The most important findings of our study were that subjective outcomes, including the Tegner-Lysolm and IKDC scores, were significantly lower in the Rural group than in the Urban group. However, the objective findings were not different statistically. The overall graft failure rate was 17.2%; however, the reoperation rate was higher in the Urban group than the Rural group. The rate of deep infection was higher in the Rural group (3%) vs. Urban group (1.8%).
In the past years, because of poor socioeconomic status of the patients and lack of expertise, the condition like ACL tears was either unrecognized or neglected in Nepal. The patients used to stay home crippled. The development of social media, health awareness and implementation of health insurance policies by the government of Nepal has led the patient to access the health care facilities for the definitive treatment of such a debilitating condition 13. Also, arthroscopy and sports medicine, as a subspecialty, have gained popularity amongst young orthopaedic surgeons as minimally invasive surgery. Orthopaedic surgeons are being trained from both the national and international training centers. However, both the patients and the clinicians are still facing technical, financial, and logistic challenges. Despite these challenges, orthopedics and sports surgeons are still providing the best possible care to the patients of all the geographical areas of the country within the limited recourses.
Unlike in the developed world where the etiology is mostly the sports-related injuries, the primary etiology of the ACL tear in our patients was RTA that consisted of 53%, mostly being two-wheelers accidents. The reason for being RTA as the primary cause of ACL injury is the poor road conditions, poor road engineering, narrow and slippery mountain roads, overcrowded automobiles in the city, low safety barriers and driver’s negligence, etc. 14,15. In the Rural population, farm work or household work was the second most common cause of ACL injury (32%). In contrast, in the Urban group, the second most common cause was sports-related injury (26%).
Our patients have not only differences in the etiology, but also they come to the hospital for the definitive treatment only when they have severe pain and significant instability 16. The main reason for coming late to the hospital is the low economic condition as most of the payments, including the cost of surgery and implants, have to make out of their pocket, and is very expensive 16. To have their surgery done, even, the patient has to sell their property, and even some family members go abroad, mostly in India and Gulf countries for earning 17 18. Unfortunately, most of the insurance policy does not cover the cost of the implants 19. As of this study, both the groups presented to the hospital significantly later (average, 20 months in Rural group and 10 months in the Urban group) than what we usually see in the developed world 16 20. Only 39 (20%) of the patients presented to the hospital within 3 months of trauma for definitive surgery.
Even though most of our patients are living in the Rural area, and they are not the sportsperson, we would assume that they are a unique group of patients with a high demand for surgery. Because most of the patients living in the hilly-mountain have to work on the farm, and each of their daily activities is pivoting activities (Figure 1).
Regardless of previous findings of having no differences in the subjective outcome when compared with early and delayed ACLR patients 20 21, our patients had significantly poor subjective outcomes in the Rural group. These differences are probably because of the delayed presentation to the hospital, as many of the patients have already developed some degenerative changes in the cartilage and the meniscus, resulting in pain 16 22–24. That could also be shown by the postoperative radiograph of the patients where 9% of the patients had abnormal and severely-abnormal radiographic changes in the Rural group vs. 4% in the Urban group.
AP and rotational laxity measurements were not different significantly between two groups. However, both groups showed a high proportion of laxity in the young and active male patients; it might be associated with early return to activities during graft ligamentization, as one of the global drawbacks of the soft tissue graft 2 25 26.
For any ligament reconstruction, strict rehabilitation protocol is mandatory for better postoperative outcomes. We counseled all the patients regarding the risk and benefit of the surgery, possible clinical outcomes, and the role of rehabilitation protocol before the surgery.
We performed ACLR for at least 16 patients, especially females, from the Rural area because of multiple episodes of giving away, resulting in frequent fall from height and even some reported previous fractures of extremities. Although there was no significant difference between the two groups regarding functional outcomes, marked reduction in overall IKDC score, single-leg hope test, and ROM in the Rural group, especially in the female patients, was evident. Twenty-eight percent of patients in the Rural group and 21 % of patients in the Urban group had abnormal and severely-abnormal single-leg hop test, and 24% in the Rural and 21% in the Urban group had abnormal and severely-abnormal overall IKDC score. The proportion of reduced ROM was also more in the Rural group. The discrepancy in functional outcomes is directly related to socioeconomic status and education level of the patients living in Rural area, which directly affects inadequate rehabilitation and early return to work. We prescribed all the patients with similar rehabilitation protocol and upon discharge from the hospital, all the patients were provided with a pamphlet for the instruction of rehabilitation; however, postoperative compliance for the rehabilitation was poor for our patients. The reason for a higher proportion of functional outcomes in the Urban group was a relatively younger age and motivated to the strict rehabilitation protocol.
Graft failure is defined as the presence of recurrent instability, stiffness, and persistent pain 27. Various etiological factors are associated with graft failure, including patients factors, technical factors, optimum selection of graft, and the inherent limitation of graft tissue used 3 28. In a prospective study by Magnussen et al. 1, the authors reported that the graft size of 8 mm or less in patients under 20 years of age was found to be the predictor for revision. Similarly, Kamien et al.4 found that the age group of less than 25 years had significantly higher hamstring graft failure rate as compared to age above 25 years. They did not find any differences in activity level and graft size. Barret et al. 29 reported a similar result with hamstring tendon grafts, so they recommended the utilization of bone-patellar tendon-bone graft in young and active individuals.
We defined the Lachman test of Grade 2 or grade 3 with the presence of the Pivot-shift test as a clinical failure. In our series, the overall failure rate was 17.2%, and most of the failure occurred within a year of ACL. The proportion of grade 2 and 3 Lachman test was higher in young and active individuals in both groups. However, the stiffness and pain were more evident in the rural population.
Asian people are relatively shorter stature, so the graft is. However, we insisted on every graft size to make at least 8 mm. As of previous reports, at least 2 mm of graft in each tunnel must be there in each tunnel for biological incorporation 30 31. Because of the surgeon’s preferences of making an 8 mm graft, the graft length might obviously be shorter in the tunnels and affected for biological incorporation. Sixty-five percent of all failure was within 6 months in our group, and mostly in active young male individuals. The short graft might have slipped off the interference screw, or some failure might have attributed to the screw divergence, causing early failure. Such prediction led us to use a suture post on the tibial side often if there is any doubt for adequate fixation.
Postoperative infection following ACLR is considered to be the dreadful complication and ranges from 0.14%–1.7% 32. However, the overall infection rate in our study was 6.2%, with 2.3% deep infection requiring arthroscopic debridement with antibiotic lavage. There might be various reasons for postoperative infection in our cases. Number one is the frequent use of the same set of instruments multiple times on the same day that possibly compromised the sterilization process. Another reason is because of the limited number of operating rooms available in high volume tertiary hospital, the operating room must be used for multiple purposes, including frequent use for debridement of infected cases. Because of the high infection rate, we started presoaking the graft in antibiotic (Vancomycin) solution.
Despite a single experienced orthopaedic surgeon performed all the clinical examinations, who have not involved in the surgery, to avoid the inter-observer bias, various limitations exist in our study. This study has all the biases that a retrospective, non-randomized study would have. We prescribed a similar rehabilitation for all the patients; however, many patients did not attend the complete course because of various reasons, as mentioned above, which might have directly affected the clinical outcomes of the patients. There might be an institutional bias as this study is from a single government hospital where mostly the economically poor patients come for the treatment. Lastly, laxity assessment was performed manually, measurement of laxity using KT–1000 or KT–2000 or other objective methods was not available in our center.