Inpatient Cruciate Ligament Reconstruction in the United States: A Nationwide Database Study From 1998 to 2010

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.

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction

PURPOSE

The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications.

METHODS

Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay.

RESULTS

In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%).

CONCLUSIONS

In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling.

LEVEL OF EVIDENCE

III.

Analysis of 500 anterior cruciate ligament reconstructions from a private institutional register

Purpose

The aims of this study are to describe the epidemiological characteristics of anterior cruciate ligament reconstructions in a private hospital in Brazil and to determine trends in medical practice for comparison with previous studies.

Methods

We retrospectively reviewed the anterior cruciate ligament institutional register to obtain data from all patients who underwent primary anterior cruciate ligament reconstruction from July 2014 to June 2016. Descriptive statistics were used to summarize the sample. Specific statistical tests were used to assess associations between the meniscal lesion and other variables.

Results

During the study period, 72.6% out of 500 patients were male. The mean age at surgery was 35.1 years. The mean age was higher among females than among males (37.3 ± 12.1 vs 34.3 ± 10.8 years). The median time from injury to surgery was 44 days. The most common femoral and tibial fixations used were suspensory fixation (60.8%) and interference screw (96%), respectively. The most commonly used graft was hamstring tendon (70.2%), followed by bone-patellar tendon-bone (28.8%). A meniscal lesion was noted in 44.8% of cases. Partial meniscectomy was performed in 69.5% of meniscal lesions, and meniscal repair was performed in 14.1% of lesions. The mean length of hospital stay was 1.4 days. The proportion of men in the group of patients with an associated meniscal lesion was higher than that in the group of patients without a meniscal lesion (p = 0.007).

Conclusions

In this study, we identified that the vast majority of surgeries were performed in male patients in all age groups, and patients older than 30 years and with a short time from injury to surgery predominated. Concerning surgical technique, we noted a low rate of meniscal repair and a higher preference for the use of hamstring graft and suspensory fixation on the femoral side.

Real-time optimized biofeedback utilizing sport techniques (ROBUST): a study protocol for a randomized controlled trial

Background

Anterior cruciate ligament (ACL) injuries in female athletes lead to a variety of short- and long-term physical, financial, and psychosocial ramifications. While dedicated injury prevention training programs have shown promise, ACL injury rates remain high as implementation has not become widespread. Conventional prevention programs use a combination of resistance, plyometric, balance and agility training to improve high-risk biomechanics and reduce the risk of injury. While many of these programs focus on reducing knee abduction load and posture during dynamic activity, targeting hip extensor strength and utilization may be more efficacious, as it is theorized to be an underlying mechanism of injury in adolescent female athletes. Biofeedback training may complement traditional preventive training, but has not been widely studied in connection with ACL injuries. We hypothesize that biofeedback may be needed to maximize the effectiveness of neuromuscular prophylactic interventions, and that hip-focused biofeedback will improve lower extremity biomechanics to a larger extent than knee-focused biofeedback during dynamic sport-specific tasks and long-term movement strategies.

Methods

This is an assessor-blind, randomized control trial of 150 adolescent competitive female (9–19 years) soccer players. Each participant receives 3x/week neuromuscular preventive training and 1x/week biofeedback, the mode depending on their randomization to one of 3 biofeedback groups (hip-focused, knee-focused, sham). The primary aim is to assess the impact of biofeedback training on knee abduction moments (the primary biomechanical predictor of future ACL injury) during double-leg landings, single-leg landings, and unplanned cutting. Testing will occur immediately before the training intervention, immediately after the training intervention, and 6 months after the training intervention to assess the long-term retention of modified biomechanics. Secondary aims will assess performance changes, including hip and core strength, power, and agility, and the extent to which maturation effects biofeedback efficacy.

Discussion

The results of the Real-time Optimized Biofeedback Utilizing Sport Techniques (ROBUST) trial will help complement current preventive training and may lead to clinician-friendly methods of biofeedback to incorporate into widespread training practices.

Trial registration

Date of publication in ClinicalTrials.gov: 20/04/2016. ClinicalTrials.gov Identifier: NCT02754700.