The Swedish National Anterior Cruciate Ligament Register: A report of baseline variables and outcomes of surgery for almost 18,000 patients.
Ahlden M, Samuelsson K, Sernert N, Forssblad M, Karlson J, and Kartus J. Am J Sports Med. 2012. [Epub ahead of print]
National registers for recording medical data are becoming increasingly prevalent. The purpose of these registers is to compile information on a large number of patients to detect flaws in surgical procedure, implants, grafts, etc. One such register is the Swedish National ACLRegister, which was begun in 2005. The Swedish National ACL Register contains information on primary reconstructions, revision ACL surgery, and knee reoperations for other reasons. Using this data, Alden and colleagues set out to report baseline variables and patient-based outcomes from 2005 through December 2010. The register is web based and has both a patient (KOOS pre-reconstruction, 1, 2 and 5 years post-surgery) and a surgeon answered section (activity at injury, time from injury to reconstruction, graft selection, and fixation technique). Also reported in the registry is any surgical procedures performed on the injured knee, meniscal surgery, and chondral lesions. Revision or reoperation procedures performed are reported in the Swedish National ACL Register and are correlated back to the primary ACL reconstruction procedure. Data for 16,351 ACL reconstruction patients were available. Of those 16,351, KOOS evaluations were available for 10,473 (64%) preoperatively, 7493 (58%) at 1 year, 5580 (49%) at 2 years, and 1452 (40%) at 5 years. All KOOS scores were significantly higher at 1, 2, and 5 years after ACL reconstruction. Patients who had 1 or more concomitant intra-articular injuries had a significantly higher risk of needing ACL revision surgery. Furthermore, patients who underwent primary ACL reconstruction scored higher than those who underwent ACL revision surgery. Preoperatively, patients who would receive a double-bundle reconstruction had significantly better KOOS scores than those receiving a single-bundle reconstruction. However, at 1 and 2 year follow up this difference was no longer observable.
Overall this study presents an interesting look at some factors which are associated with poor outcomes following ACL reconstruction. While this information can certainly aid a clinician in advising their patients in an attempt to avoid unwanted outcomes, it does have the limitation that the Swedish National ACL Register cannot be used to evaluate best surgical practices as the standard of care changes more rapidly than it takes to complete long-term studies which evaluate their efficacy. Perhaps the focus then should be on the rehabilitation pre and post surgery. If through registries such as the Swedish National ACL Register, we can identify predictors of successful primary ACL surgery (strength levels, ROM, edema levels), the rehabilitation could be modified to meet those goals. This way patients would have to meet certain baseline levels prior to undergoing surgery, which may then lead to better long-term outcomes and less revision surgeries. The current study does demonstrate that overall, the standard of care for ACL ruptures between 2005 and the present does result in some acceptable level of function for the patient, although without a preinjury KOOS score, which is not included in this registry, the true level of function to which the patient returns cannot be determined. Tell us what you think. Do you think that a registry such as this could aid you in making recommendations for your patients? Are there other ways that you can see using this information to influence your clinical practice?
Written by: Kyle Harris
Reviewed by: Stephen Thomas
Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction