Epidemiology of patients with anterior cruciate ligament injuries undergoing reconstruction surgery in a multi-ethnic Asian population.

We conducted an epidemiological study to identify the demographics and pre-operative characteristics of patients undergoing primary anterior cruciate ligament (ACL) reconstruction in a multi-ethnic Asian population. A retrospective study was performed on 696 patients who registered in our ACL reconstruction registry from January 2013 to August 2016. Important inter-ethnic differences were found. Indian patients were significantly older compared to Malay and Chinese patients. Malay and Indian patients were more likely to be male, overweight, and obese compared to Chinese patients. Soccer was the predominant sport involved, although ethnic predominance in specific sports exists. Novel findings from this study include increased prevalence of concomitant chondral injuries in the Chinese population compared to Malays and Indians, and significantly higher rates of concomitant intra-articular injuries in soccer and basketball compared to netball. Identification of these high-risk subgroups would serve useful in guiding the formulation of prevention strategies within our multi-ethnic community.

The Chinese ACL injury population has a higher proportion of small ACL tibial insertion sizes than Western patients.

PURPOSE: The study purpose is to characterize the sizes of the anterior cruciate ligament (ACL) insertion site and intercondylar notch in Chinese patients undergoing ACL surgery. The findings will provide a reference for individualized clinical treatment of ACL rupture. METHODS: For this study, 137 patients (102 males, 35 females) with an average age of 30.3 ± 9.5 years (range 14-52 years) undergoing ACL reconstruction were included. The tibial ACL insertion site length and width and the intercondylar notch width were measured on MRI and arthroscopically using a ruler. Descriptive statistics of the patients, the distribution of the measurements and the differences between males and females were calculated. RESULTS: The ACL tibial insertion size and intercondylar notch width in Chinese patients with ACL injuries, as obtained by MRI and intra-operatively, exhibited significant individual variability. The tibial ACL insertion site had a mean length of 13.5 ± 2.1 mm and width of 10.9 ± 1.5 mm as measured on MRI and a mean length of 13.3 ± 2.1 mm and width of 11.0 ± 1.6 mm as measured intra-operatively. The mean intercondylar notch width was 15.2 ± 2.4 mm on MRI and the mean length was 15.0 ± 2.5 mm intra-operatively. The inter-rater reliability between MRI and intra-operative measurements confirmed that the two methods were consistent. In 65.7% of individuals, the ACL tibial insertion length was < 14 mm. CONCLUSION: The distribution of tibial footprint size in Chinese patients is different from that in Western populations. There is a higher proportion of subjects with a tibial footprint size < 14 mm among Chinese patients with ACL injury. Therefore, great care should be taken when treating this population with the double-bundle technique or larger graft options. Level of evidence IV.

How Do Race and Insurance Status Affect the Care of Pediatric Anterior Cruciate Ligament Injuries?

OBJECTIVE: To identify associations between race or insurance status and preoperative, intraoperative, and postoperative findings in a large cohort of pediatric anterior cruciate ligament (ACL) reconstructions. DESIGN: Retrospective cohort study. SETTING: Division of Orthopaedics at an urban tertiary care children's hospital. PATIENTS: 915 pediatric (<21) patients undergoing primary ACL reconstruction between January 2009 and May 2016. INDEPENDENT VARIABLES: Insurance status and race. MAIN OUTCOME MEASURES: Delay to surgery, concurrent meniscal injury, sports clearance, postoperative complications, physical therapy, range of motion, and isokinetic strength reduction. RESULTS: Multivariate analysis revealed a significantly longer delay to surgery for black/Hispanic and publicly insured children compared to their counterparts (P = 0.02 and P = 0.001, respectively). Black/Hispanic patients were more likely to sustain irreparable meniscus tears resulting in meniscectomy than white/Asian patients (odds ratio 2.16, 95% confidence interval, 1.10-2.29, P = 0.01). Black/Hispanic and publicly insured children averaged fewer physical therapy (PT) visits (P < 0.001 for both). Nine months after surgery, black/Hispanic patients had significantly greater strength reduction than white/Asian patients. There were no differences in postoperative complications, including graft rupture, contralateral ACL injury, or new meniscus tear along the lines of race, although privately insured patients were more likely to suffer a graft rupture than publicly insured patients (P = 0.006). CONCLUSIONS: After ACL rupture, black/Hispanic children and publicly insured children experience a greater delay to surgery. Black/Hispanic patients have more irreparable meniscus tears and less PT visits. Black/Hispanic patients have greater residual hamstrings and quadriceps weakness 9 months after surgery.

The Association Between Race/Ethnicity and Revision Following ACL Reconstruction in a Universally Insured Cohort.

BACKGROUND: There have been few large studies involving multiethnic cohorts of patients treated with anterior cruciate ligament reconstruction (ACLR), and therefore, little is known about the role that race/ethnicity may play in the differential risk of undergoing revision surgery following primary ACLR. The purpose of this study was to evaluate whether differences exist by race/ethnicity in the risk of undergoing the elective procedure of aseptic revision in a universally insured cohort of patients who had undergone ACLR. METHODS: This was a retrospective cohort study conducted using our integrated health-care system's ACLR registry and including primary ACLRs from 2008 to 2015. Race/ethnicity was categorized into the following 4 groups: non-Hispanic white, black, Hispanic, and Asian. Multivariable Cox proportional-hazard models were used to evaluate the association between race/ethnicity and revision risk while adjusting for age, sex, highest educational attainment, annual household income, graft type, and geographic region in which the ACLR was performed. RESULTS: Of the 27,258 included patients,13,567 (49.8%) were white, 7,713 (28.3%) were Hispanic, 3,725 (13.7%) were Asian, and 2,253 (8.3%) were black. Asian patients (hazard ratio [HR] = 0.72; 95% confidence interval [CI] = 0.57 to 0.90) and Hispanic patients (HR = 0.83; 95% CI = 0.70 to 0.98) had a lower risk of undergoing revision surgery than did white patients. Within the first 3.5 years postoperatively, we did not observe a difference in revision risk when black patients were compared with white patients (HR = 0.86; 95% CI = 0.64 to 1.14); after 3.5 years postoperatively, black patients had a lower risk of undergoing revision (HR = 0.23; 95% CI = 0.08 to 0.63). CONCLUSIONS: In a large, universally insured ACLR cohort with equal access to care, we observed Asian, Hispanic, and black patients to have a similar or lower risk of undergoing elective revision compared with white patients. These findings emphasize the need for additional investigation into barriers to equal access to care. Because of the sensitivity and complexity of race/ethnicity with surgical outcomes, continued assessment into the reasons for the differences observed, as well as any differences in other clinical outcomes, is warranted. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing Anterior Cruciate Ligament Injury Risk Variables Between Unanticipated Cutting and Decelerating Tasks.

To examine the relationship between anterior cruciate ligament injury risk factors in unanticipated cutting and decelerating. Three-dimensional kinematics and ground reaction forces were collected on 11 females (22 [2] y, 1.67 [0.08] m, and 68.5 [9.8] kg) during 2 unanticipated tasks. Paired samples t tests were performed to compare dependent variables between tasks. Spearman rank correlation coefficients were calculated to analyze the relationship between peak internal knee adduction moment and peak anterior tibial shear force (ASF) during 2 unanticipated tasks. Significantly greater knee abduction angles, peak knee adduction moments, and peak ASFs were observed during cutting (P ≤ .05). A strong positive correlation existed between decelerating ASF and cutting ASF (ρ = .67), while correlations between decelerating knee adduction moment and cutting knee adduction moment and decelerating ASF and cutting knee adduction moment were not significant. In situations where time management is a necessity and only one task can be evaluated, it may be more appropriate to utilize an unanticipated cutting task rather than an unanticipated deceleration task because of the increased knee adduction moment and ASF. These data can help future clinicians in better designing more effective anterior cruciate ligament injury risk screening methods.

Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population-A 2-Year Follow-up Study.

PURPOSE: To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction in young and middle-aged Asians. METHODS: A retrospective study was performed using prospectively collected data from a tertiary institution ACL registry. All Asian patients with ACL tears who underwent primary arthroscopic ACL reconstruction by a single surgeon between 2008 and 2014, with minimum 2-year follow-up, were included. Patients with previous knee surgery or multiligamentous knee injuries were excluded. Two groups were formed: young patients (YP) (age <30) and middle-aged patients (MP) (age >40). They were compared preoperatively and 6 months, 1 year, and 2 years postoperatively for demographics, knee range of motion, anterior laxity, Tegner level, Lysholm and International Knee Documentation Committee grade, ability to return to preinjury level of activity, and patient satisfaction. RESULTS: YP (n = 84) and MP (n = 22) had differences in mean age (YP = 23.1 years, range 18-29 years; MP = 46.4 years, range 41-59 years, P < .001), preinjury Tegner level (YP = 7.4, MP = 6.4, P = .005), and preoperative Lysholm scores (YP = 65.3, MP = 53.0, P = .034). The incidence of meniscal and chondral injuries was similar. Two years postoperatively, both groups had comparable knee range of motion and anterior laxity. The Tegner score was different (YP = 6.3, MP = 5.2, P = .028), but the proportion of patients returning to preinjury Tegner level (YP = 45.2%, MP = 46.9%, P = .812), Lysholm scores (YP = 92.5, MP = 93.8, P = .794), proportion of patients with knees rated International Knee Documentation Committee A/B (YP = 77.4%, MP = 81.8%, P = .777), and satisfaction levels (YP = 98.5%, MP = 94.1%, P = .370) were similar. There were no graft ruptures or reoperations. CONCLUSIONS: In an Asian, predominantly male population, the clinical outcomes of arthroscopic ACL reconstruction in YP and MP are equally good at 2-year follow-up. MP can benefit as much as younger patients from ACL reconstruction in terms of restoration of knee function and return to preinjury activity level, are equally satisfied with outcomes, and should not be excluded from surgery on the basis of age alone. LEVEL OF EVIDENCE: Level III, retrospective comparative study.