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 Sports Test 1: The Knee
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The Journal of Bone and Joint Surgery (American) 85:1656-1666 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Scientific Article

Occupational Disability After Hospitalization for the Treatment of an Injury of the Anterior Cruciate Ligament

Warren R. Dunn, MD, MPH, Andrew E. Lincoln, ScD,MS, Richard Y. Hinton, MD, MPH, MEd, PT, Gordon S. Smith, MD , MPH and Paul J. Amoroso, MD , MPH

Investigation performed at the Department of Orthopaedic Surgery, Union Memorial Hospital, Baltimore; Center for Injury Research and Policy, Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; War-Related Illness and Injury Study Center, Washington DC Veterans Affairs Medical Center, Department of Veterans Affairs, Washington, DC; Liberty Mutual Research Institute for Safety, Hopkinton; and the United States Army Research Institute of Environmental Medicine, Natick, Massachusetts

Warren R. Dunn, MD, MPH
Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021

Richard Y. Hinton, MD, MPH, MEd, PT
Department of Orthopaedic Surgery, Union Memorial Hospital, 3333 North Calvert Street, Suite 400, Baltimore, MD 21218. E-mail address: lyn.camire{at}medstar.net

Andrew E. Lincoln, ScD, MS
War-Related Illness and Injury Study Center, 50 Irving Street N.W. (MS 11), Washington, DC 20422

Gordon S. Smith, MD, MPH
Liberty Mutual Research Institute for Safety, 71 Frankland Road, Hopkington, MA 01748

Paul J. Amoroso, MD, MPH
United States Army Research Institute of Environmental Medicine, Attn: MCMR-EMP (Amoroso), Kansas Street, Building 42, Natick, MA 01760-5007

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institute for Occupational Safety and Health RO1 OH03703-01A1 and by a grant from the Orthopaedic Research and Education Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, Department of Veterans Affairs, or the United States Government.

The analyses conducted for this study adhere to the policies for the protection of human subjects as prescribed in Army Regulation 70-25 and with the provisions of Code of Federal Regulations title 45, part 46.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: To date, no large population-based studies have focused on permanent occupational disability after injury of the anterior cruciate ligament as far as we know. The purpose of our study was to determine the risk factors for occupational disability after an injury of the anterior cruciate ligament.

Methods: We identified a cohort of 2192 active-duty personnel in the Army who had been hospitalized between 1989 and 1997 because of an injury of the anterior cruciate ligament and had completed a health risk-assessment survey. With use of the Total Army Injury and Health Outcomes Database, we retrospectively followed these individuals for up to nine years and collected clinical, demographic, occupational, and psychosocial data. These data were then evaluated with bivariate and proportional-hazards regression analyses to identify risk factors for receiving a disability discharge related to an injury of the anterior cruciate ligament.

Results: Overall, 209 (9.5%) of 2192 initial anterior cruciate ligament injuries resulted in a permanent disability discharge. In bivariate analyses, the following factors were related to a disability discharge: lower job satisfaction (p < 0.0001), lower education level (p < 0.0001), shorter length of service (p < 0.0001), lower pay grade or rank (p < 0.0001), occupational classification (p < 0.0001), older age (p < 0.01), cigarette-smoking (p = 0.01), and greater mental stress at work (p = 0.02). Associated cartilage injury (p = 0.07) and occupational physical demands (p = 0.08) approached significance; however, with the numbers available, other variables that were hypothesized to contribute to the development of disability, such as gender (p = 0.85), reconstruction of the anterior cruciate ligament (p = 0.52), and other secondary comorbidities of the knee, demonstrated no significant association. Proportional-hazards regression analysis confirmed that pay grade or rank, occupational classification, job satisfaction, age, and length of service were independent predictors of disability discharge.

Conclusions: In keeping with risk profiles of several other musculoskeletal disorders, such as low-back pain and carpal tunnel syndrome, the results revealed a multifactorial risk profile in which psychosocial factors were strongly associated with disability discharge from active military duty after injury of the anterior cruciate ligament.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.



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