Natural History of Associated Injuries in Chronic ACL Tears

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Natural History of Associated Injuries in Chronic ACL Tears

  1. 1. Natural History of Associated Injuries in Chronic ACL Tears Steven Y. Wei, M.D. Lawrence & Memorial Hospital New London, CT LTC Michael Eslava, M.D. US Army, Heidelberg, Germany
  2. 2. Steven Y. Wei, M.D. Private Practice Groton, CT Lawrence & Memorial Hospital New London, CT
  3. 3. LTC Michael Eslava, M.D. Section of Orthopaedic Surgery US Army Hospital (HMEDDAC) Heidelberg, Germany
  4. 4. Natural History of Associated Injuries in Chronic ACL Tears V iews expressed are those of the author and do not reflect the official policy of the US Department of Defense or the US government
  5. 5. PURPOSE <ul><li>To determine natural history of cartilage & meniscus injuries associated with ACL tears </li></ul><ul><li>American military personnel </li></ul><ul><li>Stationed in Germany </li></ul>
  6. 6. PURPOSE <ul><li>ACL reconstructions often delayed </li></ul><ul><li>Referral patterns </li></ul><ul><li>Geographic distance </li></ul>
  7. 7. PURPOSE <ul><li>US military population in Germany </li></ul><ul><li>Large geographic area </li></ul><ul><li>Only 3 American hospitals staffed with orthopaedic surgeons </li></ul>
  8. 8. PURPOSE <ul><li>Most patients cared for locally by primary care providers (PCP) </li></ul><ul><li>Internists & Family Practitioners </li></ul><ul><li>Physician Assistants </li></ul><ul><li>Nurse Practitioners </li></ul><ul><li>General Medical Officers </li></ul>
  9. 9. PURPOSE <ul><li>All patients require gatekeeper referral for orthopaedic evaluation </li></ul><ul><li>Limited number of orthopaedic surgeons </li></ul>
  10. 10. PURPOSE <ul><li>Rupp ( Orthopedics 2001) </li></ul><ul><li>High incidence non-specific, inaccurate and/or delayed diagnoses </li></ul><ul><li>Only 8/30 ACL tears diagnosed correctly by gatekeeper </li></ul><ul><li>4/8 presented to gatekeeper with dx </li></ul>
  11. 11. PURPOSE <ul><li>Unique opportunity observe natural history of cartilage & meniscus injuries associated with ACL tears </li></ul><ul><li>Young, active population </li></ul><ul><li>Prior to treatment or potential selection bias by orthopaedic surgeon </li></ul>
  12. 12. METHODS <ul><li>Retrospective review </li></ul><ul><li>All ACL reconstructions </li></ul><ul><li>Performed by 2 orthopaedic surgeons </li></ul><ul><li>At single US Army hospital in Germany </li></ul><ul><li>Over 2-year period </li></ul>
  13. 13. METHODS <ul><li>HMEDDAC </li></ul><ul><li>1 of 3 American facilities with orthopaedic surgeons </li></ul><ul><li>68,000 patients in 6,200 square mile area </li></ul>
  14. 14. METHODS <ul><li>HMEDDAC assigned 4 orthopaedic surgeons </li></ul><ul><li>Senior surgeon = Administrative </li></ul><ul><li>2nd surgeon = Balkans </li></ul><ul><li>2 authors = Evaluate & treat almost all patients with ACL tears </li></ul>
  15. 15. METHODS <ul><li>All referrals </li></ul><ul><li>Randomly distributed between 2 surgeons by military managed care system </li></ul><ul><li>Made to orthopaedics in general & never to specific surgeon </li></ul>
  16. 16. METHODS <ul><li>Young, active population </li></ul><ul><li>Many with military duties that require stable knee </li></ul><ul><li>Everyone with symptomatic instability & documented ACL tear underwent reconstruction with autograft </li></ul>
  17. 17. METHODS <ul><li>To determine incidence of associated cartilage & meniscus injuries </li></ul><ul><li>Review intra-operative records </li></ul><ul><li>Review arthroscopy photographs </li></ul>
  18. 18. METHODS <ul><li>To minimize differences between 2 surgeons’ diagnostic arthroscopy techniques </li></ul><ul><li>2 authors acted as first assistants for each other’s cases </li></ul>
  19. 19. RESULTS <ul><li>60 ACL Reconstructions </li></ul><ul><li>Surgeon A </li></ul><ul><ul><li>32 Cases </li></ul></ul><ul><li>Surgeon B </li></ul><ul><ul><li>28 Cases </li></ul></ul>
  20. 20. RESULTS <ul><li>Average age of patients </li></ul><ul><li>27.0 years (range 13-45) </li></ul><ul><li>Surgeon A - 26.5 years (range 13-45) </li></ul><ul><li>Surgeon B - 27.6 years (range 17-44) </li></ul><ul><li>p=0.515 </li></ul>
  21. 21. RESULTS <ul><li>Average time from date of injury (DOI) to presentation to PCP </li></ul><ul><li>30.0 days (range 0-313) </li></ul><ul><li>Surgeon A - 35 days (range 0-313) </li></ul><ul><li>Surgeon B - 24 days (range 0-162) </li></ul><ul><li>p=0.462 </li></ul>
  22. 22. RESULTS <ul><li>Average time from date of injury (DOI) to presentation to PCP </li></ul><ul><li>Excluding one patient from Group A </li></ul><ul><li>Surgeon A - 26 days (range 0-233) </li></ul><ul><li>Surgeon B - 24 days (range 0-162) </li></ul><ul><li>p=0.893 </li></ul>
  23. 23. RESULTS <ul><li>Average time from presentation to PCP to presentation to orthopaedics </li></ul><ul><li>151.2 days (range 1-1597) </li></ul><ul><li>Surgeon A - 148 days (range 1-1597) </li></ul><ul><li>Surgeon B - 155 days (range 2-1239) </li></ul><ul><li>p=0.911 </li></ul>
  24. 24. RESULTS <ul><li>Both surgeons used same protocol to evaluate & treat ACL tears </li></ul><ul><li>Except Surgeon A more likely order pre-op MRI </li></ul><ul><ul><li>Confirm diagnosis </li></ul></ul><ul><ul><li>Look for associated pathology </li></ul></ul>
  25. 25. RESULTS <ul><li>Pre-op MRI </li></ul><ul><li>Surgeon A - 28 of 32 patients (88%) </li></ul><ul><li>Surgeon B - 9 of 28 patients (32%) </li></ul>
  26. 26. RESULTS <ul><li>Average time from presentation to orthopaedics to date of surgery (DOS) </li></ul><ul><li>75.2 days (range 2-256) </li></ul><ul><li>Surgeon A - 78 days (range 2-256) </li></ul><ul><li>Surgeon B - 72 days (range 9-216) </li></ul><ul><li>p=0.666 </li></ul><ul><li>Delay reflects limited ortho OR time </li></ul>
  27. 27. RESULTS <ul><li>Average time from DOI to DOS </li></ul><ul><li>259.7 days (range 12-1622) </li></ul><ul><li>Surgeon A </li></ul><ul><ul><li>264 days (range 50-1622) </li></ul></ul><ul><li>Surgeon B </li></ul><ul><ul><li>255 days (range 12-1485) </li></ul></ul><ul><li>p=0.909 </li></ul>
  28. 28. RESULTS <ul><li>Lateral compartment damage 33% (20 patients) </li></ul><ul><li>Lateral meniscus tears 20% (12 patients) </li></ul><ul><li>Lateral cartilage damage 27% (16 patients) </li></ul>
  29. 29. RESULTS <ul><li>Medial compartment damage 50% (30 patients) </li></ul><ul><li>Medial meniscus tears 43% (26 patients) </li></ul><ul><li>Medial cartilage damage 30% (18 patients) </li></ul>
  30. 30. CONCLUSION <ul><li>Study reveals natural history of cartilage & meniscus injuries associated with ACL tears </li></ul><ul><li>Young, active population </li></ul><ul><li>Undergoing delayed ACL reconstruction </li></ul>
  31. 31. CONCLUSION <ul><li>Unique opportunity observe consequences of chronic ACL insufficiency </li></ul><ul><li>Young, active population </li></ul><ul><li>Prior to treatment or potential selection bias by orthopaedic surgeon </li></ul>
  32. 32. CONCLUSION <ul><li>Our findings confirm those of the literature </li></ul><ul><li>Meniscal tears & cartilage damage </li></ul><ul><li>More common with chronic ACL insufficiency </li></ul>
  33. 33. CONCLUSION <ul><li>Maffulli et al ( Arthroscopy 2003) </li></ul><ul><li>Degree of degenerative changes increases with time since injury </li></ul><ul><li>Greater degrees of articular damage noted with meniscal tears </li></ul>
  34. 34. CONCLUSION <ul><li>High incidence of associated meniscal & articular injury </li></ul><ul><li>Emphasizes need for prompt referral to orthopedic surgeon </li></ul><ul><li>Potentially decrease incidence of associated pathology </li></ul>
  35. 35. THANK YOU

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