Anterior Cruciate Ligament Reconstruction Rehabilitation Clinical Practice Patterns: A Survey of the PRiSM Society

A Qualitative Study of Factors Perceived to Influence Physical Activity among Young Athletes after ACL Reconstruction

Background

Despite evidence of alarming declines in physical activity levels after anterior cruciate ligament reconstruction (ACLR), very little is known about how young athletes perceive their experiences with engagement in sports and physical activity in the years following ACLR.

Hypothesis/Purpose

The purpose of this study was to answer the research question, "what are the lived experiences and perceptions of factors that facilitate or hinder physical activity among young athletes following ACLR?".

Study Design

Qualitative Study.

Methods

Ten participants were included in this qualitative study at a median of 5.9 (4.3-10.2) years after adolescent ACLR. Using an interpretive phenomenological methodology, semi-structured interviews were conducted with each participant. Data collection focused on participants' lived experiences related to physical activity participation in the years after ACLR. Iterative coding with two independent coders and a peer debriefing process were used to identify themes from the data.

Results

Factors perceived to influence physical activity after ACLR spanned all levels of the socioecological framework. Three overarching themes were generated during thematic analysis: 1) navigation of barriers (common obstacles, injury-related limitations, unique adaptations), 2) movement motives (ingrained desire to move, external motivators, internal motivation), and 3) movement mindset (envisions for future physical activity, perceived impact of injury, belief in the power of sports).

Conclusion

The themes identified in this study indicate that the adolescent ACLR experience has the potential to significantly influence one's physical activity into young adulthood, both positively and negatively. These findings serve as an important foundation for future studies to explore the psychological and environmental factors identified as important to one's physical activity participation in the years following adolescent ACLR.

Level of Evidence

Level 3.

Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients

PURPOSE OF REVIEW

Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered.

RECENT FINDINGS

Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.

Comparison of physical therapy utilization, timing of return-to-sport test completion, and hop test performance by age and between sexes in youth athletes after anterior cruciate ligament reconstruction

OBJECTIVE

To compare physical therapy (PT) utilization, timing of return-to-sport (RTS) test and hop test performance by age and between sexes in youth after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Multicenter retrospective cohort.

METHODS

A retrospective review of adolescents after primary ACLR was conducted. Participants completed return-to-sport (RTS) tests including single-legged hop testing. PT frequency, average weekly visits, and timing of RTS test were calculated. T-tests assessed the effect of age and sex on average weekly PT visits and multivariable logistic regressions assessed odds of passing hop tests.

RESULTS

289 participants were included (15.7 ± 1.9 years). There was no difference in average weekly PT visits (p = 0.321) or time to RTS test (p = 0.162) by age. There were significant differences in average weekly PT visits (p = 0.047) and mean time from surgery to RTS test (p = 0.048) between sexes with small effect sizes (d = 0.24 and d = 0.21, respectively). Age and sex had no effect on odds of passing hop tests (OR, 1.29; 95% CI, 0.71-2.35 and OR, 0.79; 95%CI, 0.43-1.45, respectively).

CONCLUSION

In a youth cohort, age and sex may have no clinically important effect on PT visit utilization, timing of RTS test or hop test performance.

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis

BACKGROUND

There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR).

PURPOSE/HYPOTHESIS

This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone-patellar tendon-bone autograft at 6 months postoperatively in an adolescent population. The authors' hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used.

STUDY DESIGN

Controlled laboratory study.

METHODS

Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb.

RESULTS

A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10-2 vs -35 × 10-2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10-2 vs -4 × 10-2 N·m/kg, respectively; P = .0426). Both the QT with bone block (-12 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0265) and QT (-13 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group.

CONCLUSION

The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft.

CLINICAL RELEVANCE

This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background

While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap."

Methods

The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients.

Results

Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation.

Discussion

While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.

Improved Patient-reported Outcomes in Patients Aged 16 and Younger at Two Years After Anterior Cruciate Ligament Reconstruction Despite Relatively High Rates of Reinjury and Repeat Surgery

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes.

METHODS

The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS.

RESULTS

A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance.

CONCLUSION

Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR.

LEVEL OF EVIDENCE

Level IV-case series.

Which Tests Predict 6-Month Isokinetic Quadriceps Strength After ACL Reconstruction? An Examination of Isometric Quadriceps Strength and Functional Tests at 3 Months

Background

Restoration of quadriceps strength after anterior ligament reconstruction (ACLR) is a persistent challenge for patients and clinicians. Inadequate recovery of quadriceps strength has been linked to increase risk of re-injury. Developing methods of early identification of strength deficits is essential to allow clinicians to provide more individualized interventions early in the rehabilitation process.

Purpose

To determine whether 3-month isometric quadriceps strength, the Y-Balance Test (YBT), and the anterior step-down test are predictive of isokinetic quadriceps strength at six months in adolescents after ACLR.

Design

Retrospective cohort.

Methods

Thirty-six adolescent patients with primary ACLR (58% female, 36% with concomitant meniscal repair, age: 15.7 ± 1.6 years). At three months post-operative, isometric quadriceps strength via isokinetic dynamometer, YBT-Lower Quarter, and anterior step-down tests were completed. At six months post-operative, an isokinetic knee strength assessment was completed. Regression analysis was used to evaluate the predictive relationship between 3-month isometric tests and 6-month isokinetic knee extension tests.

Results

Three-month post operative isometric quadriceps peak torque predicted isokinetic quadriceps peak torque at 6 months, F(1,34) = 19.61, p <0.001. Three-month isometric quadriceps peak torque accounted for 36.6% of the variance in normalized isokinetic quadriceps peak torque at 6 months with adjusted R2 = 34.7%. Including YBT anterior reach (β = 0.157, p = 0.318) in regression added 1.9% of variance when predicting 6-month isokinetic quadriceps peak torque, F (2,33) = 10.32, p <0.001, R2 = 0.385, ΔR2 = 0.019.

Conclusion

At three months post-ACLR, isometric strength testing appears more optimal than other functional tests in predicting isokinetic quadriceps peak torque in later stages of rehabilitation for adolescents. Clinicians should use tests at three months that measure quadriceps strength if aiming to predict isokinetic quadriceps peak torque at six months post-ACLR, rather than using functional tests such as the YBT-LQ or anterior step-down.

Level of Evidence

Level 3.

Postoperative considerations based on graft type after anterior cruciate ligament reconstruction a narrative review

Background and Objective

Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care.

Methods

A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation.

Key Content and Findings

Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types.

Conclusions

Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism.

There Is Substantial Variation in Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction: A Survey of 46 American Orthopaedic Surgeons

PURPOSE

To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM).

METHODS

An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process.

RESULTS

Responses from 46 orthopaedic surgeons were analyzed. Patient-reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty-eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return-to-sport phases, respectively.

CONCLUSIONS

This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision-making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice.

CLINICAL RELEVANCE

Postoperative rehabilitative protocols after ACLR vary by surgeon.

Relationship Between Quadriceps Strength and Knee Joint Power During Jumping After ACLR

Background

Knee joint power is significantly impaired during the propulsive phase of jumping after anterior cruciate ligament reconstruction (ACLR); however, it is currently unknown how quadriceps strength influences knee joint power.

Purpose

To (1) evaluate the relationship between quadriceps strength, joint power, and the percentage contribution of the hip, knee, and ankle joints to total limb power during the propulsive phase of jumping and (2) establish a quadriceps strength cutoff value for maximizing the likelihood of having knee joint power characteristics similar to healthy participants.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 75 participants were included in this study-40 patients who underwent ACLR 6 months before (18 females; mean age, 19.3 ± 5.7 years) and 35 healthy controls (HC) (20 females; mean age, 21.5 ± 4.5 years). Participants performed a drop vertical jump and underwent isometric quadriceps strength testing. The peak joint power was calculated as the product of the internal joint moment and joint angular velocity. Pearson product-moment correlations were used to assess the relationship between quadriceps strength and knee joint power. Paired samples t tests were used to quantify differences between limbs. Receiver operating characteristic (ROC) curve analysis was used to determine a quadriceps strength cutoff.

Results

The involved limbs of the ACLR cohort (INV) had significantly lower peak knee joint power and percentage contribution from the knee joint during jumping compared with the uninvolved limbs (NON) and limbs of the controls (INV, 2.5 ± 1.2 W/kg; NON, 4.4 ± 1.5 W/kg; HC, 4.3 ± 1.7 W/kg [P < .0001]). Quadriceps strength was associated with knee joint power in involved limbs and limbs of controls (INV, r = 0.50; HC, r = 0.60). A quadriceps strength cutoff value of 2.07 N·m/kg had an area under the ROC curve of 0.842, indicating good predictive accuracy.

Conclusion

Athletes at 6 months after ACLR demonstrated knee-avoidant jumping mechanics and had significant reductions in knee joint power on the involved limb. A quadriceps strength cutoff value of 2.07 N·m/kg can help predict which athletes will display knee joint power characteristics similar to those of healthy controls.

Criteria Used to Determine Unrestricted Return to Activity After ACL Reconstruction in Pediatric and Adolescent Patients: A Systematic Review

Background

The rates of anterior cruciate ligament (ACL) graft failure or contralateral ACL rupture range from 17% to 30% in pediatric patients after ACL reconstruction (ACLR). A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return to activity (RTA) postoperatively.

Purpose

To review the literature and identify the most commonly used criteria when determining unrestricted RTA after ACLR in pediatric patients.

Study Design

Systematic review; Level of evidence, 4.

Methods

A search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and SPORTDiscus databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors identified studies that included pediatric patients (<19 years of age) and specified the criteria used to determine RTA after ACLR.

Results

A total of 27 articles met all criteria for review, of which 13 studies only used 1 criterion when determining RTA. Objective criteria were the most common type of criteria for RTA (17 studies). Strength tests (15 studies) and hop tests (10 studies) were the most commonly used tasks when deriving RTA criteria. Only 2 studies used validated questionnaires to assess the patient's physiological readiness for RTA, and only 2 studies used an objective assessment of movement quality before RTA.

Conclusion

Only 14 of the 27 reviewed studies reported using >1 criterion when determining RTA. Furthermore, few studies used patient-reported outcome measures or lower limb kinematics as RTA criteria, indicating that more research is needed to validate these metrics in the pediatric population.

Knee Strength Assessment and Clinical Evaluation Could Predict Return to Running after Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Procedure

BACKGROUND AND OBJECTIVES

Muscle knee strength is a major parameter that allows return to running. Isokinetic strength parameters may predict return to running 4 months after ACLR using the bone-patellar-tendon-bone procedure.

MATERIALS AND METHODS

The isokinetic knee strength of 216 patients (24.5 ± 5 years) was measured 4 months after surgery, and progressive return to running was allowed. The effectiveness of return to running was reported at 6 months. Return to running prediction was established using multivariate logistic regression. Predictive parameters were presented with a ROC curve area to define the best cut-off, with sensibility (Se) and specificity (Sp).

RESULTS

A model was established, including the limb symmetry index (LSI), and 103 patients (47.6%) were able to run between the fourth and the sixth month after surgery. These patients presented significantly fewer knee complications, a better Lysholm score, a better Quadriceps and Hamstring LSI and better quadriceps strength reported for body weight on the operated limb. The best model was established including the Quadriceps and Hamstring LSI at 60°/s and the Lysholm score. The cut-off for Quadriceps LSI was 60% (ROC curve area: 0.847; Se: 77.5%; Sp: 77%), for Hamstring LSI 90% (ROC curve area: 0.716; Se: 65.7%; Sp: 60.2%) and for Lyshom score 97 points (ROC curve area: 0.691; Se: 65%; Sp: 66%).

CONCLUSION

Four months after ACLR using a bone-patellar-tendon-bone procedure, the Quadriceps and Hamstring LSI associated to the Lysholm score could help make the decision to allow return to running.

Financial Burden of Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

High costs and lack of price transparency for common pediatric orthopaedic procedures create financial burden for patients. We assessed (1) how patient medical debt after anterior cruciate ligament reconstruction (ACLR) correlates with health insurance type; and (2) factors associated with patient financial burden and worry after ACLR.

METHODS

We reviewed records of 122 patients aged below 18 years who underwent ACLR at our US academic hospital from 2016 to 2020. Patients were grouped by health insurance type: private (n=80) or public (n=42). A telephone survey about ACLR-related financial burden and worry was administered to patients' parents (45% response rate). Primary outcomes were patient medical debt and patient-reported financial burden measured by the financial burden composite score (0 to 6, with 6 representing highest burden) and dichotomized worry score (1 to 3, low worry; 4 to 5, high worry). We used univariate analyses to compare financial outcomes and multivariable regressions to determine factors associated with reported financial burden (alpha=0.05).

RESULTS

Debt after ACLR was reported by 10 of 122 patients (8%), all of whom had private insurance ( P =0.045). Of 55 survey respondents, treatment-related financial burden was reported by 32 (58%). Mean±SD financial burden composite scores were higher for privately insured (1.8±2.0) versus publicly insured patients (0.74±1.2) ( P =0.02), but rates of high financial worry were similar (private, 8% vs. public, 21%) ( P =0.22). A higher proportion of patients with private insurance (31%) reported having to use savings after ACLR compared with publicly insured patients (5%) ( P =0.04). The most frequently cited reason for financial burden was the cost of postoperative physical therapy (PT) (n=21). Number of PT visits was independently associated with financial burden composite scores ( P =0.02). Insurance type was not independently associated with financial burden ( P >0.05).

CONCLUSION

Although a small proportion of patients generated medical debt after ACLR (greater for those privately vs. publicly insured), the majority reported treatment-related financial burden primarily driven by PT costs.

LEVEL OF EVIDENCE

Level III.

Differences in the course of rehabilitation and outcomes for publicly insured pediatric patients after anterior cruciate ligament reconstruction

OBJECTIVE

Examine the effect of insurance type on physical therapy (PT) utilization and outcomes within pediatric and adolescent patients after anterior cruciate ligament reconstruction.

DESIGN

Multicenter retrospective cohort study.

METHODS

PT visits and functional hop test performance were extracted into a shared database. The average number of PT visits per week was assessed overall and by time period. Independent samples t-test examined the effect of insurance on PT utilization and the effect of insurance status on the odds of passing single-legged hop tests was assessed using multivariable logistic regression.

RESULTS

A total of 281 patients (15.7 ± 1.9, 42% female) were included in this analysis. Of these, 128 (45%) had public insurance. Publicly insured patients experienced a longer delay from surgery to hop test (8.3vs7.7 months, p = 0.009), attended overall fewer PT visits per week (0.92vs1.04, p = 0.005), with most of the decreased frequency occurring between weeks 7-24. Insurance status had a significant effect on the odds of passing the single leg hop test (2.72; 95%CI, 1.27-5.81).

CONCLUSION

Publicly insured patients average a lower number of weekly PT visits, experienced a longer delay from surgery to hop testing and were 2.7 times less likely to pass the single leg hop for distance test.

Protocol for the systematic review of return-to-activity criteria in adolescent patients following an anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a debilitating knee injury associated with sequela such as joint instability and progressive degeneration. Unfortunately, following surgical ACL reconstruction in adolescents, the rates of ACL graft failure range from 17 to 19%. A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return-to-activities (RTA) postoperatively. Several systematic reviews have already sought to develop a consensus on what criteria should be utilized for releasing patients to unrestricted sports activities; however, these reviews have focused on adult populations, a group at much lower risk for reinjury. Our objective is to systematically examine the literature and identify the criteria used when determining unrestricted RTA following an ACL reconstruction in an adolescent population.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search will be performed of the MEDLINE/PubMed, Cochrane, Embase, CINAHL, and SPORTDiscus electronic databases. Searches will be conducted from January 1, 2000, until submission of the final review. Studies will be identified that include adolescent patients (10-18 years old) undergoing a primary ACL reconstruction and which have specified the criteria used to determine RTA. Each article will be independently screened by two reviewers. To supplement the electronic database search, citations within all included studies will be manually reviewed. Reviewers will record the RTA assessment utilized and the rates of ACL reinjury through a standardized data extraction sheet. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the most commonly used types of RTA criteria.

DISCUSSION

This systematic review will determine the most commonly used RTA criteria in adolescent patients post-ACL reconstruction. This will help future interventions build more effective adolescent-specific RTA assessments through the validation of current RTA criteria as well as the implementation of new criteria according to the identified literature gaps.

Functional Bracing Following Anterior Cruciate Ligament Reconstruction: A Critical Analysis Review

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Anterior cruciate ligament (ACL) injuries remain common among athletes; these injuries require reconstruction to restore stability and enable successful return to sport.

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The role of postoperative dynamic knee bracing following ACL reconstruction in protecting graft integrity and promoting return to sport remains largely unknown.

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Limited biomechanical studies on functional bracing have reported decreased strain across the ACL with increasing anterior shear loading.

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Investigations evaluating functional brace use in clinical studies have not yet demonstrated consistent improvement in clinical outcomes, reduced graft retear rates, or improved return-to-sport rates in sports other than skiing.

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Additional investigation examining athletes of various ages participating in different sporting activities is necessary to better understand the role of functional bracing following ACL reconstruction.

Comparison of hamstring and quadriceps strength after anatomical versus non-anatomical anterior cruciate ligament reconstruction: a retrospective cohort study

Background

Strength recovery of injured knee is an important parameter for patients who want to return to sport after anterior cruciate ligament reconstruction (ACLR). Comparison of muscle strength between anatomical and non-anatomical ACLR has not been reported.

Purpose

To evaluate the difference between anatomical and non-anatomical single-bundle ACLR in hamstring and quadriceps strength and clinical outcomes.

Methods

Patients received unilateral primary single-bundle hamstring ACLR between January 2017 to January 2018 were recruited in this study. Patients were divided into anatomical reconstruction group (AR group) and non-anatomical reconstruction group (NAR group) according to femoral tunnel aperture position. The hamstring and quadriceps isokinetic strength including peak extension torque, peak flexion torque and H/Q ratio were measured at an angular velocity of 180°/s and 60°/s using an isokinetic dynamometer. The isometric extension and flexion torques were also measured. Hamstring and quadriceps strength were measured preoperatively and at 3, 6, and 12 months after surgery. Knee stability including Lachman test, pivot-shift test, and KT-1000 measurement and subjective knee function including International Knee Documentation Committee (IKDC) and Lysholm scores were evaluated during the follow-up.

Results

Seventy-two patients with an average follow-up of 30.4 months (range, 24–35 months) were included in this study. Thirty-three were in AR group and 39 in NAR group. The peak knee flexion torque was significant higher in AR group at 180°/s and 60°/s (P < 0.05 for both velocity) at 6 months postoperatively and showed no difference between the two groups at 12 months postoperatively. The isometric knee extension torque was significant higher in AR group at 6 months postoperatively (P < 0.05) and showed no difference between the two groups at 12 months postoperatively. No significant differences between AR group and NAR group were found regarding knee stability and subjective knee function evaluations at follow-up.

Conclusions

Compared with non-anatomical ACLR, anatomical ACLR showed a better recovery of hamstring and quadriceps strength at 6 months postoperatively. However, the discrepancy on hamstring and quadriceps strength between the two groups vanished at 1 year postoperatively.

Athletic identity and sport commitment in athletes after anterior cruciate ligament reconstruction who have returned to sports at their pre-injury level of competition

Background

This study aimed to determine the relationships between athletic identity and sport commitment and return to sports (RTS) status in athletes after anterior cruciate ligament reconstruction (ACLR).

Methods

Thirty-nine participants post-ACLR (8–24 months) were included in this cross-sectional study. Measures included the athletic identity measurement scale and sport commitment scale. In addition, we measured kinesiophobia and psychological readiness using the Tampa Scale for Kinesiophobia and ACL-Return to sport after injury scale. The subjects were categorized into Yes-RTS or No-RTS based on two questions to determine whether they were returning to sport at the same level of competition as before the injury. A Chi-squared test, Fisher’s exact test, unpaired t-test, and Mann-Whitney’s U test were used to analyze the data.

Results

The Yes-RTS group had significantly higher scores on the athletic identity measurement scale (P = 0.023, effect size [ES] = − 0.36), sport commitment scale (P = 0.027, ES = − 0.35), and ACL-Return to sport after injury scale (P = 0.002, ES = − 0.50) and significantly lower Tampa Scale for Kinesiophobia scores (P = 0.014, ES = − 0.39) compared to the No-RTS group.

Conclusion

Athletes who returned to sports at the same level of competition as before the injury had higher athletic identity and sport commitment and lower kinesiophobia compared to those who did not return to sports at the same level of competition. These self-beliefs regarding sport may play an important role in post-ACLR athletes’ RTS.

Age, rehabilitation and surgery characteristics are re-injury risk factors for adolescents following anterior cruciate ligament reconstruction

OBJECTIVES

To examine the effect of age on post-ACLR rehabilitative outcomes and identify surgical/rehabilitative characteristics as ACL re-injury risk factors in adolescents.

DESIGN

Cohort study.

SETTING

Children's hospital.

PARTICIPANTS

273 adolescents with first-time ACLR.

MAIN OUTCOME MEASURES

Demographics, injury history, surgery, and outcomes documented during post-ACLR physical therapy (PT) sessions were extracted from medical records. Effects of age on outcomes were examined using multivariate regression. ACL re-injury risk factors were identified using survival analysis with Cox regression.

RESULTS

Re-injury was recorded in 47 patients (17.2%) with a median follow-up time of 3.1 years and median re-injury time of 13.4 months post-surgery. Younger age (Hazard-Ratio, HR = 1.264 per year decrease; P = 0.005), receiving surgery within 1 month post-injury (HR = 3.378 vs. >3 months; P = 0.012), starting PT within 3 days post-surgery (HR = 3.068; P = 0.022), and decreased number of PT sessions (HR = 1.118 per 3-session decrease; P = 0.010) increased re-injury risk. Although age was associated with re-injury risk, age was not associated with any outcome (P > 0.059).

CONCLUSION

Adolescents who are younger, receive surgery and post-surgery PT sooner, or attend fewer PT sessions may be at an increased re-injury risk. Younger patients achieved similar outcomes despite elevated re-injury risk. Current discharge criteria are inadequate in identifying high re-injury risk patients.

Temporal Utilization of Physical Therapy Visits After Anterior Cruciate Ligament Reconstruction

Background:

Physical therapy (PT) rehabilitation is critical to successful outcomes after anterior cruciate ligament reconstruction (ACLR). Later-stage rehabilitation, including sport-specific exercises, is increasingly recognized for restoring high-level knee function. However, supervised PT visits have historically been concentrated during the early stages of recovery after ACLR.

Purpose/Hypothesis:

To assess the number and temporal utilization of PT visits after ACLR in a national cohort. We hypothesized that PT visits would be concentrated early in the postoperative period.

Study Design:

Descriptive epidemiological study.

Methods:

The Humana PearlDiver database was searched to identify patients who underwent ACLR between 2007 and 2017. Patients with additional structures treated were excluded. The mean ± SD, median and interquartile range (IQR), and range of number of PT visits for each patient were determined for the 52 weeks after ACLR. PT visits over time were also assessed in relation to patient age and sex.

Results:

In total, 11,518 patients who underwent ACLR met the inclusion criteria; the mean age was 32.62 ± 13.70 years, and 42.7% were female patients. Of this study cohort, 10,381 (90.4%) had documented PT postoperatively; the range of PT visits was 0 to 121. On average, patients had 16.90 ± 10.60 PT visits (median [IQR], 16 [9-22]) after ACLR. Patients completed a mean of 52% of their PT visits in the first 6 weeks, 75% in the first 10 weeks, and 90% in the first 16 weeks after surgery. Patients aged 10 to 19 years had the highest number of PT visits (mean ± SD, 19.67 ± 12.09; median [IQR], 18 [12-25]), significantly greater than other age groups (P < .001).

Conclusion:

PT after ACLR is concentrated in the early postoperative period. Physicians, therapists, and patients may consider adjusting the limited access to PT to optimize patient recovery.

Clinical Relevance:

As supervised PT visits may be limited, the appropriate temporal utilization of supervised PT visits must be maximized. Strategies to ensure sessions for later neuromuscular and activity-specific rehabilitation are needed.

Quadriceps Strength Influences Patient Function More Than Single Leg Forward Hop During Late-Stage ACL Rehabilitation

BACKGROUND

A comprehensive battery of tests are used to inform return to play decisions following anterior cruciate ligament (ACL) reconstruction. Performance measures contribute to patient function, but it is not clear if achieving symmetrical performance on strength and hop tests is sufficient or if a patient also needs to meet minimum unilateral thresholds.

HYPOTHESIS/PURPOSE

To determine the association of quadriceps strength and single-leg forward hop performance with patient-reported function, as measured by the IKDC Subjective Knee Form (IKDC), during late-stage ACL rehabilitation. A secondary purpose was to determine which clinical tests were the most difficult for participants to pass.

STUDY DESIGN

Descriptive Laboratory Study.

METHODS

Forty-eight individuals with a history of ACL-R (32 female, 16 male; mean±SD age=18.0±2.7 y; height=172.4±7.6 cm; mass=69.6±11.4 kg; time since surgery=7.7±1.8 months; IKDC=86.8±10.6) completed the IKDC survey, quadriceps isometric strength, and single-leg forward hop performance. The relationship between IKDC scores and performance measures (LSI and involved limb) was determined using stepwise linear regression. Frequency counts were used to determine whether participants met clinical thresholds (IKDC ≥ 90%, quadriceps and single-leg forward hop LSI ≥ 90%, quadriceps peak torque ≥ 3.0 Nm/kg, and single-leg forward hop ≥ 80% height for females and ≥ 90% height for males).

RESULTS

Quadriceps LSI and involved limb peak torque explained 39% of the variance in IKDC scores while measures of single-leg forward hop performance did not add to the predictive model. Nearly 90% of participants could not meet established clinical thresholds on all five tests and quadriceps strength (LSI and peak torque) was the most common unmet criteria (71% of participants).

CONCLUSIONS

During late-stage ACL rehabilitation deficits in quadriceps strength contribute more to patient function and are greater in magnitude compared to hop test performance.

LEVEL OF EVIDENCE

Cross-Sectional Study, Level 3.

Quadriceps strength to body weight ratio is a significant indicator for initiating jogging after anterior cruciate ligament reconstruction

BACKGROUND

Quadriceps strength recovery after anterior cruciate ligament (ACL) reconstruction is an important criterion for progress in rehabilitation and return to sports. The purpose of this study was to determine whether quadriceps strength to body weight ratio (QS/BW) is a significant indicator for initiating jogging after ACL reconstruction.

METHODS

Isokinetic quadriceps strength at 60°/s was measured and a jogging trial was completed 3 months after ACL reconstruction with hamstring tendon autograft in 83 patients (36 male, 47 female; mean age, 26.6 ± 12.4 years). Based on the jogging trial results, patients were assigned to either a successful jogging group (mean velocity ≥ 9 km/h) or an unsuccessful jogging group (mean velocity < 9 km/h). The association between QS/BW and successful jogging after surgery was investigated by multivariate logistic regression analysis and the cut-off value was determined by receiver operating characteristic analysis.

RESULTS

Forty-four patients (53.0%) were assigned to the successful jogging group and 39 (47.0%) to the unsuccessful jogging group. QS/BW was independently associated with initiating jogging 3 months after surgery. The cut-off value of QS/BW for successful jogging was 1.45 Nm/kg (area under the curve = 0.94; sensitivity = 88.6%, specificity = 87.2%). All of the patients who initiated jogging with QS/BW of > 1.45 Nm/kg at 3 months returned to sports without recurrence or contralateral injury by 10 months after surgery.

CONCLUSIONS

QS/BW is a significant indicator for safely initiating jogging 3 months after ACL reconstruction. The cut-off value of QS/BW for initiating jogging was 1.45 Nm/kg.

Evolution of service metrics and utilisation of objective discharge criteria in anterior cruciate ligament reconstruction rehabilitation: a retrospective cohort study with historical control in a public hospital physiotherapy department

Background

ACL reconstruction (ACLR) is a common procedure requiring rehabilitation in public hospital physiotherapy departments. The rate of re-rupture and reduced rates of return to sport following ACLR are concerning. Current guidelines recommend a progressive approach to rehabilitation based on objective criteria. The aim of this study was to determine whether a new public hospital model of care incorporating a phase-based program increased physiotherapist utilisation of objective outcome measures, improved service metrics including attendance and rehabilitation completion rates, and increased patient-reported activity and knee function.

Methods

Records from patients attending outpatient physiotherapy after ACL reconstruction (N = 132) were included in a retrospective chart review to assess utilisation of objective measures such as quadricep and hamstring strength assessment, patient attendance and rehabilitation completion. Phone followup (minimum 1 year) was conducted to retrieve patient-reported measures of knee function (IKDC) and activity (Tegner Activity Scale). Patients were categorised by rehabilitation model of care (contemporary - time based [N = 93] vs new - phase based [N = 39]) and logistic regression used to assess the influence of patient factors and model of care on outcomes.

Results

Compliance was equivalent between models of care and completion rates (formal discharge by therapist) were low (30–38%). The probability of a patient receiving objective strength assessment was associated with model of care, sex, BMI and number of sessions attended. The probability of a patient being recorded as discharged from the program was significantly associated with model of care, and duration and number of sessions.

Conclusion

Introduction of an updated model of care including a phase-based rehabilitation program increased physiotherapist utilisation of objective outcome measures in line with current ACLR rehabilitation recommendations, increased total rehabilitation duration and increased total number of sessions attended. Despite this, rehabilitation completion rates remained low, and self-reported activity and knee function remained equivalent.

Level of evidence

III, retrospective cohort study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-020-00093-9.

Functional progression milestones following anterior cruciate ligament reconstruction are more appropriate than time-based criteria: a survey among the ESSKA

PURPOSE

The aim of this study was to report current rehabilitation recommendations after ACL reconstruction in ESSKA community, with a particular focus on the specific criteria utilized to guide activity progression METHODS: A web-based survey was developed to investigate preferences between time-based and functional ACL reconstruction rehabilitation progression milestones of ESSKA community.

RESULTS

Eight hundred and twenty completed questionnaires were received. Responders were from 86 different countries worldwide, 63% of them from European countries. Functional criteria were considered more appropriate to decide if a patient can start specific activities/exercises by 67% of the responders. Good core and lower extremity neuromuscular control were the most often used functional criteria for decision-making regarding readiness for sport-specific rehabilitation (66%), sport-specific drills without (65%) and with contact (66%). Strength assessed with an isokinetic dynamometer was considered by about half of the responders a determinant to initiate sport-specific drills without (51%-isokinetic strength, LSI > 80%) and with contact (58%-isokinetic strength, LSI > 85-90%). To determine readiness for sport-specific drills, hop tests were used by 40% of respondents for drills without contact and 48% of respondents for drills with contact.

CONCLUSION

The results of this survey involving mainly orthopaedic surgeons indicate that functional measures are considered more appropriate than milestones based on time from surgery to guide progression through the postoperative rehabilitation process after ACLR. The main clinical relevance of this study is that updated information on collective agreement could be useful for clinicians and physiotherapists to delineate their postoperative treatments after ACLR. These results should be interpreted with caution, as this sample represents only a small portion of ESSKA community involved in knee surgery and treating patients following ACLR.

LEVEL OF EVIDENCE

III.

Decision Tree Learning Algorithm for Classifying Knee Injury Status Using Return-to-Activity Criteria

Anterior cruciate ligament (ACL) injury rates in female adolescents are increasing. Irrespective of treatment options, approximately 1/3 will suffer secondary ACL injuries following their return to activity (RTA). Despite this, there are no evidence-informed RTA guidelines to aid clinicians in deciding when this should occur. The first step towards these guidelines is to identify relevant and feasible measures to assess the functional status of these patients. The purpose of this study was therefore to evaluate tests frequently used to assess functional capacity following surgery using a Reduced Error Pruning Tree (REPT). Thirty-six healthy and forty-two ACLinjured adolescent females performed a series of functional tasks. Motion analysis along with spatiotemporal measures were used to extract thirty clinically relevant variables. The REPT reduced these variables down to two limb symmetry measures (maximum anterior hop and maximum lateral hop), capable of classifying injury status between the healthy and ACL injured participants with a 69% sensitivity, 78% specificity and kappa statistic of 0.464. We, therefore, conclude that the REPT model was able to evaluate functional capacity as it relates to injury status in adolescent females. We also recommend considering these variables when developing RTA assessments and guidelines.Clinical Relevance- Our results indicate that spatiotemporal measures may differentiate ACL-injured and healthy female adolescents with moderate confidence using a REPT. The identified tests may reasonably be added to the clinical evaluation process when evaluating functional capacity and readiness to return to activity.

Uninjured Youth Athlete Performance on Single-Leg Hop Testing: How Many Can Achieve Recommended Return-to-Sport Criterion?

BACKGROUND

Current anterior cruciate ligament reconstruction (ACLR) guidelines utilize single-leg hop tests (SLHTs) to assist in return-to-sport decision making. A limb symmetry index (LSI) of ≥90% is often required; however, after ACLR, most youth athletes cannot achieve this standard. Reporting the performance of age-matched normative controls will allow clinicians to compare post-ACLR performance with noninjured peers, improving the utility of SLHTs. The purpose of this study was to report hop test LSI within healthy youth athletes and determine whether athlete performance surpasses post-ACLR requirements.

HYPOTHESIS

The LSI for the majority of healthy youth athletes will be ≥90%.

STUDY DESIGN

Cross-sectional cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Each participant performed a single hop (SH), triple hop (TrH), crossover hop (CrH), and timed hop (TiH). A 3-trial mean was utilized to calculate an LSI (nondominant/dominant leg [self-reported kicking leg]) for each hop. The frequency of pass/fail at ≥90% LSI was calculated. Pearson correlation coefficients analyzed the relationship between the different hops, and a 2-way analysis of variance determined the effects of age and sex on LSI.

RESULTS

A total of 340 participants (54% male; mean age, 10.9 ± 1.5 years; range, 8-14 years) were included. The mean LSI was >95% for each SLHT (SH, 97.9% [SD, 0.7]; TrH, 96.6% [SD, 0.6]; CrH, 96.8% [SD, 0.8]; TiH, 96.5% [SD, 0.6]). When analyzed as a test battery, only 45% of participants achieved this standard. Significantly weak to moderate correlations existed among hop tests (P < 0.01; r = 0.342-0.520). Age and sex had no effect on LSI (P < 0.05).

CONCLUSION

While the mean LSI in our sample was >95% for each individual hop test, participant performance across all SLHT components varied, such that less than half of healthy athletes could achieve ≥90% LSI across all hops.

CLINICAL RELEVANCE

Current guidelines require ≥90% LSI on SLHTs. The majority of healthy youth athletes could not achieve this standard, which questions the validity of this LSI threshold in youth athletes after ACLR.

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.

OBJECTIVE

To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.

DATA SOURCES

A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.

STUDY SELECTION

Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.

CONCLUSION

A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.

Leg asymmetry and muscle function recovery after anterior cruciate ligament reconstruction in elite athletes: a pilot study on slower recovery of the dominant leg

The aim of this study was to examine performance in hopping tests in male athletes after anterior cruciate ligament reconstruction (ACLR) in the 4-to-6 months post-surgery period. A total of 36 athletes (24 ACLR and 12 controls) participated in this study. The ACLR group consisted of athletes who had undergone an ACLR on their dominant side (ACL DG n=16) or non-dominant side (ACL NDG n=8). Participants completed the following functional tests: a single-leg hop (SLH), single-leg triple hop (SL3H) and single-leg counter movement jump (SLCMJ), then the limb symmetry index (LSI) was calculated. There were no significant differences between the dominant and the non-dominant legs for all functional tests when comparing the ACL DG and the ACL NDG at 6 months after surgery. At 6 months after ACLR, the LSI of the two legs was within acceptable values, whether the athlete had the operation on their dominant or non-dominant leg (except the mean LSI for the ACL DG in the SLCMJ test). Furthermore, the control group showed higher performances as compared to the ACL group for all variables at 6 months after surgery, despite acceptable LSI. We concluded that an early return to “full participation to training” is not recommended in participants who have undergone an ACLR with patellar tendon grafts.

Variability in rehabilitation protocols following pediatric anterior cruciate ligament (ACL) reconstruction

Objectives: The objective of this study was to assess the variability of publicly available pediatric anterior cruciate ligament (ACL) reconstruction rehabilitation protocols produced by academic orthopedic surgery departments and children's hospitals.Methods: A web-based search was performed to identify rehabilitation protocols. Protocol and literature review guided the development of a comprehensive scoring rubric that was used to assess protocols for the presence and timing of postoperative adjunctive therapy and physical therapy recommendations.Results: A search of 180 academic orthopedic surgery programs and 250 children's hospitals identified 21 rehabilitation protocols. A majority of these protocols (90%) recommended postoperative adjunctive therapies such as bracing (81%), cryotherapy (43%), electrical muscle stimulation (24%), and/or continuous passive motion (14%). Several protocols (57%) recommended a specific weight-bearing status in the immediate postoperative period, but there was minimal consensus on that status. Conversely, there was more agreement amongst protocols that recommended strength exercises (52%); a majority of protocols suggested quad sets (91%), ankle pumps (73%), leg press (64%), and/or double-leg squats (55%). Ten protocols (48%) recommended initiation of stretches in the first week following surgery, and most commonly suggested patella mobilizations start at an average of 1.9 weeks postop (range 0-8 weeks). Twelve protocols (57%) discussed return to play, with an average recommended return to play at 7.5 months (range 3-11 months) postoperatively. However, few protocols recommended that patients get approval from their surgeon (19%) or pass specific tests (24%) prior to return to play.Conclusion: Few academic departments of orthopedic surgery or children's hospitals publish pediatric ACL reconstruction protocols online. Given the substantial variability observed amongst these protocols and recent findings that patients increasingly turn to the internet for medical information, this study suggests that standardization of pediatric ACL reconstruction rehabilitation has the potential to further optimize patient care.