Pain experience and functional outcome of inpatient versus outpatient anterior cruciate ligament reconstruction, an equivalence randomized controlled trial with 12 months follow-up

Feasibility and Cost-Effectiveness of Daycare Anterior Cruciate Ligament Reconstruction - A Retrospective Case Series

Introduction

Multiple reviews of the applicability, cost-effectiveness, and safety of daycare reconstruction of anterior cruciate ligament have been published in French, American, and British setups, but have not been described in our population.

Materials and methods

In this study, 25 patients who underwent Anterior Cruciate Ligament Reconstruction (ACLR) as a daycare surgery in our setup were assessed retrospectively. Post-operatively patients were reviewed for pain, complications, conversion from daycare to inpatients, readmission within two weeks post ACLR and cost-effectiveness.

Results

None of the patients required readmission within two weeks post-operatively, two patients were admitted on request from Surgical Day Care (SDC) to inpatient postoperatively, two patients developed urinary retention. Daycare ACLR was also cost-effective, as shown by cost analysis a reduction of cost by 26.9 %.

Conclusion

Daycare ACLR is safe, feasible, and cost-effective treatment modality for young patients and can provide a substantial cost saving.

Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament

Background

Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans.

Purpose

To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks.

Study Design

Cohort study; Level of evidence, 2.

Methods

All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test.

Results

Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block.

Conclusion

The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.

No correlation between performance tests, clinical measurements and data from patient-reported outcome measures (PROM) in children reconstructed for anterior cruciate ligament injury

PURPOSE

To investigate if patient-reported outcome measures (PROMs), functional tests and clinical measures correlate well in children after reconstruction of the anterior cruciate ligament (ACL). It was hypothesized that these outcomes correlate, so it is sufficient to report only one of them.

METHODS

A consecutive group of children (< 16 years old) who had an ACL reconstruction, were prospectively followed and assessed after 1-year with Pedi-IKDC and KOOS-Child, instrumented laxity measurement, range of motion, extension strength and four performance tests. Relations between the different outcomes were calculated by partial correlation coefficient analysis, controlling for gender, age, height, and weight.

RESULTS

Outcomes were available for 141 of 163 children. There were only few positive and weak correlations between performance tests and PROM scores and between clinical measurements and PROM scores. There were weak to strong correlations between the scores from Pedi-IKDC and the scores from each of the five domains of KOOS-Child and a weak to moderate correlation between the different domains of KOOS-Child. Similar correlations were found between the different performance tests.

CONCLUSION

For children who had their ACL reconstructed there was no clinically important correlation between scores obtained by PROMs, a battery of functional performance tests and instrumented laxity of the knee at 1-year follow-up. This is an argument for always to include and report all three types of outcomes.

LEVEL OF EVIDENCE

Level II.

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m² underweight, ≥20 to <25 kg/m² normal weight, ≥25 to <30 kg/m² overweight, ≥30 to <40 kg/m² obese, ≥40 kg/m²to <50 kg/m² severely obese, and ≥50 kg/m² extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.

Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases

BACKGROUND

The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications.

METHODS

A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan.

RESULTS

Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization.

CONCLUSIONS

Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting.

LEVEL OF EVIDENCE

Level IV-case series.

Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis

PURPOSE

To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications.

METHODS

An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications.

RESULTS

After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR.

CONCLUSIONS

Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Are PROMs used adequately in sports research? An analysis of 54 randomized controlled trials with PROMs as endpoint

Deviations from adequate use and reporting of PROMs may be problematic and misleading. The aim of this study was to investigate the extent of such problems in randomized clinical trials (RCTs). RCTs involving sports medicine research that used PROMs as primary outcomes were identified in 13 preselected journals. The articles were reviewed for nine potential problems related to how the PROM was used and how the data had been reported. The potential problems were as follows: aggregating subscale scores; combining patient-reported scores with physical, clinical, or para-clinical measures; using a PROM to diagnose or evaluate the individual patient; using a PROM for one leg or arm; selectively excluding domains or items; constructing a PROM for the specific occasion; mixing PROM formats (ie, digital, paper, telephone, e-mail, in person); ambiguous instructions for how the PROM should be completed; and recall bias. As covariates, we registered journal impact factor, year of publication, and existence of a registered protocol. In 29 (53.7%) of 54 identified RCTs, at least one potential problem was identified, the most common being aggregation of domain scores. This was not different with a published protocol or dependent on journal rankings, except for exclusion of domains, which was most common in high-ranking journals. Aggregation of domain scores was significantly less common in recently published articles compared with older articles (P = .03). Potential problematic use of PROMs and reporting of PROM data are common in RCTs, also in high-ranking journals, but less so in more recent articles.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications

PURPOSE

To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction.

METHODS

The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05.

RESULTS

From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001).

CONCLUSIONS

Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk.

LEVEL OF EVIDENCE

III.

Home-based intravenous analgesia with elastomeric pump as an outpatient procedure for pain control after anterior cruciate ligament repair

OBJECTIVE

To follow up pain in the immediate postoperative period, using an elastomeric pump in anterior cruciate ligament surgery.

MATERIAL AND METHODS

309 patients who had undergone anterior cruciate ligament repair with bone-tendon-bone allograft. Pain control was assessed with a visual analogue scale (VAS) during the immediate postoperative period, in the postoperative care unit, in the recovery room, and after the first 24-48-72hours following home discharge. The need for rescue medication, adverse effects observed and emergency visits were also registered.

RESULTS

309 patients were assessed (264 males, 45 females), mean age 33 (range: 18 - 55). Postoperative pain was mild in 44.7% of patients, and 38.5% were pain-free. At discharge, 41.1% of patients reported mild pain and 57% were pain-free. At home, mild to moderate levels of pain were maintained and over 97% of patients presented VAS values ≤ 3. Fewer than 3% had adverse effects, 8.7% had to use analgesic medication at some point. Pruritus occurred in less than 1% of patients receiving intravenous analgesia at home, and fewer than 2% had device-related complications.

DISCUSSION

There is no consensus regarding the postoperative management of anterior cruciate ligament lesions, although most surgeons use multimode anaesthesia and different combinations of analgesics to reduce postoperative pain.

CONCLUSIONS

The use of an intravenous elastomeric pump as postoperative analgesia for anterior cruciate ligamentoplasty has yielded good results.

Economic Burden of Inpatient Admission of Ankle Fractures

BACKGROUND

Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures.

METHODS

A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation.

RESULTS

Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures.

CONCLUSION

In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually.

LEVEL OF EVIDENCE

Level III, comparative series.

Outpatient versus inpatient anterior cruciate ligament reconstruction: A systematic review with meta-analysis

BACKGROUND

Efforts to reduce the financial costs related to anterior cruciate ligament reconstruction (ACLR) include reducing the length of hospitalization of the patient undergoing ACLR. However, it is unclear if inpatient and outpatient ACLR differ in terms of safety, satisfaction, costs and clinical outcomes.

AIM

To systematically review and synthesize the literature that directly compared costs and outcomes after outpatient and inpatient ACLR.

METHODS

Studies that directly compared outcomes of inpatient and outpatient ACLR were retrieved via searches in MEDLINE, EMBASE, CINAHL, AMED, Cochrane, SPORTDiscus, Web of Science and SCOPUS databases. Random effects meta-analysis and descriptive analysis were performed for relevant outcomes.

RESULTS

Costs analysis suggests that outpatient ACLR may be a cost effective procedure with savings ranging from $1371 to $7390. There were no differences for systemic and local complications p=0.64 (odds ratio 1.65, 95% confidence interval 0.20 to 13.49) and p=0.72 (0.81, 0.26 to 2.56) respectively, or pain in the second and seventh days after surgery, p=0.78 (mean difference -0.16; 95% confidence interval -1.28 to 0.96) and p=0.44 (0.48, -0.75 to 1.71), respectively. However, the outpatient group had less pain than the inpatient group in the first and third days after surgery, p=0.0001 (-0.39, -0.57 to -0.21) and p=0.0001(-0.39, -0.39 to -0.20), respectively. Descriptive analysis revealed that the outpatient group experienced similar or better satisfaction, strength and knee function compared to the inpatient group.

CONCLUSION AND KEY FINDINGS

Complications, pain, satisfaction, knee function and strength are similar or better after outpatient compared to inpatient ACLR. Furthermore, cost savings may be achieved with outpatient ACLR. However, included studies presented low methodological quality and the quality of evidence was very low, so these results need to be confirmed by future studies.

REGISTRATION NUMBER

PROSPERO (CRD42015024990).

French prospective multicenter comparative assessment of ambulatory surgery feasibility in anterior cruciate ligament reconstruction

INTRODUCTION

The main objective of this multicenter study was to assess the feasibility of ambulatory surgery in France in anterior cruciate ligament (ACL) reconstructions for any technique or graft used (hamstring, patellar tendon, fascia lata). We hypothesized that a dedicated organization would guarantee the patient's safety.

PATIENTS AND METHODS

A multicenter, non-randomized, prospective, comparative study, conducted within the SFA symposium was conducted between January 2014 and March 2015, included all the patients operated on for arthroscopic ACL reconstruction using different surgical techniques. The outpatient group (OP) included patients eligible for day surgery who provided informed consent; the conventional hospitalization group (CH) comprised patients declined for outpatient surgery for organizational reasons. The main outcome was failure of the admission mode defined by hospitalization of a patient undergoing outpatient surgery or rehospitalization within the 1st week after discharge. The secondary outcomes were assessment of pain and postoperative complications. A total of 1076 patients were studied with 680 in the OP group and 396 in the CH group. The mean age was 30years±9years. In the CH group, the mean hospital stay was 2.7±0.8days.

RESULTS

Twenty-three OP patients were hospitalized or rehospitalized (3.4%). Thirty-six (5.2%) early postoperative complications were noted in the OP group and 17 (4.3%) in the CH group (non-significant difference). Mean postoperative pain on D0-D4 and satisfaction were comparable between the two groups.

CONCLUSION

This prospective multicenter study observed no serious incidents. In a selected population, the risks are comparable to those of conventional hospitalization. Outpatient ACL surgery is therefore feasible in France in 2016.

LEVEL OF PROOF

III: case-control study.

Pain after out-patient vs. in-patient ACL reconstruction: French prospective study of 1076 patients

BACKGROUND

Anterior cruciate ligament (ACL) repair is increasingly performed on an out-patient basis. In France, however, concern about post-operative pain remains a strong barrier to out-patient ACL repair. The primary objective of this study was to compare post-operative pain after ACL repair as out-patient versus in-patient surgery. The secondary objectives were to assess the time-course of post-operative pain and to identify factors associated with pain intensity.

MATERIAL AND METHODS

A multicentre, prospective, comparative, non-randomised study was conducted in France for the French Society for Arthroscopy (SFA) symposium. Patients who underwent primary ACL repair between January 2014 and March 2015 were included if they were eligible for out-patient surgery. The choice between out-patient and in-patient surgery was based on organisational and logistical considerations. Pain intensity was self-evaluated by the patients using a visual analogue scale (VAS), pre-operatively then in the evening after surgery, during the night after surgery, and 1, 3, and 5 days after surgery. The patients performed the evaluations at home using websurvey.fr^® software. Demographic data, the characteristics of the surgical procedure, and the IKDC and Lysholm scores before and after surgery were collected.

RESULTS

Of the 1076 patients included in the study, 680 had out-patient surgery and 396 in-patient surgery. Mean age was 30±9 years. The two groups were comparable at baseline. Pain intensity was not significantly different between the two groups at any of the measurement time points. Pain intensity showed a peak on post-operative day 1 that was similar in the two groups. The initial post-operative pain intensity score predicted subsequent pain intensity: patients with VAS scores <2 on the day of surgery also had low pain scores after surgery. In both groups, factors associated with greater pain intensity were age <25 years, high pre-operative pain score, and surgery performed after noon. Neither surgical technique nor concomitant lesions and methods used to treat them were associated with pain intensity. Risk factors for severe post-operative pain (VAS score >7) in the out-patient group were younger age, female gender, pre-operative VAS score >3, and tourniquet time >50minutes.

CONCLUSION

Pain intensity is similar after out-patient and in-patient ACL repair. Concern about pain should not be a barrier to performing ACL repair on an out-patient basis. Our data on the time-course of the pain and factors associated with greater pain intensity should prove useful for improving patient management after ACL repair.

LEVEL OF EVIDENCE

Level III, case-control study.

EPIDEMIOLOGY OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN BRAZIL'S PUBLIC HEALTH SYSTEM

ABSTRACT Introduction: Several studies have reported on the epidemiology of Anterior Cruciate Ligament Reconstruction (ACLR) in Europe and North America; however, there is currently no data relating to Brazil. Objective: To describe the incidence of ACLR in Brazil and investigate temporal trends and differences between age and sex groups. Methods: All reported ACLR cases in the public hospital system between January 2008 and December 2014 were extracted from the Information Technology Department of the Brazilian Ministry of Health. Linear regression analysis was used to assess changes in ACLR incidence in the overall population and among sex and age groups, hospitalization time, and health care costs. Results: A total of 48,241 ACLR were reported from 2008-2014 with an overall incidence of 3.49 per 100,000 persons/year. Males accounted for 82% of the procedures. The incidence of ACLR increased by 56% among males (p=0.01) and by 112% among females (p=0.001). The mean hospitalization time decreased from 2.4 days in 2008 to 1.8 day in 2014 (R2 = 0.883, p= 0.002). The total cost across all years was US$56 million, with a mean of US$1,145 per ACLR. Conclusion: Although the total incidence of ACLR in Brazil is lower compared to other countries, it has increased over the years, especially in females. The creation of an ACLR registry is necessary in the future, for more accurate control and new investigations.

Arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft without wound drainage: short- to middle-term outcome

Introduction

Several studies have suggested that anterior cruciate ligament reconstruction (ACLR) without wound drainage has no impact on long-term follow-up.

Aim

To investigate a prospective patient series as measured by the patient-administered disease-specific questionnaire Knee injury and Osteoarthritis Outcome Score (KOOS).

Material and methods

The study included 101 consecutive patients (71 men and 30 women) with a mean age of 30 years (SD 10, range: 15–62 years), who had undergone primary single incision arthroscopic bone-patellar tendon-bone autograft (BPTB) ACLR without wound drainage. All patients completed KOOS questionnaires, preoperatively and at a mean follow-up of 1.4 years (range: 0.4–3.4). Satisfactory clinical outcome (function recovery – FR) was defined as the lower threshold for the 95% CI of 18–34-year old males and corresponded to a KOOS score > 90 for Pain, 84 for Symptoms, 91 for Activities of Daily Living (ADL), 80 for Sports/Recreation, and 81 for Quality of Life (QOL). A non-satisfactory result was defined as treatment failure (TF) and corresponded to a QOL score < 44.

Results

All patients achieved 90° of knee flexion on the first postoperative day and full extension 2 weeks postoperatively. A full range of motion was achieved in less than 6 weeks postoperatively. No postoperative complications were reported. Score improvement at follow-up was observed in the KOOS subscales Pain, Symptoms and ADL. Criteria for FR were fulfilled by 52% of patients for Pain, 47% for Symptoms, 62% for ADL, 34% for Sports/Recreation and 15% for QOL, whereas criteria for TF were fulfilled by 29% of patients.

Conclusions

The study demonstrated that the primary ACLRs without wound drainage did not have any negative impact for patient-reported recovery.

Do outcomes of outpatient ACL reconstruction vary with graft type?

BACKGROUND

Studies establishing the feasibility of anterior cruciate ligament (ACL) reconstruction as an outpatient procedure in France were usually conducted with hamstring tendon grafts. The objective of this study was to evaluate the outcomes of outpatient ACL reconstruction according to whether the graft was harvested from the hamstring tendons or patellar tendon.

HYPOTHESIS

Outpatient ACL reconstruction can be performed using any type of graft.

METHODS

A single-centre retrospective study was conducted in consecutive patients older than 16 years who had primary ACL reconstruction using patellar tendon or hamstring tendons, with or without lateral tenodesis. Patients who underwent other procedures on bones or peripheral ligaments and those with a previous history of ACL reconstruction were excluded. The primary evaluation criterion was the occurrence of complications within 45 days after surgery. Secondary evaluation criteria were the visual analogue scale (VAS) for pain during the first 3 postoperative days, patient satisfaction on day 3, and the IKDC and Lysholm clinical scores on day 45.

RESULTS

The analysis included 104 knees (one knee per patient). Hamstring tendons were used in 77 (74%) knees and patellar tendon in 27 (26%) knees. In the hamstring group, 2 (2.6%) patients spent the first postoperative night in the hospital and 2 others were re-admitted. No hospitalisations were recorded in the patellar-tendon group. None of the patients required revision surgery within 45 days of the reconstruction procedure. None of the postoperative criteria studied showed statistically significant differences between the two groups.

DISCUSSION

ACL reconstruction can be performed on an outpatient basis using any type of graft. The main determinants of successful outpatient ACL reconstruction are a standardised clinical management strategy and an appropriate anaesthesia protocol.

LEVEL OF EVIDENCE

Level IV, retrospective study.