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Objectives: To investigate the incidence and demographic features of anterior cruciate ligament (ACL) reconstructions in Australia by age and sex, and to determine whether the incidence has changed during the past 15 years. Design and setting: Descriptive epidemiological analysis of longitudinal data on ACL reconstructions (July 2000 - June 2015) in the National Hospital Morbidity Database. Main outcome measures: Population ACL reconstruction rates, by age group and sex. Results: 197 557 primary ACL reconstructions were performed during the study period; the annual incidence increased by 43% (from 54.0 to 77.4 per 100 000 population), and by 74% among those under 25 years of age (from 52.6 to 91.4 per 100 000 population). In males, the peak incidence in 2014-15 was for 20-24-year-olds (283 per 100 000 population); for females, it was for 15-19-year-olds (164 per 100 000 population). Annual growth in incidence was greatest in the 5-14-year-old age group (boys, 7.7%; girls, 8.8%). Direct hospital costs of ACL reconstruction surgery in 2014-15 were estimated to be $142 million. The annual incidence of revision ACL reconstructions increased from 2.49 (2000-01) to 5.65 per 100 000 population (2014-15), or by 5.6% per year; revisions as a proportion of all ACL reconstruction increased from 4.4% to 6.8%. Conclusions: The increasing incidence of ACL reconstructions in young Australians over 15 years is worrying. The individuals at greatest risk are men aged 20-24 years and women aged 15-19 years; the rate of reconstruction is increasing most rapidly among those aged 5-14 years. Revision rates are increasing more rapidly than those of primary reconstructions.
Increasing rates of anterior cruciate ligament
reconstruction in young Australians, 2000e2015
David Zbrojkiewicz
, Christopher Vertullo
, Jane E Grayson
The known Rupture of the anterior cruciate ligament (ACL) is
a common and devastating injury that is largely preventable by
neuromuscular agility training.
The new The incidence of ACL reconstructions in Australia is
the highest in the world, and is increasing. At greatest risk are
men aged 20e24 years and women aged 15e19 years, but
incidence is increasing most rapidly among 5e14-year-old
children. The incidence of revision ACL is increasing more
rapidly than that of primary ACL reconstructions.
The implications These ndings justify establishing a national
ACL injury prevention program and an ACL reconstruction
registry to improve outcomes for active young Australians.
Rupture of the anterior cruciate ligament (ACL) is a com-
mon and debilitating injury that typically results from a
non-contact event in which a previously healthy indi-
vidual changes direction at speed while playing a multi-
directional sport. ACL ruptures were once thought to be
uncommon in the skeletally immature,
but recent evidence
suggests that the global burden of ACL injury falls increasingly
on adolescents and young adults.
The short term consequences
of ACL rupture include the inability to participate in sport,
reconstructive surgery, and prolonged rehabilitation.
In the long
term, regardless of whether or not an ACL reconstruction is
performed, almost all individuals who tear an ACL are at
increased risk of osteoarthritis and disability,
and this risk is
substantially increased by concurrent meniscal injury.
Descriptive analyses of population-based data indicate that the
incidence of ACL reconstruction in Australia is among the highest
in the world.
Recent analyses of data in Victorian injury data-
bases have found increasing rates of sport-related hospitalisations
and lower limb injuries in older children and young adults,
but it
is uncertain whether this trend applies to the entire country, is
conned to younger people, or is sex-specic.
Several studies have found that neuromuscular agility and pro-
prioceptive training programs are effective as preventive measures,
averting 50e80% of ACL injuries.
Sports injuries, particularly
ACL injuries, are emerging as an internationally recognised public
health problem, making it vital that the demographic features
associated with an increased risk of ACL injury are characterised.
The aim of our study was to investigate the incidence and
demographic features of ACL reconstructions in Australia, by
age and sex, and to determine whether the incidence of ACL
reconstructions has changed during the past 15 years.
Study design
Longitudinal data for ACL reconstructions were extracted from the
National Hospital Morbidity Database (NHMD) of the Australian
Institute of Health and Welfare (AIHW) (
au/hospitals-data/procedures-data-cubes). The NHMD com-
prises condential electronic record summaries for episodes of care
provided by state and territory health authorities, including data
from public and private hospitals, as well as from private surgical
centres. The database affords national coverage of information on
inpatient hospital treatments, with a negligible proportion of
missing data (0.004% of cases per year).
The database collects
information on the type of procedure (according to the Interna-
tional Statistical Classication of Diseases and Related Health
Problems, 10th revision, Australian modication [ICD-10-AM]
and the third to eighth editions of the Australian Classication of
Health Interventions [ACHI]
), year of procedure, sex and age
group of patient, and whether the procedure required day or
overnight admission.
Patients who underwent a primary knee reconstruction during the
period 1 July 2000 e30 June 2015 were identied by ICD-10-AM
block number 1522 (with ICD-10-AM procedure codes 49539-00,
49539-01, 49542-00, 49542-01). AIHW procedure numbers included
both isolated cruciate reconstruction and cruciate reconstruction
with concurrent meniscal injury. Revision knee reconstructions
Objectives: To investigate the incidence and demographic
features of anterior cruciate ligament (ACL) reconstructions in
Australia by age and sex, and to determine whether the
incidence has changed during the past 15 years.
Design and setting: Descriptive epidemiological analysis of
longitudinal data on ACL reconstructions (July 2000 eJune
2015) in the National Hospital Morbidity Database.
Main outcome measures: Population ACL reconstruction rates,
by age group and sex.
Results: 197 557 primary ACL reconstructions were performed
during the study period; the annual incidence increased by
43% (from 54.0 to 77.4 per 100 000 population), and by
74% among those under 25 years of age (from 52.6 to 91.4 per
100 000 population). In males, the peak incidence in 2014e15
was for 20e24-year-olds (283 per 100 000 population); for
females, it was for 15e19-year-olds (164 per 100 000 population).
Annual growth in incidence was greatest in the 5e14-year-old age
group (boys, 7.7%; girls, 8.8%). Direct hospital costs of ACL
reconstruction surgery in 2014e15 were estimated to be
$142 million. The annual incidence of revision ACL reconstructions
increased from 2.49 (2000e01) to 5.65 per 100 000 population
(2014e15), or by 5.6% per year; revisions as a proportion of
all ACL reconstruction increased from 4.4% to 6.8%.
Conclusions: The increasing incidence of ACL reconstructions in
young Australians over 15 years is worrying. The individuals at
greatest risk are men aged 20e24 years and women aged
15e19 years; the rate of reconstruction is increasing most rapidly
among those aged 5e14 years. Revision rates are increasing
more rapidly than those of primary reconstructions.
Knee Research Australia, Gold Coast, QLD.
Grifth University, Gold Coast, QLD.
Gold Coast Orthopaedic Research and Education Alliance, Grifth University, Gold Coast, QLD.
University of Sydney, Sydney, NSW. jdoi: 10.5694/mja17.00974 jSee Editorial, p. 341 jPublished online 23/04/2018
Podcast with Christopher Vertullo available at
MJA 208 (8) j7 May 2018
were identied by ICD-10-AM block number 1524 with the ICD
procedure code 49551-00.
ACL incidence rates were expressed as number per 100 000 pop-
ulation for each year of the study, based on Australian Bureau of
Statistics population gures.
Statistical analysis
Trends in population-adjusted numbers of procedures were ana-
lysed in SPSS Statistics 23 (IBM). P< 0.05 was deemed statistically
Ethics approval
The base data for this investigation were de-identied data
publicly available from the AIHW. Our investigation was
therefore granted exemption from formal ethics review by the
Grifth University Human Research Ethics Committee.
During 2000e2015, 197 557 primary ACL reconstructions were
performed in Australia: 134 695 (68.2%) in males and 62 862
(31.8%) in females. The annual number of primary ACL re-
constructions increased from 9662 in 2000e01 to 16 990 in 2014e15;
the overall incidence of ACL reconstructions increased by
43% during this period, from 54.0 to 77.4 per 100 000 population.
The rate in males increased from 73.3 to 101.6 per 100 000, in fe-
males from 35.0 to 53.4 per 100 000 population (average annual
growth rates of 2.2% and 2.9% respectively) (Box 1).
Throughout the study period, the rates were higher for males than
for females in all 5-year age groups. In males, the peak incidence in
2014e15 was for the 20e24-year-old group (283 per 100 000 pop-
ulation), but rates were also high for 15e19-year-olds (241 per
100 000) and 25e29-year-olds (232 per 100 000). In females, the
peak incidence was for the 15e19-year-old group (164 per 100 000
population) (Box 2,Box 3).
Annual growth in the incidence of ACL reconstruction was highest
for the 5e14-year-old age group (7.7% for males, 8.8% for females);
the rates for 15e19-year-olds were 4.4% (males) and 5.0% per year
(females). The growth rates were also large for older age groups:
5.3% (males) and 4.2% annually (females) for people aged 45e49
years, and 6.0% (males) and 4.8% per year (females) for those aged
50e54 years (Box 4).
During the 15-year period analysed, the annual incidence of ACL
reconstruction in people under 25 years of age grew by a total of
73.8% (3.8% per year); the incidence for those aged 25 or more
increased by 28.4% (1.7% per year) (Box 5). The incidence in females
under 25 grew by a total of 90.6% (4.4% per year), in males under 25
by 69.3% (3.7% per year) (Box 6). Incidence rates for 2015e16 to
2024e25 were forecast by assuming that trends over the past 15
years will be maintained. On this basis, overall growth in incidence
for the period 2000e01 to 2024e25 will be greatest for females
under 25 (239%, or 8.5% per year); the projected total growth for
males under 25 is 119% (5.4% per year), and for all people over 25 it
is 48.7% (2.7% per year) (Box 6).
Estimated costs of anterior cruciate ligament surgery
According to the 2017 variance report of the Royal Australasian
College of Surgeons and Medibank, the average direct hospital and
surgery cost per ACL reconstruction was $8364.
The estimated
direct costs of primary ACL reconstruction surgery in 2014e15
were $142 million. This gure does not include the rehabilitation,
disease burden, and societal costs associated with the injury.
1 Incidence of primary anterior cruciate ligament
reconstruction in Australia, 2000e2015, by sex
2 Incidence of primary anterior cruciate ligament
reconstruction in males, 2000e2015, by age group
3 Incidence of primary anterior cruciate ligament
reconstruction in females, 2000e2015, by age group
MJA 208 (8) j7 May 2018
Revision anterior cruciate ligament surgery
A total of 12 878 revision ACL reconstructions were reported
during 2000e01 to 2014e15; 9588 (74.5%) were for males and 3290
(25.5%) for females. The annual number increased from 477 in
2000e01 and to 1328 in 2014e15; the annual incidence increased by
127%, from 2.49 to 5.65 per 100 000 population, or by 5.6% per year.
The incidence in males increased from 3.62 to 8.35 per 100 000
population (5.7% per year), in females from 1.37 to 2.98 per 100 000
population (5.3% per year) (Box 7). Revision ACL reconstructions
as a proportion of all reconstructions increased from 4.4% in
2000e01 to 6.8% in 2014e15.
During 2000e2015, the incidence of ACL reconstruction surgery
increased in Australia in all age groups; the overall incidence was
greatest among 15e24-year-olds. Consistent with other recent
the rate of growth in incidence was greatest among
5e14-year-old children.
Our calculated primary ACL reconstruction incidence of
77.4 per 100 000 population is the highest population-
adjusted rate in the world; lower rates in comparable
Organisation for Economic Cooperation and Develop-
ment (OECD) nations include those for the United States
(52), New Zealand (37), Denmark (38), Norway (34), and
Sweden (32 per 100 000 population).
We identied age and sex differences in the incidence of
ACL reconstruction surgery, with the peak incidence in
males being for a slightly older age group and
73% higher than the peak incidence in females. This is
consistent with studies that have reported higher rates
of ACL reconstruction in males,
despite females
being two to ten times more likely to rupture their ACL
when participating in high risk sports such as basketball
and soccer.
It is conceivable that the higher incidence
in males reects greater participation in sports such as
Australian rules football, in which pivoting, jumping
and rapid deceleration increase the risk of ACL injury.
That the peak incidence for females is in a younger age
group is consistent with their higher rates of sports
participation during early adolescence, declining when they reach
18e24 years.
ACL rupture imposes a considerable health burden on a young and
active population. We identied an annual incidence growth in its
incidence for Australians under 25 of 3.8%, compared with 1.7% for
those over 25. Moreover, growth in reconstruction incidence was
most rapid for boys (7.7%) and girls (8.8%) aged 5e14 years,
although it should be noted that the base ACL reconstruction
incidence in this age group was low. The increased incidence in
children is nevertheless of particular concern, as ACL injury in this
age group was previously rare. The burden of future degenerative
disease falls most heavily on our youngest patients.
The rising incidence of ACL reconstruction during 2000e2015 can
be attributed to several factors, including increasing medical and
public awareness of the procedure, diagnostic improvements, the
availability of magnetic resonance imaging, and increased access to
orthopaedic surgeons.
About 72% of ACL reconstructions in
Australia are sport-related; the sports most frequently involved are
Australian rules football, rugby union, rugby league, netball,
basketball, soccer, and skiing.
The rise of ACL injury in young
people has been attributed to earlier specialisation by younger
5 Incidence of primary anterior cruciate ligament
reconstruction in Australia, 2000e2015, by
broad age group
4 Annual growth in the incidence of primary anterior
cruciate ligament reconstruction, 2000e2015, by sex and
age group
6 Incidence of primary anterior cruciate ligament reconstruction in
Australia, 2000e2015, by sex and broad age group
MJA 208 (8) j7 May 2018
athletes, longer sporting seasons, more intense training, higher
levels of competition,
and a lack of free play.
The costs of ACL injury can be divided into direct and indirect
costs. We estimated the direct hospital costs for ACL re-
constructions were $142 million in 2014e15, a substantial cost to
the health care system that is growing with the incidence of ACL
injuries. Despite the considerable direct hospital costs, ACL
reconstruction surgery is signicantly more cost-effective than
rehabilitation alone in both the short and long term, with patients
experiencing greater improvements in quality-adjusted life-years
at a lower cost.
An American group calculated the average life-
time costs to society per ACL rupture to be $US88 938 with reha-
bilitation only and $US38 121 with ACL reconstruction.
In young
people, delaying ACL reconstruction surgery or opting for non-
operative management is associated with signicantly poorer
outcomes in both the short and long terms.
Nevertheless, prevention is much more cost-effective than either
ACL reconstruction or rehabilitation. Establishing a national ACL
injury prevention program has been reported as a cost-effective
strategy for improving sporting health outcomes for young Aus-
tralians, with low barriers to implementation.
In addition to
reducing health care costs, prevention programs allow athletes to
avoid the consequences of injury, including reduced functional
capacity because of pain, chronic knee instability,
and time away
from work or education.
In the longer term, the future compli-
cations of osteoarthritis
can lead to loss of productivity, fewer
employment opportunities, reduced social interaction, and lower
quality of life.
The link between ACL injury and knee replacement later in life is
also important.
The incidence of knee replacements in Australia
is high compared with other OECD nations, and it is expected to
continue to increase.
An estimated annual loss of $9.4 billion in
GDP has been attributed to early retirement caused by arthritis in
The incidence of revision ACL reconstruction surgery increased
across the study period by an average 5.6% per year, and the
proportion of reconstructions that were revision reconstructions
rose from 4.4% to 6.8%. While graft position, tunnel placement,
younger age, and early return to sport are established risk factors
for ACL graft failure,
further investigations are warranted, and
the need to carefully document emerging trends, risk factors and
the effects of interventions would justify the establishment of a
national ACL reconstruction registry.
As we analysed national electronic records summaries for episodes
of care, our investigation had some limitations. Firstly, AIHW
procedural data cubes did not allow differentiation between ACL
and posterior cruciate ligament (PCL) reconstructions. While iso-
lated PCL injuries requiring reconstruction are uncommon (fewer
than 1% of all knee injuries seen in the clinic),
the risk of osteo-
arthritis after PCL reconstruction is similar to that for ACL recon-
struction. Secondly, the AIHW data did now allow analysis of
reconstruction rates by state and territory, limiting our analysis to
the national scale. Additionally, as with any database study, cod-
ing errors are possible. Accurate direct hospital costs per ACL
reconstruction were unavailable for 2014e15, and the estimated
costs for this year were calculated using 2017 costing data. The
validity of comparing ACL reconstruction rates in different coun-
tries is limited by the availability of data on the incidence of ACL
injuries and reconstruction, which are related but distinct phe-
nomena. While the rate of ACL reconstruction may be an indirect
measure of that of ACL injury, many ACL injuries are either not
diagnosed or do not lead to surgical reconstruction.
This Australian population-level data analysis found a worrying
increase in the incidence of ACL reconstructions in young Aus-
tralians during 2000e2015. Most such reconstructions could be
averted by neuromuscular agility training and other preventive
measures. The individuals at greatest risk are men aged 20e24
years and women aged 15e19 years; the rate of reconstruction is
increasing most rapidly among boys and girls aged 5e14 years.
Moreover, rates of revision reconstruction are increasing more
rapidly than the rate of primary ACL reconstructions. The
increasing incidence of ACL injury in Australia is an emerging
public health problem with potentially detrimental long term
health outcomes, especially for young people.
Competing interests: No relevant disclosures.
Received 5 Oct 2017, accepted 12 Dec 2017. n
ª2018 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
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MJA 208 (8) j7 May 2018
... Knee injuries are not only inherent to sports fields but also can occur during activities of daily living [3,4]; at the same time, the increased uptake of sports has led to a similar rise in sports-related injuries. Figure 1.1 shows that these injuries can occur to ordinary people and athletes, either young or old, and several animals, such as horses, cows, dogs, and pigs [5][6][7]. Specifically, the knee joint includes soft tissues, hard tissues, and synovial fluid (see Figure 1.2). The soft/connective tissues of the knee, such as the tendon and ligaments (Anterior cruciate ligament (ACL), Posterior cruciate ligament (PCL), Medial collateral ligament (MCL), and Lateral collateral ligament (LCL)) are static stabilizers for the knee joint. ...
... Therefore, ligament tears are the most common knee injury encountered [5,6]. Knee ligament tears can be devastating and require surgical intervention and long-term (up to one year) rehabilitation for complete tear cases. ...
... year, at an estimated cost of over $40 billion and in Australia alone, nearly 17,000 anterior cruciate ligaments (ACL) are reconstructed per year [6,8]. ...
Full-text available
The knee is prone to injuries more often than other joints in the body due to its complexity and weight-bearing role. These injuries are not only inherent to sports fields but also to everyday lifestyles. Connective tissue injuries are the most prevalent knee diagnoses, accounting for 50% of musculoskeletal injuries. They are the most critical knee injuries because they can require surgical intervention and prolonged rehabilitation. In the United States, roughly 17 million ligamentous injuries necessitate medical care each year, at an estimated cost of over $40 billion. Early detection of a partial tear for knee ligaments without obstructing natural activity reduces the severity of the injury and its transformation into a complete tear, which can only be treated using interventional surgery. Besides, the treatment period is shortened from nearly one year in complete tears to several weeks in the case of mild or moderate tears. Moreover, early detection decreases the risk of other injuries that are associated with complete ligament tears, such as meniscal and tendon tears, posttraumatic osteoarthritis, and dislocation. Therefore, onsite diagnostic tools are required because the current scanning modalities, such as MRI and CT, are not suitable for use outside the hospital. Meanwhile, Electromagnetic imaging (EMI) has undergone rapid development and has become one of the promising biomedical imaging modalities because of its unique features, such as low cost, simple structure, portability, and non-ionization. EMI modality is based on the significant changes in dielectric characteristics of tissues due to abnormality or injuries. When the ligament tear happens for knee injuries, the synovial fluid increases inside the knee joint, which can be detected using EMI. Thus, EMI is an attractive solution to address the mentioned limitations. Implementing a complete EMI system that includes antenna array designs, hardware platforms, and microwave imaging algorithms is of significant interest in this context. In order to test and validate new EMI systems for knee injuries, a realistic durable knee phantom is required. Therefore, the first contribution of this thesis is to introduce knee phantom with realistic dielectric and anatomical properties fabricated using proper molds and equivalent mixtures. The fabricated phantom is based on a composite material of polymer and additive materials such as aluminium-oxide and graphite. In the second part of this thesis, a portable EMI system for knee injuries is designed, fabricated, tested, and validated for the first time in the literature. Specifically, design an eight-element wide band biconical antenna array at 0.7-2.2 GHz with a unidirectional radiation pattern to improve penetration into the knee. To reconstruct knee images, a modified multi-static confocal algorithm is used. Since humans' left and right knees are mirror-symmetrical, the modified algorithm uses a differential approach to remove signal clutters, muti-static coherence factor to improve the quality of channels, and applies dielectric mapping to reduce detection error. The images indicate the ability of the system to detect different types of ligament tears with an accurate localization. The third contribution in this thesis is presented as an essential step to verify the proposed system on the ex-vivo pig knee joint before clinical trials. Six healthy hind legs from three dead adult pigs were removed at the hip, suspended in the developed system, and scanned. Then, ligament tear was emulated by injecting distilled water into the middle of the left knee joint of each pig for early and mid-stage injuries. The injured knees were re-scanned. Furthermore, all knee’s connective tissues are extracted from a healthy hind leg along with collected synovial fluid. The extracted tissues and fluid were characterized and modelled, then imported to build an equivalent model for pig knee of 1 mm3 resolution in a realistic simulation environment to be used in the numerical studies by the researchers. The last part of this thesis focuses on introducing textile brace systems to be more conformable with the knee and can be worn for knee imaging and daily monitoring. The two braces are designed to match the human knee for enhanced electromagnetic wave penetration. The antennas in two braces achieve wide bandwidth and unidirectional radiation. The first brace consists of a simple 12-element textile slot loop antenna array. In contrast, the second brace consists of 8-element dual-polarized octagonal aperture antenna array. The dual-polarized brace system demonstrates a high capability to detect accumulated fluid with an arbitrary shape, slant angle, small size or deeper than the center of the brace. The reconstructed knee images in this section are based on a modified double-stage delay multiply and sum algorithm. The presented results in this context demonstrate the capability of detecting and monitoring knee injuries. The introduced systems break the hospital boundaries to real-time onsite scanning for knee injuries, can be used at home, sports fields, and clinics, making it easy to detect and manage early injuries and avoid serious consequences.
... 7 In recent decades, the incidence of ACL injuries has increased by up to 40%. 15,33 Increased knowledge of the physiology behind ACL tears and patient-specific differences in prognosis have provided us with a better understanding of options for both treatment and effective postoperative rehabilitation. 16,19,29,31 Furthermore, shared decision making plays a key role in deciding how to treat an ACL tear to achieve the optimal results. ...
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Background: Numerous studies, including randomized controlled trials (RCTs), have been published on the optimal graft choice for primary anterior cruciate ligament (ACL) reconstruction. Purpose: To review existing studies to investigate whether advances in orthopaedics have affected revision rates after primary ACL reconstruction. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed database was searched from inception to December 31, 2020, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patient series, observational studies, clinical trials, and registry-based studies investigating primary ACL reconstruction were included, as were high-quality RCTs from an additional study. The minimum required follow-up time for inclusion was 1 year. The primary outcome measure was the pooled prevalence of revision ACL reconstruction. The effect of the year the surgery was performed on revision rates was evaluated with metaregression analysis. All graft types were analyzed simultaneously, and all analyses were repeated separately for each graft type. Results: Overall, 330 articles with 52,878 patients were included, with a median patient age of 28 years (range, 15-57 years). The primary ACL reconstructions were performed between 1969 and 2018. At a median of 2.3 years of follow-up, the overall revision rate was 3.14% (95% CI, 2.76% to 3.56%); it was 2.71% (95% CI, 2.25% to 3.27%) for hamstring autografts, 2.38% (95% CI, 1.82% to 3.11%) for bone–patellar tendon–bone (BPTB) autografts, and 5.24% (95% CI, 4.02% to 6.80%) for other graft types. For hamstring grafts, the revision rate increased over time (year of surgery), with a 0.0434 (95% CI, 0.0150 to 0.0718) increase effect in the logit-transformed scale for every additional year. There was a slight decrease in revision rates for BPTB (β = –0.0049; 95% CI, –0.0352 to 0.0254) and other graft types (β = –0.0306; 95% CI, –0.0608 to −0.0005) over time; however, confidence intervals for BPTB included the zero change. Conclusion: Based on this systematic review and meta-analysis, ACL reconstruction is a reliable procedure with overall low historical revision rates. BPTB autograft had the lowest revision rate and a slightly decreasing trend of failures during the past 45 years, although both BPTB and hamstring autografts are reliable graft choices.
... This increase has occurred despite awareness of the serious long-term consequences for knee health following ACL injury [2] and efforts to reduce injury risk. Pubertal and young adults have experienced particularly large increases in rates of ACL injury [3], with young females at elevated risk for ACL rupture compared to their male counterparts [1,4] even when accounting for their lower relative exposure to athletic activity [5]. The natural questions follow, why do females at, or around, the time of sexual maturation rupture their ACL so frequently, and what can be done to ameliorate the situation? ...
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Rates of anterior cruciate ligament (ACL) rupture in young people have increased markedly over the past two decades, with females experiencing greater growth in their risk compared to males. In this study, we determined the effects of low- and high-support athletic footwear on ACL loads during a standardized drop–land–lateral jump in 23 late-/post-pubertal females. Each participant performed the task unshod, wearing low- (Zaraca, ASICS) or high- (Kayano, ASICS) support shoes (in random order), and three-dimensional body motions, ground-reaction forces, and surface electromyograms were synchronously acquired. These data were then used in a validated computational model of ACL loading. One-dimensional statistical parametric mapping paired t-tests were used to compare ACL loads between footwear conditions during the stance phase of the task. Participants generated lower ACL forces during push-off when shod (Kayano: 624 N at 71–84% of stance; Zaraca: 616 N at 68–86% of stance) compared to barefoot (770 N and 740 N, respectively). No significant differences in ACL force were observed between the task performed wearing low- compared to high-support shoes. Compared to barefoot, both shoe types significantly lowered push-off phase peak ACL forces, potentially lowering risk of ACL injury during performance of similar tasks in sport and recreation.
Purpose: Anterior cruciate ligament (ACL) injuries are one of the most frequently studied injuries in orthopedic care and research. However, limited epidemiological data are available in Canada regarding trend and distribution of anterior cruciate ligament reconstruction (ACLR). In this paper, our purpose was to assess trends of ACLR between 2002/03 and 2018/19 by age, sex, season of surgery, and location (inpatient vs outpatient) of surgery. Methods: In this descriptive epidemiological study of retrospective data available from Alberta Ministry of Health, we report annual incidence of ACLR between 2002/03 until 2018/19 among Albertans aged 10 years and older. Information was collected by authors from physician claims database for primary ACLR and revision ACLR and linked with other databases. Incidence proportions (number of ACLR/100,000 population) were calculated and compared by age category and gender over the study period. Results: A total of 28,401 primary ACLR and 2085 revision ACLR were identified during the study period. Age-standardized annual incidence of primary ACLR increased from 40.6 to 51.2 per 100,000 population aged 10 years and older. Average annual increase in ACLR incidence was higher among females (1.8% per years) compared to males (0.96% per year). The overall peak incidence and peak incidence among males was observed in 20-29 year age group, whereas peak incidence in females was observed in 10-19 years of age. The number of ACLR in females outnumbers those among males for 10-19 year age group. Generally, a lower proportion of ACLR were conducted in summer compared to other seasons. Primary ACLR conducted in outpatient setting increased from 72% in 2002/03 to 97% in 2018/19. Conclusion: The incidence of ACLR is increasing in Alberta, especially among females and among younger cohorts under 20 years of age. This information can help clinicians to provide patient education and policy-makers to design and implement targeted ACL injury prevention programs. Level of evidence: Level III.
Background The rate of anterior cruciate ligament (ACL) reconstruction is increasing over time in pediatric/adolescent populations, but there is less evidence to support how concomitant meniscal procedures are changing over time. There are also less data to suggest which characteristics are associated with meniscectomy versus meniscal repair treatment. Hypothesis Age, sex, race/ethnicity, income, and insurance type may independently affect the rate of concomitant meniscal procedures and treatment modalities in pediatric patients with ACL reconstruction. Study Design Descriptive epidemiology study. Methods The Pediatric Health Information System database was queried for all patients aged ≤18 years who underwent ACL reconstruction with or without concomitant meniscal procedures from 2015 to 2019. Basic demographic data including age, sex, self-identified race/ethnicity, rural-urban commuting area code, predicted median income, and insurance status were collected. Linear regression was used to model trends and multiple logistic regression modeling was used to test for associations. Results A total of 14,398 patients aged ≤18 years underwent ACL reconstruction during the study period, with 8337 patients (58%) having concomitant meniscal procedures with a 1.24-fold increase over 5 years. Of the concomitant meniscal treatment cohort, 41% had a meniscectomy and 59% had meniscal repair. There was a 0.82-fold change in meniscectomy and a 1.67-fold increase in meniscal repair during the study period. Male patients, older patients, Black race, living in an urban area, and those with nonprivate insurance had increased odds of undergoing a concomitant meniscal procedure (all P < .05). Patients of non-White race and those with nonprivate insurance had increased odds of having a meniscectomy versus meniscal repair (all P < .05). There were no associations detected between income bracket and the outcomes in this study. Conclusion This study shows that in pediatric and adolescent patients undergoing ACL reconstruction, there was a rise in concomitant meniscal procedures from 2015 to 2019. In addition, patients of non-White race and those with nonprivate insurance have increased odds of undergoing meniscectomy versus meniscal repair.
Objectives Determine the safety and initial efficacy of a novel biofeedback intervention to improve landing mechanics in patients following anterior cruciate ligament reconstruction (ACLR). Methods Forty patients post-ACLR (age: 16.9 ± 2.0 years) were randomly allocated to a biofeedback intervention or an attention control group. Patients in the biofeedback group completed 12 sessions over six-weeks that included bilateral unweighted squats with visual and tactile biofeedback. Patients in the control group completed a six-week educational program. Lower extremity mechanics were collected during a bilateral stop jump at baseline, six-weeks, and 12-weeks post-intervention. Linear mixed-effects models adjusted for sex and graft type determined the main effects of and interactions between group and time. Results No group by time interaction existed for peak knee extension moment symmetry. A group by time interaction existed for peak vertical ground reaction force symmetry (p = 0.012), where patients in the biofeedback group had greater improvements in symmetry between baseline and post-intervention that were not maintained through the retention assessments. Conclusion This novel biofeedback program did not reduce risk factors for second ACL injuries. Future work could develop and test multidisciplinary interventions for reducing second ACL injury risk factors. identifier (NCT03273673)
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Background Recent studies have shown that bone marrow stromal cell-derived exosomes (BMSC-Exos) can be used for tissue repair. However, whether the BMSC-Exos can promote tendon-bone healing after anterior cruciate ligament reconstruction (ACLR) is still unclear. In this study, we observed in vivo and in vitro the effect of rat BMSC-Exos on tendon-bone healing after ACLR and its possible mechanism. Methods Highly expressed miRNAs in rat BMSC-Exos were selected by bioinformatics and verified in vitro . The effect of overexpressed miRNA in BMSC-Exos on M2 macrophage polarization was observed. A rat model of ACLR was established. The experimental components were divided into three groups: the control group, the BMSC-Exos group, and the BMSC-Exos with miR-23a-3p overexpression (BMSC-Exos mimic) group. Biomechanical tests, micro-CT, and histological staining were performed for analysis. Results Bioinformatics analysis showed that miR-23a-3p was highly expressed in rat BMSC-Exos and could target interferon regulatory factor 1 (IRF1, a crucial regulator in M1 macrophage polarization). In vitro, compared with the control group or the BMSC-Exos group, the BMSC-Exos mimic more significantly promoted the polarization of macrophages from M1 to M2. In vivo, at 2 weeks, the number of M2 macrophages in the early local stage of ACLR was significantly increased in the BMSC-Exos mimic group; at 4 and 8 weeks, compared with the control group or the BMSC-Exos group, the bone tunnels of the tibia and femur sides of the rats in the BMSC-Exos mimic group were significantly smaller, the interface between the graft and the bone was narrowed, the bone volume/total volume ratio (BV/TV) increased, the collagen type II alpha 1 level increased, and the mechanical strength increased. Conclusions BMSC-Exos promoted M1 macrophage to M2 macrophage polarization via miR-23a-3p, reduced the early inflammatory reaction at the tendon-bone interface, and promoted early healing after ACLR.
Objective: Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes. Design: Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence. Data sources: MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. Eligibility criteria: Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults. Results: We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion. Conclusion: The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.
Background Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete. There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes. Aim This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective. Methods A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review. Results There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete. Conclusion Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.
Purpose: To compare return to sport and clinical results in young active patients who underwent anatomic single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). Methods: Young active patients undergoing SB or DB ACLR from 2017 to 2019 at our institution were retrospectively reviewed. The primary outcome measures were the rate and time to return to sports, with secondary measures including the Lachman test, pivot shift test, Lysholm scores, International Knee Documentation Committee (IKDC) scores and graft rupture. Results: The study included a total of 90 patients (DB group, 42; SB group, 48), with a mean follow-up of 27.1 ± 6.1 months. Young active patients who underwent DB ACLR had a higher rate of return to pivoting sports than those who underwent SB ACLR (HR = 2.4; 95% confidence interval [CI]: 1.4, 4.1; p = 0.013). The DB group returned to pivoting sports at a mean ± SD of 11.0 ± 2.9 months compared with 12.7 ± 2.7 months in the SB group (p = 0.01). There was one traumatic failure in the SB group and one contralateral ACL rupture in the DB group. There was no significant difference in the rate and time to return to running, Lachman test, pivot-shift test, Lysholm or IKDC scores in either group. Conclusion: Both anatomical SB and DB techniques achieved satisfactory clinical outcomes. DB techniques led to superior performance of return to pivoting sports but nonsignificant differences in time and rate of return to running, passive stability measurement, subjective knee function outcome and graft rupture rate in both groups at the 2-year follow-up. The DB ACLR should be considered a viable option to treat young patients with high activity demands. Level of evidence: III.
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Anterior cruciate ligament (ACL) injuries in children and adolescents have been the focus of recent media attention and parental concern, given their potential for adverse long-term health outcomes and healthcare costs. However, there is limited formal evidence on trends in the incidence of ACL injuries in children. This study utilizes the Victorian Admitted Episodes Dataset (VAED) to characterize epidemiologic trends of hospital-admitted ACL injuries in those aged 5 to 14 years over a period of 10 years from 2005 to 2015. There was a total of 320 cases and the overall annual rate of ACL injuries increased by 147.8% from 2.74 per 100, 000 population in 2005/2006 to 6.79 per 100, 000 in 2014/2015. The majority (96.9%) of these injuries were in 10-to 14-year-olds. The main in-hospital procedure provided to over 80% of the hospitalized cases involved ACL reconstruction. Sporting activities accounted for 56.6% of ACL injuries. For females, over half (52.4%) of ACL injuries occurred whilst playing ball sports, compared to 35.4% of males. The large increase in ACL injuries in 5-to 14-year-olds in the state of Victoria, Australia over a 10-year period indicates they are a significant and emerging health burden. Population-wide ACL prevention policies are required to halt these trends. Cost effective prevention programs that involve neuromuscular training must be implemented in schools and junior sports teams.
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Background The incidence of joint arthroplasty is increasing worldwide. International estimates of future demand for joint arthroplasty have used models that propose either an exponential future increase, despite obvious system constraints, or static increases, which do not account for past trends. Country-specific projection estimates that address limitations of past projections are necessary. In Australia, a high-income country with the 7th highest incidence of TKA and 15th highest incidence of THA of the Organization for Economic Cooperation and Development (OECD) countries, the volume of TKAs and THAs increased 198% between 1994 and 2014. Questions/purposeTo determine the projected incidence and volume of primary TKAs and THAs from 2014 to 2046 in the Australian population older than 40 years. Methods Australian State and Territory Health Department data were used to identify TKAs and THAs performed between 1994 and 1995 and 2013 and 2014. The Australian Bureau of Statistics was the source of the population estimates for the same periods and population-projected estimates until 2046. The incidence rate (IR), 95% CI, and prediction interval (PI) of TKAs and THAs per 100,000 Australian citizens older than 40 years were calculated. Future IRs were estimated using a logistic model, and volume was calculated from projected IR and population. The logistic growth model assumes the existence of an upper limit of the TKA and THA incidences and a growth rate directly related to this incidence. At the beginning, when the observed incidence is much lower than the asymptote, the increase is exponential, but it decreases as it approaches the upper limit. ResultsA 66% increase in the IR of primary THAs between 2013 and 2046 is projected for Australia (2013: IR = 307 per 100,000, [95% CI, 262-329 per 100,000] compared with 2046: IR= 510 per 100,000, [95% PI, 98-567 per 100,000]), which translates to a 219% increase in the volume during this period. For TKAs the IR is expected to increase by 26% by 2046 (IR = 575 per 100,000; 95% PI, 402-717 per 100,000) compared with 2013 (IR = 437 per 100,000; 95% CI, 397-479 per 100,000) and the volume to increase by 142%. ConclusionA large increase in the volume of arthroplasties is expected using a conservative projection model that accounts for past surgical trends and future population changes in Australia. These findings have international implications, as they show that using country- specific, conservative projection approaches, a substantial increase in the number of these procedures is expected. This increase in joint arthroplasty volume will require appropriate workforce planning, resource allocation, and budget planning so that demand can be met. Level of EvidenceLevel II, economic and decision analysis.
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Purpose: Rupture of the anterior cruciate ligament (ACL) is a common and debilitating injury that impacts significantly on knee function and risks the development of degenerative arthritis. The outcome of ACL surgery is not monitored in Australia. The optimal treatment is unknown. Consequently, the identification of best practice in treating ACL is crucial to the development of improved outcomes. The Australian Knee Society (AKS) asked the Australian Orthopaedic Association (AOA) to consider establishing a national ACL registry. As a first step, a pilot study was undertaken by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to test the hypothesis that collecting the required information in the Australian setting was possible. Methods: Surgeons completed an operative form which provided comprehensive information on the surgery undertaken. Patients provided pre- and post-operative questionnaires including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Marx Activity Scale (MA Scale). The number of ACL procedures undertaken at each hospital during the recruitment period was compared against State Government Health Department separation data. Results: A total of 802 patients were recruited from October 2011 to January 2013. The overall capture rate for surgeon-derived data was 99%, and the capture rate for the pre-operative patient questionnaire was 97.9%. At 6 months, patient-reported outcomes were obtained from 55% of patients, and 58.5% of patients at 12 months. When checked against State Government Health Department separation data, 31.3% of procedures undertaken at each study hospital were captured in the study. Conclusion: It is possible to collect surgeon-derived and pre-operative patient-reported data, following ACL reconstruction in Australia. The need to gain patient consent was a limiting factor to participation. When patients did consent to participate in the study, we were able to capture nearly 100% of surgical procedures. Patient consent would not be an issue in for a national registry where inclusion is automatic unless the patient wishes to opt out. The collection of post-operative patient-reported outcome measures (PROMs) is more problematic, due to an insufficient proportion of individuals providing patient-reported outcomes. Alternative outcome measures are required for an ACL registry in Australia to be successfully implemented. Level of evidence: Diagnostic, Level III.
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Background: The anterior cruciate ligament (ACL) is the most frequently injured ligament in the knee for which surgery is performed. United States national estimates of ACL reconstruction vary widely. Purpose: This study sought to use the most recently available Centers for Disease Control and Prevention data to investigate changes in the utilization of inpatient and ambulatory surgery for ACL tears in the United States. Study design: Descriptive epidemiology study. Methods: The National Survey of Ambulatory Surgery, conducted in 1994, 1995, 1996, and 2006 (data from 1994, 1996, and 2006 were used in the study), and the National Hospital Discharge Survey, conducted between 1990 and 2007, were used to identify cases of ACL reconstruction. The data were analyzed for trends in demographics, treatment, and utilization. Results: Between 1994 and 2006, the population-adjusted estimate of the rate of ACL reconstructions increased by 37% (33.0/100,000 capita or 86,837 total procedures to 45.1/100,000 capita or 134,421 total procedures). There was an increase in the proportion of females undergoing reconstruction in both the ambulatory (30% to 40%) and inpatient (29% to 47%) settings over the study period, with a 304% increase in the sex-adjusted estimate of the rate of female ambulatory procedures between 1994 and 2006. Age-adjusted estimates of the rates of ambulatory ACL reconstruction increased among all age groups, with a 924% increase in patients less than 15 years of age. Concurrent meniscectomy remained relatively constant in the ambulatory (37% to 40%) and inpatient (37% to 33%) settings between 1994 and 2007. Private insurance was the largest compensator, representing 77% of cases in 2006. Between 1994 and 2006, the use of peripheral nerve blocks during ambulatory surgery increased from 0.7% to 30.8%. Conclusion: The rate of ACL reconstruction increased dramatically between 1990 and 2007 based on the National Survey of Ambulatory Surgery and National Hospital Discharge Survey databases, which represents the most up-to-date publicly available data. Knowledge of this increase and national practice patterns may aid policy makers and surgeons in appropriately allocating health care resources to ensure quality patient care.
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Background: Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases. Purpose: To determine the incidence of ACL reconstruction (ACLR) in the United States; to identify changes in this incidence between 1994 and 2006; to identify changes in the demographics of ACLR over the same time period with respect to location (inpatient vs outpatient), sex, and age; and to determine the most frequent concomitant procedures performed at the time of ACLR. Study design: Descriptive epidemiological study. Methods: International Classification of Diseases, 9th Revision (ICD-9) codes 844.2 and 717.83 were used to search the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) for the diagnosis of ACL tear, and the procedure code 81.45 was used to search for ACLR. The incidence of ACLR in 1994 and 2006 was determined by use of US Census Data, and the results were then stratified based on patient age, sex, facility, concomitant diagnoses, and concomitant procedures. Results: The incidence of ACLR in the United States rose from 86,687 (95% CI, 51,844-121,530; 32.9 per 100,000 person-years) in 1994 to 129,836 (95% CI, 94,993-164,679; 43.5 per 100,000 person-years) in 2006 (P = .015). The number of ACLRs increased in patients younger than 20 years and those who were 40 years or older over this 12-year period. The incidence of ACLR in females significantly increased from 10.36 to 18.06 per 100,000 person-years between 1994 and 2006 (P = .0003), while that in males rose at a slower rate, with an incidence of 22.58 per 100,000 person-years in 1994 and 25.42 per 100,000 person-years in 2006. In 2006, 95% of ACLRs were performed in an outpatient setting, while in 1994 only 43% of ACLRs were performed in an outpatient setting. The most common concomitant procedures were partial meniscectomy and chondroplasty. Conclusion: The incidence of ACLR increased between 1994 and 2006, particularly in females as well as those younger than 20 years and those 40 years or older. Research efforts as well as cost-saving measures may be best served by targeting prevention and outcomes measures in these groups. Surgeons should be aware that concomitant injury is common.
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Osteoarthritis (OA) is a highly prevalent, disabling disease, with a commensurate tremendous individual and socioeconomic burden. This Perspectives article focuses on the burden of OA for the individual, the health-care system and society, to draw attention to the magnitude of the current problem with some reference to projected figures. We have an urgent opportunity to make fundamental changes to the way we care for individuals with OA that will have an effect upon the direct and indirect costs of this disease. By focusing on the burden of this prevalent, disabling, and costly disease, we hope to highlight the opportunity for shifts in health-care policy towards prevention and chronic-disease management.
Background: Anterior cruciate ligament (ACL) tears are thought to occur with increasing frequency in young patients. No study has shown increased incidence over time. We hypothesized the incidence of ACL tears in young patients has increased over the past 20 years. Methods: This descriptive epidemiology study is a retrospective review of insurance billing data of all patients aged 6 to 18 years with Current Procedural Terminology, Fourth Revision codes for ACL tear and reconstruction or International Classification of Diseases, Ninth Revision, Clinical Modification codes from 1994 to 2013. Injuries were normalized to persons per year enrolled in the insurance database based on age and sex. Analysis was performed based on sex and age (6-14, 15-16, and 17-18 years). Results: The rate of ACL tears per 100 000 person-years averaged 121 ± 19 (range 92-151). All trends increased significantly except for the male 6- to 14-year-old and 17- to 18-year-old age groups. Overall there was an annual increase of 2.3%. Females had significantly higher incidence except in the 17- to 18-year-olds. Females peaked at age 16 years and males at age 17 years, with rates of 392 ACL tears and 422 ACL tears per 100 000 person-years, respectively. Conclusions: The incidence of ACL tears in pediatric patients increased over the last 20 years. Females were at higher risk except in the 17- to 18-year -old group. Peak incidence is noted during high school years. These data help target the most at-risk patients for ACL prevention programs.
Background/aim: Anterior cruciate ligament (ACL) injury is a common and devastating sporting injury. With or without ACL reconstruction, the risk of knee osteoarthritis (OA) and permanent disability later in life is markedly increased. While neuromuscular training programmes can prevent 50-80% of ACL injuries, no national implementation strategies exist in Australia. The aim of this study was to compare the ability of four alternative national universal ACL injury prevention programme implementation strategies to reduce future medical costs secondary to ACL injury. Methods: A Markov economic decision model was constructed to estimate the value in lifetime future medical costs prevented by implementing a national ACL prevention programme among four hypothetical cohorts: high-risk sport participants (HR) aged 12-25 years; HR 18-25 years; HR 12-17 years; all youths (ALL) 12-17 years. Results: Of the four programmes examined, the HR 12-25 programme provided the greatest value, averting US$693 of direct healthcare costs per person per lifetime or US$221 870 880 in total. Without training, 9.4% of this cohort will rupture their ACL and 16.8% will develop knee OA. Training prevents 3764 lifetime ACL ruptures per 100 000 individuals, a 40% reduction in ACL injuries. 842 lifetime cases of OA per 100 000 individuals and 584 TKRs per 100 000 are subsequently averted. Numbers needed to treat ranged from 27 for the HR 12-25 to 190 for the ALL 12-17. Conclusions: The HR 12-25 programme was the most effective implementation strategy. Estimation of the break-even cost of health expenditure savings will enable optimal future programme design, implementation and expenditure.
With the increasing involvement in organized athletics among children and adolescents, more anterior cruciate ligament (ACL) injuries are being recognized in the skeletally immature population. The goal of the present study is to utilize a national database to characterize the recent epidemiologic trends of ACL injuries, ACL reconstruction, and treatment of associated meniscal and chondral pathology in the pediatric and adolescent populations. A national database was queried for ACL tear (ICD-9 844.2) and arthroscopic reconstruction of an ACL tear (CPT 29888) from 2007 to 2011. Searches were limited by age group to identify pediatric and adolescent cohorts: (1) ages 5 to 9 years old, (2) ages 10 to 14 years old, and (3) ages 15 to 19 years old. A comparative cohort of adult patients from ages 20 to 45 was also created. The database was also queried for concomitant procedures at the same time as ACL reconstruction for each age group, including partial meniscectomy, meniscus repair, microfracture, osteochondral autograft or allograft transfer, and shaving chondroplasty. The χ analysis was used to determine statistical significance. A total of 44,815 unique pediatric or adolescent patients with a diagnosis of an ACL tear and 19,053 pediatric or adolescent patients who underwent arthroscopic ACL reconstruction were identified. Significant increases in pediatric and adolescent ACL tear diagnosis and reconstruction compared with adult patients were noted. Significant increases in many concomitant meniscus and cartilage procedures in pediatric and adolescent patients compared with adult patients were also noted. The present study demonstrates a significant increase in the overall diagnosis of ACL injury and ACL reconstruction in both pediatric and adolescent patients, rising at a rate significantly higher than adults. In addition, pediatric and adolescent patients who undergo ACL reconstruction had significant increases in incidences of concomitant meniscal and cartilage procedures. Level III-retrospective cohort study.
Previous sports injury is a known risk factor for subsequent osteoarthritis, but population-based rates of sports injury are unknown. The aims of this study were to: i) describe the trends in the population incidence and burden of all hospital-treated sports injury in Victoria, Australia in adults aged 15+ years; ii) determine the incidence of lower limb and knee injuries; and iii) quantify their population health burden as average direct hospital costs per injury and lengths of stay. Health sector data relating to adults aged 15+ years, for 2004-2010 inclusive, was extracted from the Victorian Admitted Episodes Dataset and Victorian Emergency Minimum Dataset. Data relating to sports injuries were identified using activity codes in each dataset Trends in injury frequency and rates were determined, and economic burden was calculated. The overall annual rate of hospital treated sports injuries increased by 24% (p=0.001), and lower limb injuries by 26% (p=0.001) over the seven years. The associated accumulated economic burden was $265 million for all sports injuries and $110 million for lower limb injuries over the 7-years. The findings of this study show a significant increase in sports injuries in the state of Victoria, Australia over a 7-year period. As previous sports injury is a risk factor for the development of osteoarthritis, the future incidence of osteoarthritis will escalate, placing an even greater burden on health care systems. Population-wide preventative strategies that reduce the risk of sports injury are urgently required in order to reduce the future burden of osteoarthritis. Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.