Epidemiology of knee injury and anterior cruciate ligament (ACL) reconstruction in Alberta
Creators: Paudel, Yuba Raj
Publisher: name: University of Alberta Library
Year: 2023

<p>Current trends of knee injuries and anterior cruciate ligament reconstruction (ACLR), as well as incidence of and factors associated with primary and recurrent ACLR in Alberta, are not well understood. This thesis aims to fill this knowledge gap by using administrative data from Alberta’s Ministry of Health. Data covering the period from 2002/03 to 2018/19 were obtained. Multiple databases (ambulatory care, inpatient, physician claims, and population registry) were linked for analysis. Furthermore, this thesis synthesizes literature on facilitators and barriers to implement ACL injury prevention programs.<br>
There was a decline in knee injury-related emergency department (ED) visits in the province over the 17-year study period. Males experienced a significant decline in the knee injury-related ED visits, while the proportion of ED visits remained almost constant among females. Sprain and strain of joints and ligaments and internal derangement of the knee comprised more than 90% of knee injury-related ED visits. <br>
Between 2002/03 and 2018/19, age-standardized annual incidence of primary ACLR among those aged 10 years and older increased from 44.7 to 54.9 per 100,000 people among males. Among females, it increased from 32.9 to 47.5 per 100,000 people. Although overall incidence was higher among males, the average annual growth rate was higher among females compared to males, contributing to a narrowing gender gap in annual ACLR incidence in Alberta. Revision ACLR incidence increased from 1.9 to 5.4 per 100,000 people among males and 1.8 to 5.0 per 100,000 people among females. <br>
Among ACL injuries diagnosed in the ED between 2010/11 and 2015/16, less than half (45%) underwent ACLR within three years of follow-up. Whereas nearly two-third (64.5%)  underwent ACLR among those who were diagnosed in a non-emergency setting.  Living in rural areas or poorer income quintile neighbourhoods was associated with lower chances of ACLR compared to living in the highest income quintile neighbourhoods, after adjusting for age, gender, season of ACL injury diagnosis, place of diagnosis, and other covariates. Females showed a higher chance of ACLR compared to male counterparts. Females under 20 years old had a higher chance of ACLR compared to older females, as well as all male age categories. Chances of ACLR peaked before 20 years in females and peaked before 30 years in males. Average time from first diagnosis to ACLR was found to be almost a year among those diagnosed in the ED and more than eight months among those diagnosed in a non-ED setting. Of the total ACLR with an initial ACL injury diagnosis made in ED, just above one-third (35.6%) underwent surgery within five months from diagnosis. The remaining two-third operated on five months or more after diagnosis, were considered “delayed surgeries.” <br>
Among those with a history of primary ACLR between 2010/11 and 2015/16, ipsilateral revision was found in 3.9% (95% CI: 3.5-4.3) and a contralateral ACLR was found in 3.6% (95% CI: 3.2-3.9) with an average follow-up period of 5.7 years. Patients aged 10-19 years had substantially higher chances of revision (7.7%) and contralateral ACLR (6.2%) compared to other groups. Having primary ACLR in winter (HR: 1.6, 95% CI: 1.2-2.2) compared to summer, and/or having allograft (HR: 1.5, 95% CI: 1.0-2.3) compared to autograft, were associated with increased risk of revision ACLR. <br>
A systematic review on facilitators and barriers found that people (coaches and athletes) are the most critical elements of Injury Prevention Program (IPP) implementation. The IPPs need to focus on capacity enhancement and motivation of coaches and athletes. Further, IPPs that need minimal additional resources (budget, and human resources) are more likely to be adopted. Secondary factors include the program’s adaptability, collaborative design, cost, and timing of implementation, as well as duration of the program per session. Furthermore, the inner setting (availability of supportive resources and people, enabling environment), outer setting (policy environment, media role, favourable evidence) and process of program implementation (frequent supervision, feedback, and support) were also very important. </p>