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Global and Economic Environment of Business

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Toi J. Gorham

Global and Economic Environment of Business

Economic Audit: Pediatric Orthopaedics: ACL Reconstruction Surgery


Dr. Garrett Harper

December 22, 2016

Industry Description

        In this audit we will focus on ACL Reconstruction Surgery in the healthcare sector. Specialized Terminology: ACL – Anterior cruciate ligament, VCH – Vanderbilt Children’s Hospital, RVU’s – Relative value unit, UHC – United Health Care, and BC – Blue Cross/Blue Shield.

Reconstruction of the anterior cruciate ligament (ACL) is among one the most frequently performed procedures in knee surgery today. The history of ACL surgery can be dated back to Egyptian times. The early years reflect the efforts to establish a doable, consistent successful reconstruction technique. Throughout the early part of the 20th Century research brings awareness to the interest in the ligaments and its legions. Lastly, we will focus on the important steps in the evolution of ACL reconstruction surgery by discussing all the various techniques developed over the years.

“Rupture of the anterior cruciate ligament (ACL) is a common injury in active people and is one of the most common knee injuries in sports. It is estimated that the annual incidence of ACL injury is about 3,000 amongst the general population in the USA. That means that more than 150,000 new ACL ruptures annually” (Davarinos, O’Neil, and Curtin, 2014, p. 1). The healing process for this type of injury is poor. If the patient does not receive surgical reconstruction the ACL defective knee is limited. If the knee goes untreated it will lead to future degenerative changes. ACL reconstruction surgery is a major area of research worldwide. This is partly due to the large numbers of athletes being involved in school sports and professional sports. Today people expect a faster recovery and rehab is essential to return to normal activities. Also, we now have a greater awareness of the injury and people in general are taking more interest in their own/children’s healthcare matters. Children and adults with this injury have a greater expectation to get back to their activities whether that is school sports, professional sports, or a non-sports person. Research and Innovation thrive in this area, because of improved clinical outcomes. Knowledge of the progression of ACL reconstruction is vital to those who continue to try and improve the outcomes of the procedure, therefore, refining what’s already been done, and reducing the risk of repeat injury.

History of ACL Treatment

        Cruciate ligaments have been acknowledged since Egyptian times. Claudias Galen, a Greek physician in the Roman Empire, was the first to document the true description of the ACL. Previously, it was believed that the cruciate ligaments were a part of the nervous system, but Galen defined the ACL as being a structure that supported the joint and stopped abnormal knee function.  Galen cared for gladiators and possibly had the chance to see the ACL through gashes in the knee from gladiator battle. “In 1836, the Webber brothers from Goettingen in Germany noted an abnormal anterior-posterior movement of the tibia after transection of the ACL. They described the roll and glide mechanism of the knee and tension pattern of the different bundles of the cruciate ligaments and, to our knowledge, were the first to describe that each bundle of the ACL was tensioned in different degrees of flexion of the knee joint” (Davarinos, O’Neil, and Curtin, 2014, p. 1). In 1845, Amedee Bonnet of Lyon, France reported patients having swelling and loss of function of the knee upon hearing a snap would most likely have a ligament injury, which could include ACL injury (Davarinos, O’Neil, and Curtin, 2014, p. 2).

        “In 1875, the Greek Georgios C. Noulis described the technique of the Lachman test for the first time. He wrote: “fix the thigh with one hand, while the other hand holds the lower leg just below the knee with the thumb in front and the fingers behind. Then, try to shift the tibia forward and backward. When only the anterior cruciate ligament is transected, this forward movement is seen when the knee is barely flexed, whereas a backward movement is noted in 110 degrees of flexion when the posterior cruciate ligament is transected” (Davarinos, O’Neil, and Curtin, 2014, p. 2). “In 1879, Paul Segond described an avulsion fracture of the anterolateral margin of the tibial plateau. This is a routinely associated with ACL disruption. This fracture is now known universally as a Segond fracture and is considered pathognomonic for ACL tears” (Davarinos, O’Neil, and Curtin, 2014, p. 2).

        In the 1900’s was the first reported satisfactory surgery for an ACL repair. In 1903, cast immobilization was implemented as a part of treatment/recovery process. “In 1913, Goetjes produced a detailed study of ruptures of the cruciate ligaments. He discussed ligament function and mechanisms of rupture, as determined by cadaver studies. He advocated repair for the acute injury and conservative treatment for chronic ruptures” (Davarinos, O’Neil, and Curtin, 2014, p. 2). In 1917, Hey Groves published his findings on Autologous Fascia Lata and Meniscal Grafts. In, 1918 physicians using his techniques reported cases that they treated using Groves technique. “In 1934, Orthopaedic surgeon Riccardo Galeazzi describes a technique for ACL reconstruction using the semi-tendinosus tendon. The tendon was released from its musculotendinous junction and placed inta-articularly through 5 mm diameter bone tunnel drilled in the tibal epiphysis and a tunnel drilled through the lateral femoral condyle, where it was fixed to the periosteum. Galeazzi used three incisions one for harvesting of the semitendinosus tendon, another for arthotomy, and a third for laterally for fixation. He used a cast for four weeks and partially weight bearing for six weeks. Galeazzi was the first to publish the usage of hamstring tendon autograft in ACL reconstruction” (Davarinos, O’Neil, and Curtin, 2014, p. 2). Due to continued research, physicians were able to build on their previous findings and create new techniques to further the advances of ACL reconstruction surgery. In 1935, the patella tendon grafts were introduced, in 1963, bone –patellar tendon-base grafts were introduced, by the 1970’s synthetic grafts were introduced, the 1980’s began the use of the allograft, and by the early 2000’s the double –bundle graft was implemented. The double-bundle was the result of 6o plus years of research on the hamstring grafts. This technique avoided the use of hardware in the knee and skin graft fixation (Davarinos, O’Neil, and Curtin, 2014, p. 5).

All athletes in all sports are at risk for anterior cruciate ligament injuries, and there have been several advancements to traditional treatment over the past few years. Surgeons are researching ways anatomically to reconstruct the ACL with less invasive procedures. “ACL injuries are common in athletes. Some studies estimate that as many as 175,000 ACL reconstructions are done each year in the United States (Lyman, S, Koulouvais, P, Sherman, S, Do, H, Mandl, 2009, para 3). A child beginning sports should be six years of age before participating in an organized team sport, such as soccer, baseball, basketball, and football. As the pediatric population continues to organize athletics on a year round basis, more ACL injuries are being recognized in the pediatric population. “A recent surveillance study reported that ACL injuries represent nearly a quarter of all high school knee injuries” (Werner, Yang, Looney, Gwathmey, 2015, p.1). Usually, conservative management of the ACL injuries in the children athletes is done with bracing, rehabilitation, and activity modification. The actual ACL reconstruction would not be performed until skeletal maturity. “Several studies revealed poor outcomes with this approach. ACL techniques have been created to minimize the risk of growth arrest in the skeletally immature patient. Depending on the skeletal age and growth remaining, the categories of the construction techniques include physeal-sparing all epit-physeal or iliotibial band reconstruction for prepubescent patients with high remaining growth potential, partial transphyseal for young adolescents, or complete transphyseal for older adolescents near skeletal maturity. Outcomes for these techniques have demonstrated safety as excellent clinical stability and low revision rates” (Werner, Yang, Looney, Gwathmey, 2015, p.1). Over the years there have been several studies done to examine trends in ACL reconstruction rates in both adults and recently, in pediatric orthopaedic patients. It is harder to gather a significant amount of data on pediatric patients due to the diagnosis. The studies are done through data base studies and researchers rely on procedural codes, which do not always give them the data they need. What researchers have found is that ACL tears in pediatric and adolescent patients are no longer considered a rare entity. ACL injury and reconstruction in pediatric patients is rising at a significant rate (Werner, Yang, Looney, Gwathmey, 2015, p.3-5).


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