Web-based survey results: surgeon practice patterns in Italy regarding anterior cruciate ligament reconstruction and rehabilitation

Abstract

Purpose

The aim of this study was to report Italian orthopaedic surgeons’ management of choice for ACL reconstruction and rehabilitation, and to compare surgical applications and rehabilitation approaches of Italian surgeons to the current approaches of “ACL Study Group”. A secondary purpose was to compare the preferences of subgroup based on graft choice, surgical techniques and experience.

Methods

A web-based survey was developed to investigate the attitudes of members of a national association specialized in sports traumatology and knee surgery (SIGASCOT) regarding surgical techniques, routine post-operative applications, rehabilitation approaches and starting time of specific activities and exercises following ACL reconstruction.

Results

The response rate was 17 % (131 questionnaires). The most popular graft type was hamstring tendon (81 % in male patients, and 91 % in female patients). The rate of continuous passive motion use was 55 %. Half surgeons routinely used a brace (49 %), usually a hinged brace. In total, 33.0 % of surgeons allowed patients to load the operated knee as much as tolerated within the first 2 weeks. Fifty-nine per cent of surgeons did not limit full flexion within the first 2 weeks. Most surgeons advise to wait until 4 months or more (97 %) for return to sports not requiring contact, and 6 months or more for full-contact sport (86 %).

Conclusions

This survey demonstrates clear trends in the practice of ACL reconstruction and rehabilitation in Italy. The data obtained from the SIGASCOT members revealed a more conservative approach when compared to the current approaches of “ACL Study Group”.

Level of evidence

Cross-sectional survey, Level III.

Appendix: Study questionnaire with summarized results

(1) How many ACL reconstructions are you performing per year?
<25	25–50	50–100	More than 100
37.2 %	28.7 %	22.5 %	11.6 %

(2) What type of graft you use preferably in the reconstruction of the anterior cruciate ligament in male patients?
Patellar tendon	Hamstring (semitendinosus/gracilis) tendons	Quadriceps tendon	Allograft	Artificial ligament
16.5 %	81.1 %	0 %	1.6 %	0.8 %

(3) What type of graft you use preferably in the reconstruction of the anterior cruciate ligament in female patients?
Patellar tendon	Hamstring (semitendinosus/gracilis) tendons	Quadriceps tendon	Allograft	Artificial ligament
6.4 %	91.2 %	0 %	1.6 %	0.8 %

(4) What type of graft you use preferably in the reconstruction of the anterior cruciate ligament in professional athletes?
Patellar tendon	Hamstring (semitendinosus/gracilis) tendons	Quadriceps tendon	Allograft	Artificial ligament
49.6 %	44.8 %	0 %	4.8 %	0.8 %

(5) Do you use the same graft regardless of the sport practiced?	Yes	No
	56.0 %	44.0 %

(6) What type of surgery you use preferably?	Double bundle	Single bundle
	7.0 %	93.0 %

(7) What type of surgery you use preferably to perform the femoral tunnel?	Transtibial	Anteromedial portal	Out-in technique
	60.5 %	29.0 %	10.5 %

(8) What type of femoral fixation you use preferably?
Compression	Expansion	Cortical suspension	Cortico-cancellous suspension	Others
11.2 %	24.0 %	51.2 %	4.0 %	9.6 %

(9) Do you routinely brace your patients post-operatively?	Yes	No
	49.19 %	50.8 %

If yes. What type of brace?	Mouldable	Hinged	Rigid
	5.5 %	64.4 %	30.1 %
If yes. How long?	≤2 weeks	2–4 weeks	4–6 weeks	≥6 weeks
	19.2 %	69.8 %	11.0 %	0.0 %

(10) What is the duration of loading post-operatively?	≤2 weeks	2–4 weeks	4–6 weeks	≥6 weeks
As much as it is tolerated	33.0 %	44.4 %	20.9 %	1.7 %
Limited loading	72.2 %	26.9 %	0.9 %	0.0 %

(11) Do your patients routinely use continuous passive motion post-operatively?	Yes	No
	55.12 %	44.88 %

(12) Do you limit full flexion at the knee?	≤2 weeks	2–4 weeks	4–6 weeks	≥6 weeks
No	58.6 %	9.9 %	22.5 %	9.0 %
0°–90°	61.9 %	30.5 %	7.6 %	0.0 %
0°–45°	87.8 %	12.2 %	0.0 %	0.0 %
0°–20°	97.6 %	2.4 %	0.0 %	0.0 %

(13) Which of the below do you prefer following ACL reconstruction?
Home exercise programmes	Professional rehabilitation programmes
10.2 %	89.8 %

(14) Do you have standard rehabilitation programme?	Yes	No
	84.3 %	15.7 %

(15) When do you start below specific activities/exercises?
	≤2 weeks	2–4 weeks	4–6 weeks	≥6 weeks
Proprioceptive exercise	14.4 %	21.6 %	45.6 %	18.4 %
Exercise bicycle	2.4 %	30.4 %	50.4 %	16.8 %
	≤4 weeks	4–6 weeks	6–8 weeks	≥8 weeks
Running in treadmill	1.6 %	9.6 %	37.60 %	51.20 %
Running in outside	0.8 %	2.5 %	12.3 %	84.4 %
	≤6 weeks	6–12 weeks	3–6 months	≥6 months
Strengthening open kinetic chain quadriceps between 90° and 40°	12.0 %	44.8 %	34.4 %	8.8 %
	≤2 months	2–4 months	≥4 months	never
Isokinetic exercises for strengthening	29.8 %	44.4 %	21.8 %	4.0 %

	≤2 months	2–4 months	4–6 months	6–8 months	8–10 months	10–12 months	>12 months
Sport-specific rehabilitation	3.2 %	29.8 %	56.5 %	9.7 %	0.8 %	0.0 %	0.0 %
Skills on sports not requiring contact	0.8 %	21.8 %	64.5 %	12.1 %	0.8 %	0.0 %	0.0 %
Skills on sports requiring contact	0.8 %	1.6 %	41.6 %	48.0 %	6.4 %	0.8 %	0.8 %
Return to sports not requiring contact	0.0 %	3.3 %	44.7 %	43.9 %	7.3 %	0.8 %	0.0 %
Return to sports requiring contact	0.0 %	0.8 %	13.6 %	58.4 %	20.8 %	6.4 %	0.0 %