SYNOPSIS
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
“TO COMPARE THE OUTCOME BETWEEN EARLY AND DELAYED ARTHROSCOPIC RECONSTRUCTION OF ANTERIOR CRUCIATE LIGAMENT TEARS ”
Name of the candidate : Dr. ANOOP P.
Guide : Dr. GAURAV SHARMA
Course and Subject : M.S (Orthopaedics)
Department of Orthopaedics,
St. John’s Medical College,
Sarjapur, Bangalore – 34.
SEPTEMBER – 2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF THE SUBJECT FOR
DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / DR.ANOOP P.P.G. RESIDENT
ST JOHNS MEDICAL COLLEGE HOSPITAL,
BANGALORE – 34.
2. / NAME OF THE INSTITUTION / ST JOHNS MEDICAL COLLEGE HOSPITAL,
BANGALORE – 34.
3. / COURSE OF STUDY AND SUBJECT / M.S. (ORTHOPAEDICS)
4. / DATE OF ADMISSION TO COURSE / 01-06-2013
5. / TITLE OF THE TOPIC:
TO COMPARE THE OUTCOME BETWEEN EARLY AND DELAYED ARTHROSCOPIC RECONSTRUCTION OF ANTERIOR CRUCIATE LIGAMENT TEARS.
6. / Brief Resume of the Intended Work:
6.1. Need for the study:
Anterior cruciate ligament reconstruction(ACLR) improves the stability and function of the knee. The surgical technique continues to evolve and several controversial issues exist, such as graft selection (patellar tendon, hamstring, quadriceps tendon, or allografts), surgical technique (double versus single bundle), and timing of surgery. Controversy exists over the most suitable time for reconstruction of surgery after injury. Reconstruction within 12weeks have been recommended by few authors(1,3,7). Early surgical treatment may prevent increased instability of the knee and decrease the risk of meniscal and chondral injury. Other studies found the results of early reconstruction to be unpredictable due to problems such as deficit of motion,pain,arthrofibrosis and patellar contracture syndrome and recommended delayed surgery after 12weeks(1,2,3,6). This study will help the surgeon to choose the correct timing of reconstruction of Anterior cruciate ligament tear arthroscopically.
6.2 Review of Literature:
Precise knowledge of timing is critical for the approach to ACL surgery, which is based on the application of early recovery and minimal injury to meniscal,cartilage. Several authors have discussed the early versus the delayed techniques for ACL reconstruction. Many have concluded delayed surgery has better clinical outcome. A D Tambe et al had done prospective study in atheletes which showed better clinical outcome in patients who underwent surgery after 6 weeks of injury,.37 patients were included and 89% said they found improvement(1). Meighan et al included 46 patients 38 male & 8 female with average age of 30. A mean follow of 2years suggested an average post injury score Tegner score was 2.97 and 5.2 with mean improvement of 2.09(95% CI 1.52) significant with paired t test , 85% rated outcome better, 91% as knee normal or nearly normal, 71% returned to sporting activity(2). Marcacci et al compared a group who had very early reconstruction with in 15days of injury vs those who had surgery >3months after injury found results better in groups treated early.(3) Craig R Bottoni said earlier the surgery better the outcome .Other study by Ravi et al did not find any difference in outcome of whether early or delayed surgery(7).
6.3 Objective of the study:
To assess the functionality of arthroscopically reconstructed ACL using IKDC score, Lysholm-Tegner Score, KOOS scoring and concurrently using clinical testing by pivot shift test, Anterior drawer, Lachmann test and range of movements both pre and post operatively.
7. / Materials and Methods
7.1 Source of data:
A minimum of 40 patients belonging to the age group of 18-60 years who have symptomatic acl tear requiring arthroscopic reconstruction admitted in St. John’s Medical College Hospital will be included in this study between October 2013-october 2015.
7.2. Sample size:
Forty patients diagnosed to have acute and chronic ACL injury will be included using purposive sampling technique.
Design of the study:
Prospective cohort study.
Duration of the study:
The study period will be two years.
7.3 Method of collection of data:
About 40 patients with ACL injury admitted to St John’s Medical College Hospital will be included in this study after obtaining informed consent. A detailed history and clinical examination will be done. Diagnosis will be confirmed with standard clinical test & with the help of Magnetic Resonance Imaging (MRI) (Sigma HDxT-GE 1.5 Tesla). Patients with complete or partial ACL Tear who are undergoing ACL reconstruction will be randomly categorized for early <12 weeks and delayed >12weeks groups depending on the time of presentation to hospital. These patients with established ACL tear (partial or complete) will be taken up for ACL reconstruction using arthroscopic reconstruction with semitendinosis and gracilis quadraple grafts. Functional evaluation of the reconstructed ACL will be done using IKDC score, Lysholm-tegner, KOOS scoring between a period of 6 months to 1year once post operatively at the department orthopaedics at St John’s Medical College Hospital. The scoring will also be compared with clinical tests by pivot shift test,Anterior drawer test , Lachmann test, and range of movement of knee.
Inclusion Criteria
· Patients with complete or partial ACL Tear who are undergoing ACL reconstruction .
· Patients belonging to the age group of 18-60 years with ACL injury either isolated or
· acute or chronic
· Associated Meniscal injury
· Medial collateral ligament injuries
· Lateral collateral ligament injury
Exclusion Criteria
· Patients with associated Posterior Cruciate Ligament (PCL) injury.
· Patients with ACL reinjury.
· Patients with associated periarticular fracture.
· Patients with associated ipsilateral lower limb fracture.
· Grade 3 & 4 chondral injuries(detected intraoperatively)
Data Analysis
Data will be analysed pre-operatively with assessment of clinical tests including Lachmann test, Anterior Drawer test, Pivot shift, X ray Knee, MRI Knee, IKDC score, Lysholm-Tegner scoring KOOS scoring.
Post Operatively data will be functionally analysed with IKDC, Lysholm-Tegner score, KOOS scoring
Pivot shift tests, Anterior drawer test, Lachmann test post operatively. The scores of both time points will be expressed as mean + or – SD. The normality of the data will be examined. If the scores follow normal distribution it will be compared between pre and post operative time points using paired student t-test. All statistical analysis will be considered significant at P <0.05 level of significance.
7.4 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?
Laboratory investigations like complete blood count, knee X ray AP/Lateral, MRI of injured knee on patients posted for surgery.
7.5 Has ethical clearance been obtained from your institution in case of 7.4?
YES
8. / References:
1. A.D Tambe,S P.Godiff,S Mulay& M Joshi: ACL insufficiency:does delay in index surgery affect outcome in recreational atheletes.ncbi.gov 2006apr;30(2)104-9
2. Meighan, Keating J F, Wille:-outcome after Reconstruction of ACL in atheletic patients. A comparison of early vs delayed surgery. J Bone joint Surg br. 2003 May;85(4):521-4
3. A case of early reconstruction of the ACL,by annie Hayashi, Craig R Bottoni AAOS, oper tech Sports med JULY 2005:13(3):169-175
4. Smith T O, Davies L, Hing C B. Early vs Delayed surgery for ACL reconstruction: a systematic review and metaanalysis. Knee surgery, sports tramatol arthroscopy 2010:18:304-11.
5. Andersson D, Samuelsson k, Karlsson J: Treatment of acl injuries with special reference to surgical technique and rehabilitation:an assessment of RCT Arthroscopy 2009:25:653-85.
6. D. Edmund Anstey, BA; Benton E. Heyworth, MD; Mark D price,MD, PhD; Thomas J. Gill, MD. DOI:10.3810/psm.2012.02.1949.
7. Comparison between early and delay reconstruction of acl- A RaviRaj, A Anand, G Kodikal, M Chandrashekar ,S Pain. bone Comparison between early and delayed reconstruction of acl. Bone and joint.org.uk br. 2010 Apr;521-6. Doi:10.1302/0301-620X.92B4.22973
9. / SIGNATURE OF THE CANDIDATE -
10. / REMARKS FROM GUIDE-
11. / 11.1 NAME & DESIGNATION OF
GUIDE / DR. GAURAV SHARMA
M S ORTHOPAEDICS,
PROFESSOR & HEAD OF ARTHROSCOPIC UNIT
DEPARTMENT OF ORTHOPAEDICS
ST JOHNS MEDICAL COLLEGE HOSPITAL
SARJAPUR, BANGALORE – 34
11.2 SIGNATURE
11.6 HEAD OF DEPARTMENT / DR.THOMAS ISSAC ,D-ORTHO, MS
PROFESSOR AND HOD OF ORTHOPAEDICS
DEPARTMENT OF ORTHOPAEDICS
ST JOHNS MEDICAL COLLEGE HOSPITAL
SARJAPUR, BANGALORE – 34
11.4 SIGNATURE
12 / 12.1 REMARKS OF THE CHAIRMAN AND DEAN
12.2 SIGNATURE