No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review

Demographic and surgical characteristics in patients who do not achieve minimal important change in the KOOS Sport/Rec and QoL after ACL reconstruction: a comparative study from the Swedish National Knee Ligament Registry

OBJECTIVES

This study aimed to compare demographic and surgical characteristics between patients who do and do not achieve minimal important change (MIC) in the Knee injury and Osteoarthritis Outcome Score (KOOS) Sports and Recreation (Sport/Rec) and Quality of Life (QoL) subscales 1 year after anterior cruciate ligament reconstruction.

DESIGN

Comparative cross-sectional.

SETTING

The MIC for the KOOS Sport/Rec subscale was ≥12.1 and ≥18.3 for the KOOS QoL subscale from before surgery to 1-year follow-up using data from the Swedish National Knee Ligament Registry.

PARTICIPANTS

In total 16 131 patients were included: 11 172 (69%) with no MIC for the Sport/Rec scale, and 10 641 (66%) for the QoL.

RESULTS

Patients with no MIC for Sport/Rec and QoL had a higher body mass index (BMI) (24.8±3.5 vs 24.6±3.3 and 24.7±3.5 vs 24.6±3.2, respectively, p<0.0001), were younger (years) at time of surgery (28.5±10.3 vs 29.1±10.8 and 27.4±9.8 vs 29.7±11.0, respectively, p=0.0002 and <0.0001), had longer time from injury to surgery (months) (Sports/Rec 22.0±38.5 vs 19.3±36.6, respectively, p=0.0002), and greater rates of concomitant cartilage injuries especially to the lateral femoral condyle (22.7% vs 19.4% and 23.3% vs 19.0%, respectively, p=0.001 and p=0.005) compared with patients who achieved the MIC. A smaller proportion of patients treated with a hamstring tendon autograft had no MIC (91.4%) compared with patients with MIC (94.1%).

CONCLUSIONS

Patients with no MIC for KOOS Sport/Rec and QoL subscales had a higher BMI, longer time from injury to surgery and were younger at the time of surgery compared with patients who did achieve MIC. Although differences were small, they may reframe management strategies with patients who have these characteristics.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

OBJECTIVE

Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

DESIGN

Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

RESULTS

We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

CONCLUSION

The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Delayed Versus Accelerated Weight-bearing Rehabilitation Protocol Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Objective

To compare accelerated and delayed weight-bearing rehabilitation of anterior cruciate ligament reconstruction regarding clinical outcome measures of knee function (International Knee Documentation Committee Subjective Knee Form (IKDC), Lysholm Knee Scoring Scale, Tegner Activity Scale, and Knee Injury and Osteoarthritis Outcome Score (KOOS)), knee laxity, range of movement, quadriceps, and bone tunnel enlargement.

Design

Systematic review and meta-analysis.

Methods

Systematic searches of Embase, MEDLINE, CINAHL, and the Cochrane Library databases, from inception to February 2021, for studies comparing delayed or accelerated weight-bearing rehabilitation protocol after anterior cruciate ligament reconstruction in adult patients.

Results

Nine studies met the eligibility criteria. A meta-analysis revealed a higher risk of knee laxity in the accelerated weight-bearing group. Accelerated weight-bearing may be related to higher IKDC scores, while there was no statistical difference for Lysholm, Tegner, and KOOS scores at a follow-up within 2 years. Four of 5 studies reported no statistical difference for quadriceps strength and range of movement scores, while 2 studies reported bone tunnel enlargement in the accelerated weight-bearing group.

Conclusion

This systematic review confirmed that accelerated weight-bearing caused more serious knee laxity and bone tunnel widening than delayed weight-bearing after anterior cruciate ligament reconstruction. We therefore recommend that clinicians should select postoperative rehabilitation programmes with caution.

Concomitant full-thickness cartilage lesions do not affect patient-reported outcomes at minimum 10-year follow-up after ACL reconstruction

PURPOSE

To compare patients with a concomitant full-thickness cartilage lesion and anterior cruciate ligament (ACL) injury to patients with an isolated ACL injury at 10-15 years post ACL reconstruction.

METHODS

This is a longitudinal follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the index study in 2007. The study group consisted of 30 patients that underwent ACL reconstruction and had a concomitant, isolated full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grade 3-4). Each study patient was matched with two control patients who underwent ACL reconstruction but had no cartilage lesions (ICRS grade 1-4) (n = 59). At a median follow-up of 10.2 years (range 9.9-15.6), 65 patients (74%) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was the main outcome measure, resulting in 23 pairs after matching.

RESULTS

At a follow-up of 10-15 years after ACL reconstruction, no significant differences in KOOS were found between patients with a concomitant full-thickness cartilage lesion and patients without cartilage lesions. There was also no significant difference between the two groups when comparing the change over time in KOOS scores from preoperative to follow-up. Both groups showed significant improvement in all KOOS subscales from preoperative to follow-up, except for in the Symptoms subscale for the control group. The greatest improvement was in the QoL subscale for the study group.

CONCLUSION

ACL-reconstructed patients with a full-thickness cartilage lesion did not report worse outcomes at 10-15 years after surgery compared with patients with an isolated ACL injury. Our findings support that there is no long-term negative effect of a concomitant cartilage lesion in an ACL-reconstructed knee. These findings should be considered when discussing treatment and informing about the expected long-term outcome after ACL reconstruction to patients with such combined injuries.

LEVEL OF EVIDENCE

II.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

OBJECTIVES

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making.

METHODS

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

RESULTS

Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.

CONCLUSION

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.

Effect of Graft Rupture Prevention Training on Young Athletes After Anterior Cruciate Ligament Reconstruction: An 8-Year Prospective Intervention Study

Background:

There is a lack of research on the effects of a postoperative rehabilitation program on anterior cruciate ligament (ACL) graft rupture.

Hypothesis:

We hypothesized that a hip-focused rehabilitation protocol with graft rupture education and avoidance training (HIP-GREAT program) would demonstrate lower ACL graft rupture rates compared with a traditional physical therapy (PT) program.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study consisted of young athletes who had undergone ACL reconstruction at a single institution. Postoperatively, 136 participants (mean age, 16.9 ± 2.4 years) were enrolled in a traditional PT protocol between 2006 and 2010, and 153 participants (mean age, 17.0 ± 2.3 years) were enrolled in the HIP-GREAT protocol between 2011 and 2015. Follow-up rates were 31% (42/136) and 27% (41/153) in the traditional PT and HIP-GREAT groups, respectively, at 3 years postoperatively. The hazard ratio was calculated, and absolute risk reduction (ARR) and number-needed-to-treat (NNT) analyses were performed to compare the 2 protocols.

Results:

ACL graft rupture occurred in 10 patients (7.4%) in the traditional PT group and 5 patients (3.3%) in the HIP-GREAT group. This difference was not statistically significant (hazard ratio, 0.39; 95% CI, 0.14 to 1.16; P = .09). The ARR was 0.041 (95% CI, –0.011 to 0.093), and the NNT was 24.5.

Conclusion:

This study did not demonstrate a statistically significant reduction of ACL graft rupture in patients in the HIP-GREAT group. However, high ARR values and low NNT values were found, which suggests the possible effectiveness of the HIP-GREAT protocol to reduce ACL graft ruptures in young athletes.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

PURPOSE

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making.

METHODS

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

RESULTS

Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.

CONCLUSION

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery.

LEVEL OF EVIDENCE

IV.

Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group

Background

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level.

Purpose

The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making.

Study Design

Consensus statement.

Methods

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

Results

Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries.

Conclusion

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

Cartilage damage at the time of anterior cruciate ligament reconstruction is associated with weaker quadriceps function and lower risk of future ACL injury

PURPOSE

To determine whether articular cartilage damage noted at the time of primary anterior cruciate ligament reconstruction (ACLR) affects the likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery or risk of recurrent ACL injury.

METHODS

Five hundred and eight patients underwent primary ACLR and diagnostic arthroscopy. All identified cartilage lesions were graded using the Outerbridge system. All patients underwent isokinetic strength testing. The association between cartilage Outerbridge grade and a ≥ 90% Limb Symmetry Index (LSI) and recurrent ACL injury risk at mean 38.7 month follow-up (SD 31.8) was evaluated via multivariate regression analysis.

RESULTS

Grade 2 or higher damage was present in 394 (77.5%) of patients, grade 3 or higher in 143 (28.1%) and grade 4 in 83 (16.4%) at time of ACLR. Ipsilateral ACLR graft rupture occurred in 31 (6.1%) of patients. Contralateral ACL injury occurred in 19 (3.7%). Patients with grade 2 or higher damage were significantly less likely to meet an LSI goal of ≥ 90% for fast (300°/s) isokinetic extension. There was no association with slow isokinetic extension. Cartilage lesion severity at or beyond grade 2 had a similar effect on isokinetic testing results regardless of compartment involvement or performance of microfracture. Patients with grade 2-4 cartilage damage were less likely to sustain a second ipsilateral ACL injury or a contralateral native ACL injury.

CONCLUSIONS

Cartilage damage seen at time of ACL reconstruction is common and associated with lower likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery. However, lower recurrent ACL injury rates are seen in patients with concurrent cartilage damage. These data may inform future clinical decisions regarding operative managment of recurrent ACL injuries.

LEVEL OF EVIDENCE

III.

Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts

BACKGROUND

Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential.

PURPOSE

(1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo).

STUDY DESIGN

Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3.

METHODS

A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes.

RESULTS

No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores (P < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS-Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON (P = .011).

CONCLUSION

Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR.

REGISTRATION

NCT01773317 (ClinicalTrials.gov identifier).

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

OBJECTIVES

To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction.

DESIGN

Systematic review of CPGs (PROSPERO number: CRD42017020407).

DATA SOURCES

Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018.

ELIGIBILITY CRITERIA

English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction.

RESULTS

Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was 'applicability' (can clinicians implement this in practice?) (29%) and the highest 'scope and purpose' (78%) and 'clarity of presentation' (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing.

CONCLUSION

The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

Bone-to-bone integrations were complete within 5 months after anatomical rectangular tunnel anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft

PURPOSE

Anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) graft is known to provide secure fixation due to the direct bone-to-bone integration of the bone plug and bone tunnel. It is important to know the time required for bone integration when designing the postoperative rehabilitation protocol or deciding when the patient can return to competition-level activity, especially if the patient is an athlete. However, because reports are scarce, the period necessary for bone-to-bone integration after ACL reconstruction using a BTB graft remains unclear. The purpose of this study was to clarify this issue. It was hypothesised that ACL reconstruction using a BTB graft via an anatomical rectangular tunnel would help in the integration between bone plugs and bone tunnels on both the femoral and tibial sides after at least 6 months, at which point basic exercises similar to pre-injury sporting activity levels can be resumed.

METHODS

This study included 40 knees treated with ACL reconstruction using a BTB graft via anatomical rectangular tunnel reconstruction between 2013 and 2014 in a single institute. The integration between bone plugs and bone tunnels was evaluated using multi-slice tomosynthesis, which is a technique for producing slice images using conventional radiographic systems, at 1, 3, and 5 months postoperatively. All procedures were performed by two experienced surgeons. Bone integration was evaluated by two orthopaedic doctors.

RESULTS

The rates of integration of the bone plug and femoral bone tunnel on tomosynthesis at 1, 3, and 5 months postoperatively were 0, 55, and 100%, respectively. On the tibial side, the corresponding rates were 0, 75, and 100%, respectively. The rate of integration on the tibial side was significantly higher than that on the femoral side at 3 months postoperatively (p = 0.031).

CONCLUSIONS

Bone-to-bone integration on the femoral and tibial sides was complete within 5 months after surgery in all cases. Since the time required for bone integration is important in designing the postoperative rehabilitation approach, these results will serve as a useful guideline for planning rehabilitation protocols.

LEVEL OF EVIDENCE

IV.