Volume 208 - Issue 8
The rate of anterior cruciate ligament reconstruction in Australia is high: a national registry is needed
Authors: John W Orchard, Lars Engebretsen and Julian A Feller
Med J Aust 2018; 208 (8): 341-342. || doi: 10.5694/mja18.00095
Published online: 7 May 2018
Published online: 7 May 2018
Support for a registry is an investment in the long term health of our nation
Supporting a registry is an investment in the long term health of our nation
This issue of the MJA includes the results of an important study that again indicate the high rate of anterior cruciate ligament (ACL) reconstruction in Australia.1 It was already known that Australia has relatively high rates of knee ACL injuries, surgical reconstruction,2,3 and knee replacement (arthroplasty).4 The new data highlight worrying increases in the rates of both primary and revision ACL reconstruction, particularly in adolescents.1 Many factors could potentially explain an increase in the rate of ACL surgery, including more accurate diagnosis, greater access to surgery, and more people playing sport (factors that would be pleasing), but also an increase in the rate of ACL injuries per exposure (which would be disappointing). It is harder to envisage a positive explanation for an increase in the revision ACL reconstruction rate, but it is important to differentiate between contributors to failure, particularly between surgical factors (ie, techniques associated with a higher failure rate) and rehabilitation factors, such as returning to sport before adequate functional recovery has been achieved.5,6
In order to better answer questions about increases in ACL surgery rates, further information about both the results of surgery and the causes of injury is needed. It is clear from international experience7,8 and local community registries9 that ACL registries are a feasible and cost-effective strategy for gathering information about the causes of ACL injury, about non-operative and surgical management, and, ultimately, about long term progression to knee arthroplasty.
Scandinavians have been world leaders in national medical registries, starting with the National Leprosy Registry of Norway in 1856. In 1975, the Swedish knee arthroplasty registry was the first national registry in orthopaedic surgery.10 The primary objective of the first arthroplasty registries was the early detection of inferior procedures, a goal achieved from 1995 onwards.10 Australia and New Zealand were among the first non-Scandinavian countries to establish national arthroplasty registries (in 1999),11 with the Australian registry also successfully identifying poorly performing prostheses.
The Scandinavian countries were also the first to establish national registries of ACL reconstruction surgery,7 although New Zealand currently has the only national database of all knee ligament injuries, whether managed surgically or non-surgically.12 Australia has undertaken a pilot study and established the feasibility of an ACL surgery registry,3 but still has not joined the growing number of countries with national registries, despite having perhaps the world’s highest rate of such operations.13
If Australia can join the list of countries with an ACL surgical registry, factors can be assessed that might explain the high re-injury rate for young patients after ACL reconstruction and the rapidly increasing rate of revision ACL reconstruction.1,14 These factors are also relevant to Australia’s high rate of total knee replacement, as patients with a history of ACL injury have a sevenfold greater risk of total knee replacement.15 ACL registries (including any to be developed in Australia) should ideally also capture injuries that do not lead to surgery, as this would allow both comparison of their outcomes with surgically managed injuries and assessment of preventive factors based on more complete incidence data.
Ultimately, however, we want to prevent ACL injuries. It is known, for example, that certain movement patterns14,16 and ground surfaces17 are modifiable risk factors for ACL injury. There is some evidence that prevention programs can be effective, and they should therefore be encouraged and appropriately monitored.16 A properly designed ACL injury registry would improve our understanding of the factors that influence the risk of ACL injury, allowing us to develop effective preventive strategies.
A review of arthroplasty registries concluded that government funding and support is critical for success.11 This support should be seen as an investment in the long term health of our nation; the funding of ACL registries overseas has been justified by the important research findings from the countries that have invested in them. Although there are significant challenges to establishing an ACL registry,3 Australia should aspire to enjoying the same success we have experienced with our highly valuable arthroplasty registry.
Competing interests
No relevant disclosures.
References
- Zbrojkiewicz D, Vertullo C, Grayson JE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. Med J Aust 2018; 208: 354-358.
- Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012; 22: 495-501.
- Lekkas C, Clarnette R, Graves SE, et al. Feasibility of establishing an Australian ACL registry: a pilot study by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Knee Surg Sports Traumatol Arthrosc 2017; 25: 1510-1516.
- Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage 2015; 23: 1664-1673.
- Nagelli CV, Hewett TE. Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports Med 2017; 47: 221-232.
- Grindem H, Snyder-Mackler L, Moksnes H, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 2016; 50: 804-808.
- Granan LP, Forssblad M, Lind M, et al. The Scandinavian ACL registries 2004-2007: baseline epidemiology. Acta Orthop 2009; 80: 563-567.
- Magnussen RA, Trojani C, Granan LP, et al. Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts. Knee Surg Sports Traumatol Arthrosc 2015; 23: 2339-2348.
- Maletis GB, Granan LP, Inacio MC, et al. Comparison of community-based ACL reconstruction registries in the US and Norway. J Bone Joint Surg Am 2011; 93 Suppl 3: 31-36.
- Havelin L, Espehaug B, Vollset S, et al. The effect of the type of cement on early revision of Charnley total hip prostheses. A review of eight thousand five hundred and seventy-nine primary arthroplasties from the Norwegian Arthroplasty Register. J Bone Joint Surg Am 1995; 77: 1543-1550.
- Kolling C, Simmen B, Labek G, et al. Key factors for a successful National Arthroplasty Register. J Bone Joint Surg Br 2007; 89: 1567-1573.
- Gianotti S, Marshall S, Hume P, et al. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport 2009; 12: 622-627.
- Moses B, Orchard J, Orchard J. Systematic review: annual incidence of ACL injury and surgery in various populations. Res Sports Med 2012; 20: 157-179.
- Ardern CL, Ekås G, Grindem H, et al. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Knee Surg Sports Traumatol Arthrosc 2018; doi:10.1136/bjsports-2018-099060. [Epub ahead of print].
- Khan T, Alvand A, Prieto-Alhambra D, et al. ACL and meniscal injuries increase the risk of primary total knee replacement for osteoarthritis: a matched case-control study using the Clinical Practice Research Datalink (CPRD). Br J Sports Med 2018; doi:10.1136/bjsports-2017-097762. [Epub ahead of print].
- Taylor JB, Waxman JP, Richter SJ, et al. Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis. Br J Sports Med 2015; 49: 79-87.
- Orchard J, Chivers I, Aldous D, et al. Ryegrass is associated with fewer non-contact anterior cruciate ligament injuries than bermudagrass. Br J Sports Med 2005; 39: 704-709.
Provenance: Commissioned; externally peer reviewed.