ACL reconstruction surgeries were symptoms of instability (91.1%), Clinical evaluation (94.8%), MRI finding (65.2%), and duration from injury (27.4%) (Fig. 3) Majority of surgeons (57%) perform surgery after the knee is quiescent, while (37%) perform surgery after a period of rehabilitation. Only 6% of the surgeon perform surgery as soon as possible. As per the survey, quiescent knee meant “when patient achieved full passive extension, mild swelling and minimal pain allowing easy unsupported ambulation”. The period of rehabilitation required before surgery is about 6 weeks as per the majority of surgeons (70%). In the setting of ACL injury with associated osteoarthritis (defined as per Kellgren and Lawrence classification), 45% of surgeons do not prefer to perform reconstruction, 20% will do ACL reconstruction while the rest 35% will do some associated ligament reconstruction or corrective osteotomy with ACL reconstruction. 35% of surgeons feel that no ACL reconstruction should perform in patients with age >55 years. while 32% of surgeons think that there is no upper age limit.
3.1.2 Graft options, fixation methods and additional fixations
Hamstring tendon autograft is the commonest used graft. The majority of surgeons in India (94%) use hamstring tendon grafts. Other commonly used grafts are bone-patellar tendon-bone graft, quadriceps and peroneus tendon graft (Fig. 4).
Fig. 4Commonly used graft for ACL reconstruction in this survey?
The most commonly used fixation method is the suspensory fixation on the femur side and interference screw on the tibial side (80%). Other commonly used methods are suspensory fixation of femur and fixation on the tibial side can be suspensory/preserved insertion/suture post and suture disc.
In the setting of explosive pivot shift (Grade III Pivot, with complete subluxation and relocation of lateral condyle of femur on applying valgus and rotatory force), approximately 50% of respondents are performing Lateral extra-articular (LET)/ALL reconstruction. However, the rate of LET reconstructions varies. Out of the total, 44% of respondents are performing LET reconstruction in <10% of total ACL patients. While 6% are performing LET reconstruction in 10–30% of total cases (Fig. 5).
Fig. 5In addition to ACL reconstruction, do you use extra-articular augmentation?
Knee bracing is commonly used by most surgeons (67%) for at least 06 weeks, while 23% do not use brace post-operatively. Rest use brace for 3 or 6 months. 60% of respondents keep patients full weight-bearing, while 38% keep patients partial weight-bearing following ACL reconstruction. However, 68% keep patients non-weight bearing for 6 weeks and 29% allow partial weight-bearing following meniscus repair. When respondents were asked about criteria for return to sports following ACL reconstruction, variable responses were recorded like the range of movements, strength of quadriceps, timing from surgery, grade of laxity and negative pivot shift test. 50% of respondents recommended return to non-pivoting sports at 6–8 months while 64% recommends return to sports at 9 months for pivoting sports. The majority of surgeons (>60%) are not sure about the percentage of operating patients returning to sport. While approximately 25% of surgeons feel that 60% of their patients return to some level of sports after the surgery. Most of the respondents (>73%) do not assess psychological readiness before return to sports.
The failure rate at 2 years after the return to sports is <5% as per 58%, 5–10% as per 37% of respondents while for the rest of them it was more than 10%.
4. Discussion
This survey aimed to assess the practices followed by orthopaedics surgeons in the management of patients with ACL tears. Also, to compare their choices with literature.
The clinical evaluation in terms of symptoms of instability and positive tests of instability were the most common factors deciding for ACL reconstructions. These findings are similar to those reported in the literature. (Table 1). According to Shafizadeh et al.,
) subjective instability was the most important criteria for which reconstruction was performed followed by tests for instability. While the other parameters like radiographic analysis are of less importance.
Table 1Review of Literature and comparison with various studies.
The timing of surgery after initial injury remains debatable, but the majority of respondents in our study prefer to operate after 06 weeks of injury. Only very few respondents operate as soon as possible. Various recent studies documents that there is no increase in the incidence of stiffness even if patients are operated as early as the first week after the injury.
) surgeons prefer to operate within 06 weeks of injury without much complications and stiffness. However, the ACL study group further recommends that each case should be assessed separately and clinical evaluation like the range of motion, effusion, pain and stiffness should be taken into account before deciding about the reconstruction.
Another factor that remains a matter of debate is the choice of graft. The most commonly used graft in the present study is the hamstring tendon graft (94%). The percentage of surgeons using hamstring grafts is much higher than various other surveys.
Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.
) Further, usage of fixation method in our study is also similar to various other studies and trends in recent past which favour suspensory fixation on femur side and interference screw on the tibial side as preferred options.
One of the findings of our study which is similar to various other studies is the use of brace post-operatively. 67% of respondents in our study are using knee brace post-operatively. These findings are similar to various other studies which have also documented bracing at the rate of 35–60%.
Regarding weight bearing on the operated limb, the majority of respondents (60%) allow full weight-bearing postoperatively. However, studies have not found any difference in terms of functional outcome or stability between full weight bearing from day one or delayed weight-bearing.
Return to non-pivoting sports has been recommended at 6–8 months by 50% of respondents, while two-thirds of respondents recommend return to pivoting sports at 9 months. These findings of our survey are similar to various studies published worldwide.
Outcome of hamstring autograft with preserved insertions compared with free hamstring autograft in anterior cruciate ligament surgery at 2-year follow-up.
Arthrosc J Arthrosc Relat Surg.2017 Dec 1; 33: 2208-2216
The strengths of this survey are that it included the right mix of orthopaedics and fellowship-trained knee arthroscopy surgeons (67%–33%). Also, the group has a good mix of experience <6 years (30%), 6–12 years (33%), and >12 years (37%). Another strength of our study is that only 19% of respondents were performing less than 25 surgeries in a year as compared to a study from Italy in which 37% of respondents were performing <25 surgeries annually.
The present survey is the first conducted from the Indian/Asian population regarding preferences of surgeons regarding ACL reconstruction. The results suggest that the Hamstring tendon graft is preferred for ACL reconstruction with the suspensory loop on the femoral side and interference screw on the tibial side as the preferred fixation method. The results showed a conservative approach employed by this group in terms of timing of surgeries and post-operative bracing.
Source of income
Nil.
Financial disclosure
None to declare.
Declaration of competing interest
Nil.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
ACL injuries in men's professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture.
Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.
Original report: transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: a comparative study conducted at an armed forces hospital.
Clinical and functional outcomes and proprioception after a modified accelerated rehabilitation program following anterior cruciate ligament reconstruction with patellar tendon autograft.
Outcome of hamstring autograft with preserved insertions compared with free hamstring autograft in anterior cruciate ligament surgery at 2-year follow-up.
Arthrosc J Arthrosc Relat Surg.2017 Dec 1; 33: 2208-2216
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