The most important finding of this research was that RTA was the most common cause of ACL injury (38.8%, 92/237) followed by sports-related injuries 33.3% (79/237) and fall was the third leading cause of ACL injury, which accounted for 16.5% (39/237) of cases.

Although ACL injuries are considered sports injuries, sporting activities are still limited to a small interested specific population in our country [10]. Recreational and professional sporting activities are on the rise in our country but they are not widespread and are not the most common cause of knee injuries. Non-sports-related causes (RTA, fall, and others) constituted most ACL injuries (66.7%) in our study. Similar to our result, previous research [11] evaluating meniscal injury in patients with an ACL tear and another paper from Nepal [12] evaluating the outcome of single-bundle ACLR also mentioned RTA being the most common cause of ACL injury. However, those studies did not elaborate on the several epidemiological aspects of ACL injury and focused primarily on the incidence of meniscal injury. In this study, sports was the most common cause of ACL injury in patients below 30 years of age. In contrast, RTA was the most common cause of injury in patients above 30 years. The reason for this outcome could be because sports activities are popular among students who are usually below 30 years; and patients above 30 were office workers.

In contrast to our findings, a study from Singapore found that only 17.6% of their cases had sustained ACL injury because of non-sports activity [13]. The Norwegian registry reports non-sporting activities contributing to 24% of cases, whereas the Kaiser Permanente registry reports it to be 29.5% [14]. As per Kaiser Permanente and Norwegian registries, RTA only constituted 4.2 and 1.1% of total ACL injuries, respectively [14]. Meanwhile, Luxembourg, UK, and Swedish registries reported it to be 1, 1.1, and 4.4%, respectively [4]. This is in sharp contrast to our study, which had a significantly higher percentage of cases occurring due to RTAs (38.8%). Moreover, accidents involving two-wheelers constituted 86.9% of cases of ACL injuries. Among these, 77.1% of the cases were riding on the two-wheeler, and drivers were injured more than the pillion riders. Since the most usual mode of transportation in Nepal is on two-wheelers, it is possible that two-wheeler accidents are more common statistically [15].

Also, several studies published from all over the world have mentioned sports injury as the most common cause of ACL tear [4, 16,17,18,19,20]. According to registries, Football (Soccer) has been reported as the most common sports activity causing ACL injuries. In the Singaporean population, sports activities resulted in 83.4% of the injuries, out of which the most common sport was football [13]. Although sports-related activities were the second most common cause of ACL injury in our study, soccer was the most common sport (83%) in our study, followed by basketball, badminton, cricket, and volleyball. Football is the most popular sport amongst young Nepalese; hence is the leading cause of ACL injuries in this age group.

In our study, most injuries occurred in the 15–30 years age group, and 73% of patients were male, with a male to female ratio of 2.7:1. The male to female ratio in the RTA group was 2.8:1, whereas it was 25:1 in the sports group. In contrast, females were more in Fall and other groups. This disparity may be because fewer women are involved in sporting activities compared to their male counterparts in Nepal. Additionally, men are more prone to injuries because of being mobile and frequenting places while women are comparatively occupied within the boundaries of the house. Our findings are similar to that of other published registry cohorts in which patients were mostly male and < 30 years of age [4]. Luxembourg and UK registries [4, 21, 22] had similar distribution like ours, with 71.7 and 72.4% male cases, respectively. Singaporean cohort had an average age of 29.4 +/− 8.69 years, with a relatively higher number of male patients than ours (83.9%) [13]. The mean age of females (39.27+/− 10.2 years) was higher than those of male patients (29.8+/− 9.6 years) in our study. In contrast, the Swedish registry [23] mentioned that the average age of men at surgery is higher than that of women. Luxembourg registry [21] (men: 28 ± 10; women: 32 ± 12, P < 0.01) reported findings similar to our study but with a relatively lower average age of females. The possible explanation for women having an injury at higher age is that they are less involved in sports, which in turn results in injury at a younger age, and the majority of the injury in this group are due to RTA and falls, which occur predominantly in the older age group.

Based on the profession of the patients, RTA (43.47%) was the most common injury in office worker, followed by sports injuries and falls. The RTA is the most common mode because office workers mostly travel by motorcycle and are more prone to accidents. In contrast, ACL injuries in housewives were mainly due to falls and twisting, and there was no sports-related injury in this group. The housewives in Nepal are presumably not very active in sports or athletics due to socio-cultural barriers, so there are no sports-related ACL tears in this group. Sports-related ACL injuries are the most common mode in students, followed by RTA. In Nepal, students partake in various sporting activities during their school and college level of study and the sporting activities start waning after that time period. Two-wheelers are very popular among student for traveling around and could be a reason why RTA is the second most common mode of injury in this age group.

We also evaluated the influence of geographical distribution on the occurrence of ACL injuries. It was found that the majority of injuries occurred in people residing in Hilly areas (60.3%), followed by people from Terai (38%), and only 4 cases were reported from the Himalayan region. Sports activities were the most common mode of injury in the Hilly region followed by RTA and falls. RTAs caused most cases in Terai, followed by sports activities. Football is frequently played in Hilly regions of Nepal, and two-wheeler ownership is higher in the Terai region [15]. This explains why sports-related injuries are more common in the Hilly region and RTAs in Terai. Also, Football is not very popular in Terai, which might be the possible reason for fewer sports-related ACL injuries comparatively.

Patients in our study had an average delay of 296.8+/− 696.8 days (Range 1 day to 14 years) from injury to surgery. The median delay in the MOON cohort [24] was 2.4 months, and an average of more than six months delay was seen in Scandinavian cohorts [4]. We also calculated the average delay from injury to ACLR based on the mode of injury in our context. In our study, 56.7% of RTAs were operated on within a month from the date of injury, while the sports injury group had a more significant delay in seeking ACLR (mean delay-11.79 months). This delay can be explained because most RTA is reported early to hospitals for receiving treatments since the medical expenses are covered by a third party causing the accident. On the other hand, sports injury cases are reported later to hospitals since treatment expenses might be a constraining factor for the delay in surgery. Analysis of outcome based on presentation delay would have been interesting, but this was beyond the scope of this study.

Limitations

There were several limitations of this study and the major one being the study focusing cases from a single center which did not portray a complete comprehensive profile of the injury of the country. The study also excluded non-operatively managed cases. Other limitations include the retrospective nature of study, a small sample size, a short sample period of two years and a lack of power analysis. Furthermore, 51 cases (17%) were excluded due to lack of verifiable data from patients which might have affected power of analysis and generalizability of the findings. A multi-center study consisting of larger sample size and duration from different parts of the country would have been ideal but we believe that this study represents a significant proportion of the patients presenting at tertiary centers of Nepal as this is one of the largest series from this part of the world where registries are not existing.

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