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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 4  |  Page : 127-131

Functional outcome of anterior cruciate ligament reconstruction in Saudi patients at Western Region


1 Department of Orthopedic, King Fahad Armed Forces Hospital, Jeddah, KSA
2 Faculty of Medicine, College of Medicine and Surgery, King Abdulaziz University, Jeddah, KSA

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Abdullah H AlZahrani
College of Medicine, King Abdulaziz University, Jeddah
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_17_18

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  Abstract 

Introduction: Anterior cruciate ligament (ACL) is an integral stabilizing structure of the knee. Rupture of the ACL impairs the stability of the knee leading to difficulty with athletic performance and increasing the risk of subsequent meniscal injury. It accounts for 50% of all knee ligaments injuries. ACL reconstruction (ACLR) is the gold-standard treatment to restore the stability of the knee and improve the function. We aimed to assess the functional outcomes of the ACLR in Western area of Saudi Arabia.
Materials and Methods: One hundred and four patients who had ACLR between 2014 and 2016 in King Fahad Armed Forces Hospital, Jeddah, had participated in this study by filling a self-administer questionnaire. Oxford Knee Score consisting of 12 questions is a valid and sensitive tool to assess the function and pain after ACLR.
Results: One hundred and three male (99%) and one female (1%) were included in the study with a mean age of 34.92 (standard deviation [SD] of 8.3) years and mean body mass index of 27.69 (SD of 4.74) kg/m2. Sixty-five of them had results suggestive of satisfactory joint function (61.9%), 32 had results suggestive of mild-to-moderate knee pain (30.5%), 6 of had moderate-to-severe knee pain (5.7%), and only one had a result of severe knee pain. The most common difficulties claimed by the participants, rated 1 or 2 in the score are: persistent pain (16 out of 104, 15.4%), pain with kneeling (14 out of 104, 13.5%), usual daily chores (10 out of 104, 9.6%), and knee pain at night (9 out of 104, 8.6%).
Conclusion: Majority of the participants were satisfied with the ACLR representing more than 60% of patients. On the other hand, out of 104 participants, only one had the worst outcome representing < 1% of the sample size.

Keywords: Anterior cruciate ligament, athletes injuries, knee injuries, knee surgery


How to cite this article:
AlShareef HA, AlZahrani AH, Sabar S, Alharbi AA, Halawani HA, Althinayyan BA, Alsheikh BK, Aldaheri A. Functional outcome of anterior cruciate ligament reconstruction in Saudi patients at Western Region. Saudi Surg J 2018;6:127-31

How to cite this URL:
AlShareef HA, AlZahrani AH, Sabar S, Alharbi AA, Halawani HA, Althinayyan BA, Alsheikh BK, Aldaheri A. Functional outcome of anterior cruciate ligament reconstruction in Saudi patients at Western Region. Saudi Surg J [serial online] 2018 [cited 2019 Jun 25];6:127-31. Available from: http://www.saudisurgj.org/text.asp?2018/6/4/127/247412


  Introduction Top


The anterior cruciate ligament (ACL) is an integral stabilizing structure in the knee, preventing anterior translocation and rotation of the tibia in relation to the femur. Rupture of the ACL is established as one of the most common sports injuries in active young people[1],[2] accounting for about 50% of all knee ligament injuries.[3] With an estimate of 250,000 new ACL injuries and more than 100,000 ACL reconstruction (ACLR) procedures in the US Annually.[1],[2] Rupture of the ACL impairs its stability, leading to difficulties in athletic performance, also increasing the risk of subsequent meniscal injury, as well as increasing the risk of early degenerative disorders.[1],[2]

ACL injury is one of the most frequent injuries faces orthopedic surgeons today.[4],[5] ACLR is considered the gold-standard treatment for active young patients to restore knee stability and integrity, Besides; it improves the functional outcomes.[6],[7] The incidence of the ACLR is rising. In the United States, the incidence of ACLR raised from 86,687 in 1994 to 129,836 in 2006.[8],[9] In Europe, this procedure is also rising in France, where 29,400 ACLR was performed in 2006 and more than 41,937 in 2013.[10],[11],[12]

A study was conducted in Colorado, USA, aiming to assess the satisfaction of patients who underwent ACL repair surgeries. The study concluded that univariate and multivariate determinants of patient satisfaction with the outcome after reconstruction of the ACL were established. Although some specific surgical and objective variables were important, subjective variables of symptoms and function had the most robust associations with patient satisfaction. In assessing the outcome of reconstruction from the perspective of patient's satisfaction with the outcome, researchers concluded that we should emphasize patient-derived subjective assessment of symptoms and function, particularly those involving issues of stiffness, giving way, swelling, and patellofemoral symptoms.[13]

Finally, functional outcome of ACLR between patients is not equal, as about 60% of the patients do not come back to preinjury state.[14],[15] Thus, we will assess the functional outcomes of the ACL operation in Saudi Arabia, since our data are limited about ACLR outcome.


  Materials and Methods Top


Study settings

The study is conducted at King Fahad Armed Forces Hospital (KFAFH) Jeddah, which is one of the largest cities in the Western Region of Saudi Arabia.

It is a retrospective cohort on patients who had ACLR between 2014 and 2016 and assessed outcome of ACLR at KFAFH.

Data collection

All patients who underwent ACLR at KFAFH after at least 1 year after the procedure (between 2014 and 2016) with a total sample size of 104.

Data collection was performed by filling a self-administer questionnaire, which was divided into two parts; the first part is the demographic data (as gender and age,) while the second part was Oxford Knee Score (OKS) which is a valid measurement consists of 12 questions. Each question scored from 0 (normal) to 4 (difficult) with a total of 48 scores. Where a score of 48 represents the worst outcome and a score of 0 represents a better/normal outcome. OKS are valid measurement[16] as OKS is usually used for knee osteoarthritis we used the pain severity as a measure for the outcome instead of the degree of arthritis.

Data entry and analyzing

Data will be coded, checked, entered, and analyzed using SPSS version 23 (IBM, New York, United States).

Independent sample t-test was used to compare the mean score between the groups of the study, P < 0.05 will be considered statistically significant.

Confidentiality and ethical approval

We removed all the identifying variables of the participants. Using only anonymous data are to ensure privacy and confidentiality. Moreover, the data will be safely kept with only one of the principal investigators and no one is allowed to see it. The data will be disposed of after completing the study.

Approval was taken from KFAFH.


  Results Top


A total of 104 patients underwent ACLR between the years 2014 and 2016 were included in our analysis. One hundred and three were male (99%) and one female (1%), with a mean age of 34.92 (standard deviation [SD] of 8.3) years, mean weight of 82.09 (SD of 17.98) Kg, mean height of 169.91 (SD of 10.85) cm, and, a mean body mass index (BMI) of 27.69 (SD of 4.74) kg/m2. Thirty-four out of the 104 were smokers and 70 were not or ex-smokers (32.7% and 67.3%, respectively). Eighteen of them had chronic diseases (17.3%). Ten of them had developed a postoperative local inflammatory reaction (9.6%). And, 10 developed deep vein thrombosis (DVTs) after the procedure (9.6%) [Table 1].
Table 1: Demographic table

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Out of the 104 patients, 65 of them had a result that suggests satisfactory joint function (61.9%), 32 had results suggestive of mild-to-moderate knee pain (30.5%), 6 of had moderate to severe knee pain (5.7%), and only one of had a result that is indicative of severe knee pain [Table 2] and [Figure 1].
Table 2: Scores obtained for the patients on the knee questionnaire after at least 1 year post the procedure

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Figure 1: Histogram showing the number of participants within each category

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The most common difficulties claimed by the participants, with answers rated 3 or 4, were related to persistent pain (16 out of 104, 15.4%), pain with kneeling (14 out of 104, 13.5%), pain with usual daily chores (10 out of 104, 9.6%), and knee pain at night (9 out of 104, 8.6%) [Table 2].

On the other hand, with answers rated 1 or 2, participants had little to no difficulties related to shopping alone (102 out of 104, 98.1%), knee-buckling (95 out of 104, 91.3%), walking down the stairs (94 out of 104, 90.4%), body wash and drying (94 out of 104, 90.4%), limping (93 out of 104, 89.4%), and getting in and out of car (92 out of 104, 88.4%) [Table 2].

A significant relation between smoking and the outcome score was found by applying independent-sample t-test. As smokers and participants who never smoked (52 out of 104, 50%) had a mean score of 43.1 and 40.7, respectively (P = 0.038).

All the participants were cooperative and tolerant, also perceptive of the questions and the grading system.


  Discussion Top


After analyzing the data, almost all the participants were found to be male (103% and 99%) and only one female (1%), the reason for this was indeed due to the ACL injury being most common among athletes, the females in Saudi Arabia are in general less active in sports, moreover there is a lack of prepared facilities for female sports. Rendering them less exposed to physical activities, thus are less susceptible to ACL injuries.

The results proved that ACLR has an overall good prognosis, as more than the half of our sample (65% and 61.9%) had a postoperative score above 40, indicating the satisfactory outcome. which has been approved by another study published in “the Bone and Joint Journal” in 2006, where the authors measured the OKS in a single group of patients, preoperatively and postoperatively. The mean scores were 29 and 46, which indicates moderate-to-severe knee pain before the operation, and satisfactory outcome after it.[17]

Almost all the participants had little to no difficulties with walking down the stairs (94%, 90.4%), nor with shopping alone (95%, 91.3%) or knee buckling (95%, 91.3%), which are common fears for patients with an active style; therefore, our results should provide reassurance for patients undergoing ACLR.

We have also collected the data for the patients who developed postoperative inflammatory reaction; only 10 (10.4%) operations were complicated by inflammatory reaction in the form of local redness, swelling, or hotness. However, we found no significant result relating these postoperative inflammatory reactions to the outcome of the operation. The reason for this could be attributed to the small sample size of the study, or it could be due to postoperative inflammatory reaction having no effect on ACLR outcome. Which is contradicted by another study which has proved that patients who had postoperative local inflammatory reaction, especially infections had an inferior outcome compared to those with uncomplicated operations.[18]

The same goes for the patient who had postoperative complications such as DVT (10% and 10.4%) no significant difference in the mean scores was found between those who had DVT and those who had not. The reason for that could be attributed to the limited sample size that we used, or due to the fact that a DVT has no prognostic effect on the ACLR outcome. We could not find a significant correlation relating DVT to the outcome of ACLR.

As for smoking, between the smokers and those who never smoked was a significant difference in the outcome, as the mean scores were 43 and 40.7, respectively. However, this result was contradicted by another research published in 2012, conducted in Sweden, where nonsmoker patients had a better outcome than smoker patients (P < 0.001).[19] Hence, this significance is indeed attributed to the low sample size of the study.

The limited sample size had an effect on the significance of the study parameters, rendering some of them insignificant, such as the correlation between the score and inflammation incidence, DVT incidence, or the BMI of the participant. Also the unavailability of preoperative data has prevented us from comparing the postoperative scores, with the preoperative scores.

Furthermore, the absence of female participants might have rendered the study less universal. However, applying the results of the study in practice could still be possible, since the injury is more common in males than females which is a claim supported by a study in the US conducted published in 2014 concluded that 42% of ACLR operations performed in the US during 2006 were performed on females,[9] as well as the 2017 Annual Report of National Ligament Registry where they registered 28% of ACLR operations of 2016 were on females.

Our recommendation is to conduct other studies regarding the ACLR and the patient's selection criteria to predict the best outcome in our region.


  Conclusion Top


Patients with high score were satisfied with the ACLR representing the majority of the sample size by more than 60% of patients. On the other hand, 1 out of 104 patients, he had the worst outcome representing <1% of the sample. Most frequent complaints were persistent pain 15% and kneeling 13%. OKS is valid score system and is reliable in large sample size as in multicentric studies rather than small sample size.

Acknowledgment

We appreciate the effort of Raghad Ahmed Rezqallah, Mawaddah Farooq Batwa, and Ohud Jafar Abukammas in collecting the data and facilitating the research progress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD, et al. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc 2013;45:462-9.  Back to cited text no. 5
    
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Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG, et al. Epidemiology of anterior cruciate ligament reconstruction: Trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 2009;91:2321-8.  Back to cited text no. 8
    
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Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr., et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 2014;42:2363-70.  Back to cited text no. 9
    
10.
Lefevre N, Bohu Y, de Pamphilis O, Klouche S, Devaux C, Herman S, et al. Outpatient surgery feasibility in anterior cruciate ligament reconstruction: A prospective comparative assessment. Orthop Traumatol Surg Res 2014;100:521-6.  Back to cited text no. 10
    
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13.
Kocher MS, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Hawkins RJ, et al. Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2002;84-A: 1560-72.  Back to cited text no. 13
    
14.
Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 2005;33:335-46.  Back to cited text no. 14
    
15.
Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: A systematic review and meta-analysis of the state of play. Br J Sports Med 2011;45:596-606.  Back to cited text no. 15
    
16.
Garratt AM, Brealey S, Gillespie WJ; DAMASK Trial Team. Patient-assessed health instruments for the knee: A structured review. Rheumatology (Oxford) 2004;43:1414-23.  Back to cited text no. 16
    
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Pandit H, Beard DJ, Jenkins C, Kimstra Y, Thomas NP, Dodd CA, et al. Combined anterior cruciate reconstruction and oxford unicompartmental knee arthroplasty. J Bone Joint Surg Br 2006;88:887-92.  Back to cited text no. 17
    
18.
Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2006;22:375-84.  Back to cited text no. 18
    
19.
Ahldén M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus J, et al. The Swedish national anterior cruciate ligament register: A report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med 2012;40:2230-5.  Back to cited text no. 19
    


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