Rehabilitation After Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction

Returning Athletes to Sports Following Anterior Cruciate Ligament Tears

PURPOSE OF REVIEW

The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population.

RECENT FINDINGS

Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial

PURPOSE

The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction.

METHODS

All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension.

RESULTS

The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups.

CONCLUSION

In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain.

LEVEL OF EVIDENCE

II, prospective randomized trial.

Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction

Purpose

To identify whether any patient factors, injury factors, or symptom severity scores are associated with either psychological or physical readiness to return to sport after anterior cruciate ligament reconstruction (ACLR).

Methods

Consecutive patients with an ACL injury that required surgical treatment were included in this study. All patients completed the single-legged hop testing and the Anterior Cruciate Ligament Return to Sport Index (ACL-RSI) at 1 year postoperatively. Multivariable regression analysis models were used to determine whether an independent relationship existed between baseline patient factors (age, sex, BMI, preinjury Marx Activity Score), injury factors (meniscal tear and chondral injury), physical symptoms (Knee Injury and Osteoarthritis Outcome Score [KOOS] for pain and symptoms), and the dependent variables of physical and psychological readiness to return to sport (single-legged hop and ACL-RSI).

Results

Of the 113 patients who were included, 37% were female, and the mean age of our population was 28.2 years (SD = 8.1). Multivariable regression models demonstrated that patient-reported pain symptoms at 1 year postoperatively, as measured by the KOOS pain subscale, was significantly associated with both ACL-RSI score (Beta estimate: 1.11 [95% CI: .62-1.60] P < .001) and the ability to pass the single-legged hop test (OR: 1.07 [95% CI: 1.004-1.142] P = .037).

Conclusions

Patients with higher reported pain levels at 1 year following ACLR have lower psychological and physical readiness to return to sport.

Level of Evidence

Level 3, retrospective cohort study.

Evidence-based rehabilitation following anterior cruciate ligament reconstruction

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT's) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.