Deep venous thrombosis and pulmonary embolism after anterior cruciate ligament reconstruction: incidence, outcome, and risk factors.

AIMS: The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort. PATIENTS AND METHODS: All ACL reconstructions, primary and revision, that were recorded in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of VTE was determined by entries between the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of anticoagulants. Risk factors, outcome, and the use of thromboprophylaxis were analyzed. Descriptive statistics with multivariate analysis were used to describe the findings. RESULTS: The cohort consisted of 26 014 primary and revision ACL reconstructions. There were 89 deep venous thromboses (DVTs) and 12 pulmonary emboli (PEs) with a total of 95 VTEs (0.4 %). Six patients with a PE had a simultaneous DVT. The only independent risk factor for VTE was age greater than or equal to 40 years (odds ratio 2.31, 95% confidence interval 1.45 to 3.70; p < 0.001). Thromboprophylaxis was prescribed to 9461 patients (36%) and was equally distributed between those with and those without a VTE (37.9% vs 36.4%). All patient-reported outcome measures (PROMs) one and two years postoperatively were significantly lower in those with VTE. CONCLUSION: The incidence of VTE following ACL reconstruction is 0.4%, and the only significant risk factor is age. Patients with VTE had worse postoperative clinical outcome than patients without VTE. We recommend against the routine use of thromboprophylaxis, but it should be considered in older patients.

Incidence and body location of reported acute sport injuries in seven sports using a national insurance database.

Sports with high numbers of athletes and acute injuries are an important target for preventive actions at a national level. Both for the health of the athlete and to reduce costs associated with injury. The aim of this study was to identify injuries where injury prevention should focus, in order to have major impact on decreasing acute injury rates at a national level. All athletes in the seven investigated sport federations (automobile sports, basketball, floorball, football (soccer), handball, ice hockey, and motor sports) were insured by the same insurance company. Using this insurance database, the incidence and proportion of acute injuries, and injuries leading to permanent medical impairment (PMI), at each body location, was calculated. Comparisons were made between sports, sex, and age. In total, there were 84 754 registered injuries during the study period (year 2006-2013). Athletes in team sports, except in male ice hockey, had the highest risk to sustain an injury and PMI in the lower limb. Females had higher risk of injury and PMI in the lower limb compared to males, in all sports except in ice hockey. This study recommends that injury prevention at national level should particularly focus on lower limb injuries. In ice hockey and motor sports, head/neck and upper limb injuries also need attention.

Injuries in Swedish floorball: a cost analysis.

The epidemiology of sport injuries is well documented. However, the costs are rarely discussed. Previous studies have presented such costs in specific sports or localization. No study has investigated the costs related to injuries in elite floorball. Thus, the aim of this study was to estimate cost of injuries in Swedish elite floorball players. During 1 year, 346 floorball players were prospectively followed. All time-loss injures were recorded. The injured players were asked to complete a questionnaire regarding their costs tied to the injury. Mean costs were calculated by multiplying the total resource use with the collected unit costs and dividing these total costs with the number of injuries as well as players. The results showed that the average cost per injury increased with the level of severity and ranged from 332 to 2358 Euros. The mild and moderate overuse injuries were costlier than the corresponding traumatic injuries. However, the severe traumatic injuries were associated with higher costs than overuse injuries. Knee injuries were the costliest. Our results indicate that there are costs to be saved, if floorball injuries can be avoided. They should be of interest to decision makers deciding whether to invest in preventive interventions.

Comparison of patient-reported outcomes among those who chose ACL reconstruction or non-surgical treatment.

The aim of our study was to cross-sectionally compare patient-reported knee function outcomes between people who chose non-surgical treatment for ACL injury and those who chose ACL reconstruction. We extracted Knee Injury and Osteoarthritis Outcome Score (KOOS) and EuroQoL-5D data entered into the Swedish National ACL Registry by patients with a non-surgically treated ACL injury within 180 days of injury (n = 306), 1 (n = 350), 2 (n = 358), and 5 years (n = 114) after injury. These data were compared cross-sectionally to data collected pre-operatively (n = 306) and at 1 (n = 350), 2 (n = 358), and 5 years (n = 114) post-operatively from age- and gender-matched groups of patients with primary ACL reconstruction. At the 1 and 2 year comparisons, patients who chose surgical treatment reported superior quality of life and function in sports (1 year mean difference 12.4 and 13.2 points, respectively; 2 year mean difference 4.5 and 6.9 points, respectively) compared to those who chose non-surgical treatment. Patients who chose ACL reconstruction reported superior outcomes for knee symptoms and function, and in knee-specific and health-related quality of life, compared to patients who chose non-surgical treatment.

Incidence and severity of reported acute sports injuries in 35 sports using insurance registry data.

Acute injuries in sport are still a problem where limited knowledge of incidence and severity in different sports at national level exists. In Sweden, 80% of the sports federations have their mandatory injury insurance for all athletes in the same insurance company and injury data are systematically kept in a national database. The aim of the study was to identify high-risk sports with respect to incidence of acute and severe injuries in 35 sports reported to the database. The number and incidences of injuries as well as injuries leading to permanent medical impairment (PMI) were calculated during 2008-2011. Each year approximately 12,000 injuries and 1,162,660 licensed athletes were eligible for analysis. Eighty-five percent of the injuries were reported in football, ice hockey, floorball, and handball. The highest injury incidence as well as PMI was in motorcycle, handball, skating, and ice hockey. Females had higher risk of a PMI compared with males in automobile sport, handball, floorball, and football. High-risk sports with numerous injuries and high incidence of PMI injuries were motorcycle, handball, ice hockey, football, floorball, and automobile sports. Thus, these sports ought to be the target of preventive actions at national level.

Knee arthroscopy routines and practice.

PURPOSE: Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures, thus consuming huge medical resources. The aim of the present questionnaire survey was to study knee arthroscopy routines and practice. METHODS: An electronic web-based survey including questions around pre-, per- and postoperative routines for elective knee arthroscopy was send to all orthopaedic units associated to the Swedish Arthroscopic Society (n = 60). RESULTS: Responses covering 37 centres out of 60 (response rate 62%) were returned. Preoperative radiograph routines varied considerable between centres; conventional radiograph varied between 5 and 100% and preoperative MRI between 5 and 80% of patients. General anaesthesia was the preferred intra-operative technique used in all centres (median 79% of patients), local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10% of cases) and spinal anaesthesia was used in 15 centres (median 5% of cases). Intra-articular local anaesthesia was provided in all but one of centres. Perioperative administration of oral NSAIDs was common (31 out 37), 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID. Analgesic prescription was provided on a regular base in 18 (49%) of centres; an NSAID being the most commonly prescribed. All but one centre provided written information and instruction at discharge. Referral to physiotherapy, prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably. CONCLUSION: Routines and practice associated to elective knee arthroscopy differed; however, no clear differences in practice were seen between teaching centres, general or local hospitals apart from a lower usage of NSAID for perioperative analgesia. There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee.

Idiopathic adhesive capsulitis of the shoulder: a review.

Many terms have been used to describe what has been called idiopathic adhesive capsulitis of the shoulder. This pathology is defined as a self-limiting condition of unknown etiology. The natural history is 18-30 months even though a high-percentage of patient present impaired range of movement even at long-term follow-up. The diagnosis is mainly clinical and no significant changes are normally present at MRI or CT scan. Several treatment options have been tried over the years with different approaches and results.

Bracing versus nonbracing in rehabilitation after anterior cruciate ligament reconstruction: a randomized prospective study with 2-year follow-up.

This study prospectively randomized 62 patients to rehabilitation programs either with or without postoperative brace for 6 weeks following bone-tendon-bone anterior cruciate ligament reconstruction. The nonbraced group had a smaller knee circumference 2 weeks after surgery. At 6-month follow-up the nonbraced group had a better Tegner score. At 2 years there was no difference between the groups. There was one partial rupture of the graft in the nonbraced group after a new trauma 1 year after surgery. There were no differences between the groups in either subjective or objective knee stability at 2 or 6 weeks or at follow-up 3, 6, and 24 months after surgery. This study found no benefit of using a postoperative knee brace on patients' knee function at any stage up to 24 months after surgery. Furthermore, the braced group was not more stable than the nonbraced group, indicating that the brace does not contribute to a more stable knee during rehabilitation or 2-year follow-up.

Can local anesthesia be recommended for routine use in elective knee arthroscopy? A comparison between local, spinal, and general anesthesia.

Local anesthesia (LA) for outpatient knee arthroscopy is not a standard procedure at most hospitals. To evaluate the LA technique for knee arthroscopy on medically healthy patients, this study compared 3 anesthesia techniques. Four hundred patients were randomized to either local (n = 200), general (n = 100), or spinal (n = 100) anesthesia. Evaluated outcomes included the patient's subjective view of the procedure, and nausea and pain at rest and during active movement. All variables were recorded perioperatively and postoperatively. In addition, the performing surgeon's opinion of the degree of patient pain and the technical difficulty of the procedure were noted. Three hundred forty-two patients completed the study. In the group receiving local anesthesia (n = 180) the median visual analog scale pain score during surgery was 6 mm (mean, 17.5; SD, 23.2; range, 0 to 100 mm). Twenty-one LA patients would have preferred another form of anesthesia. In 29 patients, LA was not considered as the optimal anesthesia by the performing surgeon. Eight LA patients agreed with the surgeon that the anesthesia method used was not optimal, of these patients, 5 had synovitis (3%). In 5% of the LA patients there were technical problems. Thus, this study shows that elective knee arthroscopy can be performed under local anesthesia in 92% of the patients from a technical point of view. Excluding patients who do not choose local anesthesia and those who have hypertrophic synovitis preoperatively, knee arthroscopies can be performed as safely and effectively under local anesthesia as under any other form of anesthesia. For most patients, local anesthesia can be recommended as the standard procedure for outpatient knee arthroscopy.

Knee arthroscopy in local versus general anaesthesia. The incidence of rearthroscopy.

The choice of anaesthesia in routine knee arthroscopy varies considerably. Concerns about local anaesthesia include the fear that it will take longer to perform surgery and that the anaesthesia will be inadequate, leading to patient discomfort. In this study, data from all patients (n = 6519) who had undergone a knee arthroscopy at St Göran Hospital Artro Clinic, in Stockholm, Sweden, during a 3.5 year period, between January 1993 and July 1996, were reviewed. Of these 6519 primary arthroscopies, 4101 were performed under local anaesthesia and 2418 under general anaesthesia. The purpose of the study was first to identify those arthroscopies that could not be successfully performed because the local anaesthesia was inadequate, and second, to investigate if arthroscopy under local anesthesia was associated with an increased number of rearthroscopies compared to general anaesthesia. The total number of rearthroscopies, performed within 180 days from the primary arthroscopy, was 214. Of these 214 rearthroscopies, 146 were due to a new indication for surgery and 30 were due to persisting clinical symptoms (true rearthroscopies). The remaining 38 rearthroscopies were due to an incomplete examination (because of patient discomfort) in a primary procedure where local anaesthesia was used. Of the 30 true rearthroscopies, 19 originated from the 4101 primary arthroscopies performed under local anaesthesia (0.46%) and 11 originated from the 2418 primary arthroscopies performed under general anaesthesia (0.45%). It is concluded that 0.9% of the primary arthroscopies performed under local anaesthesia could not be performed safely due to patient discomfort. There was no difference in the frequency of rearthroscopy between the arthroscopies performed under local anaesthesia compared to those performed under general anaesthesia.

Does a major knee injury definitely sideline an elite soccer player?

Injuries occurring in three Swedish elite soccer teams were analyzed during 1 year. A total of 49 of 64 players (75%) sustained 85 injuries. The incidence of injury during games was 13 injuries per 1000 hours, while the incidence during training was 3 injuries per 1000 hours. Twenty percent of the injuries required hospital facilities. The majority of the traumatic injuries (93%) were to the lower extremities, with one third of the total injuries occurring in the knee. Overuse injuries accounted for 35% of all injuries and occurred mainly during preseason training and at the end of each season. Conversely, the majority of traumatic injuries occurred during games, equally distributed between the first and second halves with a predominance toward the end of each half. The position of the player within the team did not influence injury rate. The referee considered 28% of the traumatic injuries to be caused by violation of existing rules. Thirty-four percent of the injuries were major, causing more than 1 month of absence from training and/or games. Eleven knee injuries required surgical intervention revealing seven ruptured ACLs, of which three were chronic. At followup, 9 to 18.5 months after injury, 4 of 12 players with major knee injuries had returned to play at the elite level. The others had either been transferred to lower divisions or were still in rehabilitation.