Anterior Cruciate Ligament reconstruction : studies on morbidity, function and health-related quality of life

The aim of this thesis was to investigate the effects of graft choice, time between injury and reconstruction and injuries to the menisci on knee function and the health-related quality of life after an anterior cruciate ligament (ACL) reconstruction. In Study I, 153 patients were assessed at a mean 8 years after randomisation to an ACL reconstruction with a bone-patellar tendon-bone or four-strand semitendinosus tendon graft. The results for laxity, functional tests, functional scores and health-related quality of life were similar for the graft types. The bone-patellar tendonbone graft was associated with more morbidity from kneeling, knee-walking and disturbed sensitivity. Patients having reconstructions before six months from injury had higher Tegner activity scores, and patients with a meniscus procedure before, or at the reconstruction, had worse outcomes. In Study II, 135 patients from the same randomised controlled trial as in Study I were assessed for prevalence of radiological osteoarthritis after a mean of 14 years. The prevalence of osteoarthritis was higher after anterior cruciate ligament reconstruction compared to the healthy non-injured limb and medial compartment osteoarthritis was most common. No difference between graft types was found. Meniscus resection and overweight two years after the reconstruction increased the risk of osteoarthritis. Osteoarthritis affected the health-related quality of life and most patients with osteoarthritis were symptomatic. In Study III, 10 patients with a four-strand semitendinosus tendon and 10 patients with a four-strand semitendinosus and gracilis tendon graft were assessed after a mean of 36 months following an ACL reconstruction. No difference in rotational range of motion between the graft types was found by gait analysis and no other differences in functional scores, laxity, return to sport activities or flexion strength. In Study IV, increased time between injury and ACL reconstruction was found to increase the risk for a medial meniscus injury among 8584 patients from the Swedish National Knee Ligament Register. After two years an outcome assessment according to the Knee Osteoarthritis Outcome Score (KOOS) was available for 3556 patients. The results were stratified to a high KOOS defined as functional recovery and a low KOOS defined as treatment failure. The chance for a functional recovery was higher for males and for hamstring tendon grafts and lower for patients with a previous meniscus procedure or a notchplasty at reconstruction. The risk of treatment failure was higher for patients with a previous meniscus procedure or a medial meniscus procedure at the time of reconstruction and lower for the hamstring tendon grafts and individuals between 35 and 54 years old. For a subpopulation of 556 patients, a high pre-injury Tegner activity score increased the risk of treatment failure. In conclusion, time between injury and reconstruction affect the results after ACL reconstruction as a result of the increasing frequency of additional injuries occurring with time. Graft-related morbidity affects the short- and long-term results. Meniscus injuries influence the short- and long-term results and the prevalence of osteoarthritis after ACL reconstruction, especially if a resection is needed

The Association of On-Admission Blood Hemoglobin, C-Reactive Protein, and Serum Creatinine With 2-Year Mortality of Patients With Femoral Neck Fractures

Introduction: The mortality of femoral neck fracture (FNF) is high and every effort should be made to identify and manage any possible risk factors. The aim of this study was to evaluate whether on-admission hemoglobin (Hb) level, C-reactive protein (CRP), and serum creatinine were associated with 2-year mortality after FNF. Patients and Methods: In this retrospective observational cohort study, we considered for inclusion all displaced FNF patients 65 years and above treated with hemi-arthroplasty between February 2011 and May 2015. We documented the age, sex, cognitive status, and American Society of Anesthesiologists (ASA) classification. The Hb level, CRP, and serum creatinine were measured. The medical records were followed up for 2 years. We fitted different crude and adjusted Cox proportional hazards models to examine whether Hb level <100 g/L, CRP >20 mg/L, and serum creatinine >100 μmol/L were associated with the 2-year mortality, adjusted for age, sex, and ASA class. Results: A total of 290 patients [208 females (72%), mean age 84 years] were included in the study. More than 50% of patients had impaired cognition and ASA class 3–4. Of the 290 patients, 38.3% (n = 111) had died within 2 years after surgery. Mortality among males was 46.3% (n = 38) while mortality among females was 35,1% (n = 73), p = 0.07. We found that on-admission Hb level <100 g/L was associated with 2-year mortality (HR = 3.3, 95% CI: 1.3–8.3, p < 0.01) while CRP >20 mg/L and serum creatinine >100 μmol/L were not associated with 2-year mortality (p = 0.89 and p = 0.31, respectively). Conclusion: On-admission Hb level <100 g/L, but not CRP >20 mg/L and serum creatinine >100 μmol/L, was associated with 2-year mortality. These results can help healthcare providers identify high-risk FNF patients who probably would benefit from optimized perioperative medical management

Compensation claims following anterior cruciate ligament injuries reported to the patient insurance company in Sweden in 2005-2014

Background and purpose - Patients in the Swedish healthcare system are insured against avoidable adverse events via Landstingens omsesidiga Forsakringsbolag (LoF). We assessed the reasons for compensation claims reported to LoF following an ACL injury. Patients and methods - We searched the LoF database for compensation claims related to ACL injuries reported in 2005-2014, and cross-matched claims with the Swedish National Knee Ligament Register. We then performed a review of the medical records. Results - We identified 530 eligible claims in 2005-2014. 352 (66%) claims were accepted by LoF and 178 claims were rejected. Accepted claims corresponded to fewer than 1% of ACL surgeries performed in the same period. The most common reasons for an accepted claim were postoperative septic arthritis followed by suboptimal surgery and delay in diagnosis and treatment. Interpretation - There are different reasons for accepting a compensation claim following an ACL injury, which represents different treatment errors that can be avoided