Management of injuries to the anterior cruciate ligament: Results of a survey of orthopaedic surgeons in Canada

Objective. To identify the approaches to management of anterior cruciate li gament (ACL) injury by Canadian orthopedic surgeons. Methods. A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following info rmation: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how pa tients in any of three common ACL injury scenarios would be managed; 3) wha t variations exist in surgical technique; and 4) how patient variables such as age,gender, and alignment influence the decision-making process. Results: The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely ma naged by 80% Of the respondents. The diagnosis of acute hemarthrosis is pre dominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competit ive athlete with a complete ACL tear, 63% would recommend reconstruction an d 33% would recommend bracing and rehabilitation. For reconstruction, 59% w ould use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use ham string tendon autograft; 40% would incorporate the ACL stump during reconst ruction. Of the respondents, 77% would advocate ACL reconstruction for comp etitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B au tograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synt hetic augmentation would be used by 12% in chronic cases and by 16% in acut e cases. In making the decision to perform ACL reconstruction, 53% consider Limb alignment to be important and 67% consider moderate patellofemoral pa in to be important. Seventy-one percent are influenced by patellofemoral pa in when choosing a surgical technique, with a trend toward semi-tendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old c hild with an acute ACL injury, 63% of the respondents would recommend rehab ilitation and bracing. For the 14-year-old, 45% would recommend rehabilitat ion and bracing and 37% would recommend ACL reconstruction after physeal cl osure. Conclusion: The results of the survey indicate that, with respect to some o f the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and random ized, con trolled clinical trials should be directed toward these areas.