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EUR J PHYS REHABIL MED 2008;44:253-61

Continental variations in preoperative and postoperative management of patients with anterior cruciate ligament repair

A C I D E M ® A T V H R G E I R N I Y M P O C T

C. COOK 1, 2, L. NGUYEN 1, E. HEGEDUS 2, A. SANDAGO 3, R. PIETROBON 1, D. CONSTANTINOU 4, B. CHUCKPAIWONG 5, J. SANDHU 6, C. T. MOORMAN III 7

Aim. Surgeon decision making for non-operative anterior cruciate ligament (ACL) treatment and postoperative rehabilitation is influenced by a myriad of factors. The aim of this study was to investigate intercontinental differences in surgeon decision making for care of the ACL deficient patient. The authors hypothesized that significant variation in clinical decision of ACL deficient patients existed among surgeons in different continents. Methods. This study involved a survey design, which met the checklist for reporting results of internet e-surveys (CHERRIES) guidelines. The survey was administered to orthopedic surgeons in 15 countries and involved standardized follow up and design. Questions related to non-operative care management and postoperative/rehabilitative management were provided to each respondent. Statistical analyses included multivariate comparisons among continents and regression findings for likelihood of targeting longer term nonoperative treatment. Results. Over six hundred (634) surgeons completed the survey, representing six continents. Continental variations were found in non-operative surgical decision making and postoperative/rehabilitative management. Significant differences were noted in nearly all clinical decision making categories. Conclusion. Variations do exist across continents in the non-operative and postoperative/rehabilitative management of patients with an ACL tear. Continental variations and disparate emphases such as activity level, Conflict of interest.—None of the authors has a conflict of interest associated with this publication. Received on February 20, 2008. Accepted for publication on April 16, 2008. Epub ahead of print on May 23, 2008. Corresponding author: C. Cook PT, PhD, MBA, 2200 W. Wain Street, DUMC Box 104002, Durham, NC 27708, USA. E-mail: [email protected]

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1Centers of Excellence in Surgical Outcomes Department of Surgery, Duke University, Durham, NC, USA 2Division of Physical Therapy Department of Community and Family Medicine Duke University, Durham, NC, USA 3Steadman Hawkins Foundation, Vail, CO, USA 4Center for Exercise Science and Sports Medicine University of Witwatersrand, Johannesburg, South Africa 5Orthopedic Department, Siriraj Hospital Mahidol University, Bangkok, Thailand 6Department of Sports Medicine Guru Nanak Dev University, Amritsar, India 7Department of Orthopedic Surgery Duke University, Durham, NC, USA

age during injury, and bracing influenced treatment decision making, which could lead to variations in outcomes, costs, and appropriate care. KEY WORDS: Anterior cruciate ligament - Decision making Patient care management.

reatment of a patient with an anterior cruciate ligament (ACL) tear broadly consists of non-surgical or surgical treatment. The method of recovery is dictated by a myriad of factors including but not limited to patient age, activity level, and preference. Nonsurgical management has been suggested to lead to chronic knee instability and meniscus or chondral damage.1-3 Individuals with higher levels of activity prior to the knee injury are more likely to receive surgery 4 as non-surgical management may lead to changes in lifestyle and greater levels of disability.5, 6 Despite the suggested poor prognoses associated

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CONTINENTAL VARIATIONS IN ANTERIOR CRUCIATE LIGAMENT REPAIR

with non-operative management, the few studies that have compared non-operative versus operative management of the ACL have been inconclusive.6-8 Although the findings were inconclusive, these studies are older, characterized by poor methodological quality, and utilized outdated treatment techniques.5 Further complicating the decision process by surgeons on management of patients with ACL tears is that a non-operative approach has demonstrated both effectiveness in lower-demand populations 9, 10 and ineffectiveness in a mixed population,11 or high demand populations.12 Finally, when the patient in question is skeletally immature, there may be no clear evidence to guide the surgeon’s choice of treatment.13 Postoperative management of ACL repair appears less controversial. Many patients who receive ACL surgery are referred to physiotherapy for exercises and functional training,14 with initial treatment and education demonstrating greater importance than later rehabilitation.15 Although no specific exercise methods or approaches appear substantially superior in rehabilitating the ACL deficient knee,16 reobtaining muscular control has been shown to be essential for return to preinjury function,17, 18 the exact extent, dosage, and effort associated with this attempt is unknown.19 Less consistent in recommendations after ACL surgery is the use of a brace for stability. Mirza et al.14 reported that only 33% of Canadian surgeons recommend a brace for care. Nyland et al.20 found a division among accredited orthopedic sports medicine fellowship programs regarding prescription of de-rotation braces. Little evidence exists that bracing affects pain, range of motion, graft stability, or protection from future injury.21 Immobilization casts may demonstrate very little benefit in protecting a graft after repair and are no longer advocated.22 Indeed without definitive guidelines within the literature, some controversy exists regarding non-operative and postoperative/rehabilitative care of selective patients with an ACL tear. Controversy can lead to practice variations. Although it is expected that some variations will exist secondary to regional influences and the availability of resources,23 practice variations can lead to disparities in healthcare costs, outcomes and effectiveness of future clinical trials.24, 25 At present, no studies have looked at variations in decision making across cultures or continents. The purpose of this study was to outline continental variations in surgeon preferences in decision making for non-oper-

ative and postoperative/rehabilitative care of patients with an ACL tear. The authors hypothesize that significant intercontinental variations in decision making for non-operative and postoperative/rehabilitative care exist, which they theorize could further enhance the ambiguity in clinical practice parameters.

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Materials and methods

Development of survey

This descriptive study utilized a survey design and was approved by the local university ethics and institutional review board. Two authors (Nguyen and Moorman) developed the items of the survey after reviewing controversial concepts associated with ACL rehabilitation within the literature. Five specific constructs were targeted, which included: 1) surgical technique preference; 2) non-operative care; 3) rehabilitative management and postoperative care; 4) care of the skeletally immature patient; and 5) clinical decision making drivers and opinions. All information was uploaded into DADOS-Survey,26 which is a webbased, open-source survey application developed at Duke University Medical Center. A description of the development, design, technical features, and usability testing of DADOS-Survey can be found in previously published reports.26 Compared to most web survey software applications, one advantage of using DADOS-Survey is that the program completely satisfies the checklist for reporting results of internet e-surveys (CHERRIES) guidelines for reporting results from web-based surveys.27 The study was approved by the Duke University Ethics and Institutional review board. Targeted audience

E-mails for the US surgeons were obtained from email lists of different orthopedic societies. For the surgeons living abroad, the authors established contact with a member representative (usually someone on an executive committee) from a particular orthopedic society in the respondents’ country, or an administrator of the orthopedic society, who transferred the invitation to the survey via e-mail. In total, 15 countries were targeted for the survey. From surgeons for whom specific email address were obtained, the initial study invitation e-mail and the subsequent reminder e-mails were sent to each respondent directly. For the sur-


September 2008


geons for whom only proxy correspondence was obtained, the initial study invitation e-mail and the reminders were sent through the contact person.

COOK

country (continent) of origin only. Data collection ended in October 2007. Statistical analysis

Procedure

All statistical analyses were performed using SPSS 12.0.1 (233 S. Wacker Drive, 11th floor, Chicago, IL 60606, USA). Descriptive statistics were collected to identify the patient sample. Separate bivariate analyses were performed to measure variations between non-operative management across continents and post-operative rehabilitative management across continents. Logistic regression modeling was used to determine the likelihood of recommending non-operative care for less than or greater than 6 months. A preset alpha of 0.05 was targeted for each analysis.

A C I D E M ® A T V H R G E I R N I Y M P O C

Before the survey was administered, its technical functionality and usability were verified to ensure compliance in accordance to benchmarks established for DADOS-Survey.26 The survey was administered to all potential participants via e-mail in May 2007. The e-mail contained the purpose of the study and the uniform resource locator (URL) link through which all recipients could access the survey which was identical for all recipients. It also detailed the name, institution, and contact information of the principal investigator. In order to preserve confidentiality, all information was electronically stored on password-protected computers to which only the primary investigator and those directly involved in the study had access. The same e-mail was sent two additional times, each 10 days apart. The survey was resent to all potential participants in each wave regardless of response because the anonymous survey design prevented investigators from knowing the identity of previous responders. A second wave of e-mails was sent in July 2007, to improve the response from China, India, Brazil, and South Africa. As with the first wave, the same e-mail invitation was sent to all respondents two additional times, each 10 days apart. Clicking on the URL provided in the email directed survey participants to the website containing a onepaged survey consisting of 36 questions. The survey did not utilize randomization of the survey questions or adaptive questioning, nor were a login or password needed to access the survey. A JavaScript feature allowed respondents to review the questionnaire for unanswered questions and, if necessary, to change their answers before submitting the survey. All survey submissions were encrypted and stored on a password-protected server at Duke University Medical Center. To ensure further confidentiality, any identifying information of all potential survey participants was disposed of upon administration of the survey. No Internet protocol (IP) address checks were conducted nor were cookies used to assign unique identifiers to users’ computers. DADOS-Survey extracted all data to an Excel spreadsheet for future tabulation. Surgeons were identified by a code and identifying information was limited to

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Results

Seven hundred and eighty seven (787) surgeons who were invited to participate in the study accessed the website and 634 completed the survey (81%). Surgeons represented 15 countries including: Argentina (N.=1), Australia (N.=3), Brazil (N.=85), Canada (N.=6), China (N.=18), Greece (N.=15), Hong Kong (N.=7), India (19), Israel (N.=1), Italy (N.=18), New Zealand (N.=25), Norway (N.=1), South Africa (N.=19), Thailand (N.=218), and the United States (N.=194). Countries were categorized by six continents: Africa (N.=19), Asia (N.=262), Australia-New Zealand (N.=28), Europe (N.=35), North America (N.=200), and South America (N.=86). A preponderance of surgeons indicated a specialty of sports medicine (N.=373), followed by general orthopedics (N.=170), and total joint replacement (N.=21). Years of practice at the specialization ranged from a mean of 10.4 years (Asia) to 16.2 years (Australia-New Zealand). A majority of surgeons indicated performing 40 or over ACL surgeries within the last year (51.45) and demonstrated significant variations in inpatient or outpatient utilization. Endoscopic surgery (68.1%) was preferred more frequently by surgeons from nearly all continents, although notable variations existed across all continents. Table I outlines the descriptive statistics of this survey sample. Table II outlines significant differences in bivariate comparisons across continents for preoperative management of ACL tears. Regarding the criterion for recommending non-operative care, most surgeons outlined activity level as the most compelling factor


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TABLE I.—Descriptive statistics of surveyed sample (N.=634). North America

Europe

Asia

Africa

AustraliaNew Zealand

South America

Medical Specialty General orthopedics Traumatologist Sports medicine Total joint replacement Shoulder/upper extremity Other

32 3 152 5 4 4

13 0 19 2 1 0

69 10 157 13 6 7

13 0 3 2 0 1

19 8 37 6 3 13

21 0 4 1 1 1

P90% as inpatient 78 27

9 51 11 187

1 0 1 17

0 2 0 25

2 12 7 62

P