Results :  

The response rate of the survey was 57.14 %( 24/42). The responses were received in the form of completed questionnaire either through e-mail or by post. The results revealed that with respect to routine delay time before performing ACL reconstruction, 12.5% surgeons wait for <three weeks, 50% wait for three-six weeks while 37.5% delay the surgery for more then six weeks after ACL treatment. The single-incision arthroscopic technique is the preferred approach of the 62.5% surgeons, while 29.2% use the two-incision arthroscopic approach and only 8.3% still performed the ACL reconstruction through open repair. Majority of the surgeons (95.8%) perform the reconstruction surgery as an inpatient procedure.

              The autologous grafts are preferred over the allograft and synthetic grafts by the Indian surgeons for performing ACL reconstruction. The hamstring tendon graft (ST/GT) is used more preferentially by 40.7% surgeons, the bone-patellar tendon-bone (BPTB) graft is used by 35.6 % and quadriceps tendon is opted by 15.3% while Iliotibial band graft is used by only 3.4% of the surgeons for the reconstruction surgeries (fig.1).

Fig.1: Relative percentage of use of various graft types.

With respect to the frequency of selection of each graft during surgery, some of the surgeons always use one type of graft while others have multiple choices depending upon the requirements of the patients. In the surgeons preferring BPTB graft, 27.12% of them use it in 1-50% of their cases, 3.39% in 51-90% of their cases of reconstruction and 5.08% use this graft in majority (91-100%) of their patient. Similarly for hamstring tendon graft, 10.17% surgeons use it” exclusively” for reconstructing the ACL ligament. While15.25% prefer this graft predominantly i.e. in > 90-<100% cases, remaining 8.47% use it occasionally in 1-50% patients and 6.78% surgeons   prefer it commonly ( in 51-90% cases). For the preference of use of quadriceps tendon graft , 13.56% consider to use it occasionally in 1-50% subjects and only 1.69% surgeons opt for it in 91-<100% cases (Fig. 2).

Fig. 2: Preference for selection of each graft type for performing ACL reconstruction.

There are two main fixation methods used for stabilizing the graft in Indian sub continent, namely the bio absorbable screws (50%) and the interference (25.50%).  The remaining portion of the surgeons’ use Endobuttons (10.73%), suture posts (8.05%), staples (2.01) and 12.75% prefer some methods other than the above mentioned. Table 1.1 shows the fixation methods for other grafts with relative frequency of use of each method.

Table 1 shows the relative frequency of use of various methods of fixation for each graft type.

MS-Metal Screws       BAS-Bioabsorbable Screws   EB-Endo Buttons         SP-Suture Post

In the post-operative phase, 70.8% surgeons immobilizes the operated knee for a duration of one-three weeks, 20.8% do so for three-five weeks and the remaining 8.4% surgeons immobilize the  surgically operated knee for a period of more than five weeks. With respect to timing to allow full weight –bearing after the surgery, 33.3% surgeons initiate the full weight-bearing immediately after surgery, 12.5% prefer it by one week, 29.2% allow their patient to weight-bear on the operated knee by one-three weeks and the remaining 25% wait for a duration of three-six weeks before initiating complete weight-bearing over the knee. The typical length of  post-op physical therapy recommended by 37.5% surgeons is > 6 months, 25% do so for 1-2 months, 3-4 months is the duration considered by 20.8% and the remaining percentage prefer the therapy for 4-6 months duration. The functional status of the patient is considered to be the most important to allow return to complete activity by 70.8% surgeons and the remaining 16.7% consider strength and 12.5% consider time to be the criterion to be considered to allow return to activity. The other interesting finding is that 62.5% of our surgeons’ donot recommend the use of braces for return to complete activity while only 16.7% use braces and the remaining 20.8% prefer the braces occasionally.

The preferred  technique for reconstructing the ACL in skeletally –immature subjects on tibial side is transphyseal tunnel by 66.7% , all epiphysis by 22.2% and the 11.1% surgeons use no tunnel for tibial side. On the femoral side endoscopic transphyseal is the preferred approach of 61.1%, two-incision transphyseal of 5.6% and over the top procedure is used by 33.3% of the Indian orthopaedic surgeons. The main choice of graft for skeletally immature subjects is hamstring tendon graft which is used by 94.4% surgeons and the remaining 5.6% use the BPTB graft.

Case scenarios In this study the surgeons were presented with four different case scenarios and they were asked about their choice of treatment in those conditions. For 8-year old with complete ACL tear 50% surgeons prefer the non-operative ,physical therapy approach, 12.5% consider ACL reconstruction and the remaining 37.5% recommend to delay surgery till the child is skeletally mature. In a 35yrs old person with a painful, 50% partial thickness ACL tear with no demonstrable weakness 58.3% of our surgeons prefer no surgical treatment and only physical therapy, 33.4% recommend surgery with ACL reconstruction while the remaining 8.3% opt for surgical treatment without ACL reconstruction. Similarly for a 45 yrs old person with complete ACL (3 months ago) and dominant leg quadriceps strength 4/5, 58.3% surgeons recommend surgical treatment with ACL reconstruction and 41.7% prefer physical therapy with no surgical intervention. In a traumatic event involving 65 yrs old female suffering from knee pain and MRI revealing complete ACL tear with irreparable meniscal tear half (50%) surgeons prefer surgery without ACL reconstruction and 12.5% opt for ACL  reconstruction while the remaining 37.5% recommend physical therapy management without surgical approach.

Discussion :

This survey shows the variety of approaches in the treatment of ACL injuries among the orthopaedic surgeons of India. Approximately 87.5% of our surgeons prefer to delay the surgery for 3- 6 weeks after the acute injury that would be in light with present published evidence which suggests that the patients are more likely to get arthrofibrosis if operated on in the first one to two weeks after injury^1-2 These results are comparable with the previous studies on orthopaedic surgeons of United States of America who also preferred to wait for three-six weeks following an anterior cruciate ligament injury before performing the reconstruction surgery³. Similarly, more than half (50%) of the orthopaedic surgeons of United Kingdom delayed the surgery for three-four weeks following the ACL injury⁴.

Most of the surgeons prefer to use either two- incision arthroscopic (29.2%) or the single-incision arthroscopic technique (62.5%) to perform the surgery due to the advantages associated with them in form of cosmetic appearances, parallelism of tunnels and decreased divergence effect if interference screw is used along with less chances of arthrofibrosis when compared to traditional open repair techniques⁵.

Out of the choices available, the orthopaedic surgeons of India rely upon the use of autologous grafts for the ACL reconstruction over the allografts or the synthetic grafts. Among the autologous grafts, over all 40.7% surgeons prefer the hamstring tendon and 35.6% prefer the BPTB graft, quadriceps tendon graft is used by 15.3% of these surgeons and ITB graft is considered by only 3.4%. These results regarding the frequency of graft use may represent the trend in the debate over the benefits and drawbacks of using the BPTB or hamstring tendon for reconstructing the ACL. There is currently no conclusive evidence to suggest that one graft choice is better than the other with few studies supporting the BPTB graft while other researches showing that neither graft is better than the other . Both BPTB and hamstring tendon autografts are equally effectively in reconstructing the ACL with both of them having comparable post operative outcomes with subtle differences⁶. These results when compared  with the  previous surveys showed that 58% surgeons used BPTB autografts and 33% used ST/GT autografts in United Kingdom⁴.While most of the surgeons of American Orthopaedic Society for Sports Medicine used BPTB graft for reconstructing the ACL³. Among the Canadian surgeons 59% would use BPTB autograft and 32% would prefer the ST/GT autograft  ⁷ while 61% of the Australian orthopaedic surgeons regularly preformed both ST/GT and patellar tendon ACL reconstruction⁸.

When considering the type of fixation methods, the main methods used for the BPTB graft on the tibial side {IF screws (9.40%); BA screws (6.71%)} and femoral side {IF screws (10.06%) and BA screws (8.05%)} are the metal screws. This result  is also supported by numerous researches that stated that the interference screws is the most popular fixation methods for bone block fixation as it provides superior fixation strength and stiffness as compared to alternative fixation methods⁹. For the fixation of hamstring tendon graft on femur, the results are controversial. The soft tissue grafts like hamstring tendon, quadriceps, ITB etc.,  unlike the bone patellar tendon graft, do not have a rigid bone block at their end and have a greater chances of failure of fixation if appropriate method is not used. But there is still no conclusive evidence in this area.

In the post-operative phase , majority (70.8%)of the surgeons prefer immobilization of the operated knee for        one-three weeks and three-quarter (75%) of the surgeons initiate early full weight-bearing by one-three weeks, 33.3% among them prefer immediate full weight- bearing and only 25% surgeons wait for a period of three-six weeks to allow complete weight –bearing. it has been that have demonstrated that early joint motion and weight bearing is beneficial as it helps to a reduction in pain, lessens adverse changes in articular cartilage and helps prevent the formation of scar and capsular contractures that have the potential to limit joint motion¹⁰. Moreover, it has been proved that immediate or early weight bearing showed no difference in the AP knee laxity and patient activity level (Tegner and IKDC scores) when compared to delayed weight bearing¹¹.

With the trend of increasing participation in competitive athletics in younger population, the ACL injuries are becoming more common in them and the treatment of this injury in paediatric population presents with the unique challenge because of the substantial growth that occurs through distal femoral and proximal tibial physes. The   transphyseal tunnel technique [66.7%on tibial and 61% on femoral side] is the preferred approach of Indian surgeons for reconstruction of ACL in skeletally –immature subjects. The previous studies have reported that ACL reconstruction with a medial hamstring autograft via a transphyseal technique yields satisfactory clinical results with no new meniscal tears identified after the surgery¹² or using soft tissue graft through transphyseal tunnel and over the top position on femur are preferable¹³. These techniques have not shown to cause early closure of physes, limb-length discrepancy or angular deformity¹⁴. 

This study has some limitations. Only the members of IASM and IAS were sent this survey as due to their affiliation to these societies, they have manifested interest in treating such injuries. But it is not known whether this population provides the true representation of current practices in managing ACL injuries in India. Moreover, the response rate was 57.14% which is comparable to many other previous surveys performed in other nations. The results of this survey when compared to other studies show some variations in certain aspects as previously mentioned in the text. 

Reference :
 

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