The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review

'Going through the motions'; a rich account of the complexity of the anterior cruciate ligament reconstruction pathway, a UK qualitative study

OBJECTIVES

This study aimed to understand the lived experiences of patients on the anterior cruciate ligament reconstruction (ACLR) pathway up to 3 months before, 3 months after and 1 year after surgery. Study objectives were to explore (1) patient experiences of preoperative and postoperative treatment, (2) views of/involvement in prehabilitation and (3) sources and consistency of healthcare advice.

DESIGN

Semi-structured interviews analysed using reflexive thematic analysis.

SETTING

Midlands, England.

PARTICIPANTS

Purposive sample of 18 participants aged 18-45. Three identified as female and 15 as male. Participants' ethnic origin was white (n=14), Indian (n=2), British Asian (n=1) and Pakistani (n=1). 10 participants were awaiting ACLR, six were 3months postsurgery and two were 1 year postsurgery.

RESULTS

Participants gave a rich account of ACLR pathway experiences discussing negative impacts of the injury, difficulties with navigating the pathway and making decisions about surgery. Interacting with healthcare professionals and managing the variety of resources, advice and opinions were also highlighted as challenges. Participants reflected on their preoperative journey accounting a wide spectrum of expectations and realities of returning to work and physical activity postoperatively. Prehabilitation was perceived to offer an advantage to recovery, mental well-being, injury knowledge, postoperative rehabilitation and supports a faster return to physical activity. Five themes were identified:Injury experience, impact and support.Navigating the treatment pathway.Sense making in the preoperative period.Uncertainty, expectations and reality of the postsurgical period.Balancing resources, advice and opinions.

CONCLUSION

This study has illuminated patient experiences of the National Health Service (NHS) ACLR pathway, novel to the evidence base.The results highlight the perceived shortcomings in patient support. They also demonstrate the difficulty patients face when navigating the NHS system, communicating with clinicians, making decisions about treatment and managing conflicting sources of healthcare advice. These problems are more prominent than previously recognised in the literature.

REGISTRATION

ClinicalTrials.gov Identifier: NCT05529511.

Knee flexor strength at 6 months after anterior cruciate ligament reconstruction using hamstring tendon can be predicted from that at 3 months

PURPOSE

This study aimed to identify factors influencing persistent muscle weakness in knee flexor strength after anterior cruciate ligament (ACL) reconstruction using the hamstring tendon and establish a clear cut-off value at 3 months postoperatively for the limb symmetry index (LSI) to exceed 90% at 6 months postoperatively.

METHODS

One hundred forty-eight patients undergoing ACL reconstruction were included and categorised into two groups based on knee flexor strength at 6 months postoperatively: patients with LSI of 90% or greater (achieved group: n = 114) and patients with LSI less than 85% (nonachieved group: n = 34). Items with significant differences between the two groups (preoperative waiting period, LSI to body weight ratio of knee flexor and extensor strength at 3 months postoperatively and peak torque angle of knee flexor muscle) were included in the multiple logistic regression analysis. Additionally, a receiver operating characteristic curve was used to calculate the cut-off value of the LSI at 3 months postoperatively, which was required to achieve the LSI criteria for knee flexor strength 6 months postoperatively.

RESULTS

Multiple logistic regression analysis extracted the preoperative waiting period and LSI for knee flexor strength at 3 months postoperatively. The cut-off value at 3 months postoperatively was 76.9% (area under the curve value, 0.82; sensitivity, 0.76; and specificity, 0.81) of the LSI.

CONCLUSION

The LSI of at least 76.9% for knee flexor strength at 3 months after ACL reconstruction was an indicator for achieving the 6 months postoperatively. This is a criterion to aim for, considering the stress on the graft and the regeneration process of the semitendinosus tendon.

LEVEL OF EVIDENCE

Level III.

[Blood flow restriction training (BFRT) in patients before and after total knee arthroplasty]

BACKGROUND

In healthy individuals, blood flow restriction training (BFRT) has shown positive effects on muscle mass, strength, fatigue resistance, as well as tendon and bone metabolism. BFRT reduces blood flow in the extremities using inflatable cuffs, creating local muscular hypoxia, which produces an anabolic metabolic environment. This promotes significant muscular and cardiovascular adaptations even at low mechanical training loads.

KNEE ENDOPROSTHESES

BFRT also shows promising initial results in pre- and postoperative applications for knee endoprostheses (KTEP). Both preoperative and postoperative BFRT can improve muscle strength and joint function, accelerate recovery, and alleviate pain. Although the method is generally safe, potential risks such as discomfort and rare side effects must be considered. Clear application protocols are still lacking, necessitating further research and individualized programs to achieve optimal training effects. BFRT thus offers an innovative way to effectively rehabilitate patients despite their low load tolerance.

Anterior cruciate ligament injuries in elite badminton athletes: 84% Return to sport, half return to performance

PURPOSE

Badminton requires fast and pivoting movements, putting athletes at risk of sustaining an anterior cruciate ligament (ACL) injury. The primary purpose is to investigate the return to sport (RTS) and the return to performance (RTP) after an ACL injury in elite badminton athletes. The secondary purpose is to describe ACL injury mechanisms in elite badminton players.

METHODS

Athletes within the top 200 of the Badminton World Federation World Ranking who sustained an ACL injury between January 2001 and December 2021 were retrospectively included. An anonymous online survey was created in eight languages. RTS, RTP and contributing factors were analysed among athletes aiming to RTP. The injury mechanism was analysed in all participants.

RESULTS

Sixty-six athletes from 32 countries were included. Fifty-seven athletes (86.4%) aimed to RTP. Forty-eight out of 57 (84.2%) did RTS. Twenty-nine (50.9%) managed to successfully RTP. Forty-nine (74.2%) of ACL injuries occurred during a competition, 14 (21.2%) occured during training. Thirty-one (49.2%) occurred in the rear court backhand side and 47 (74.6%) occurred during landing after a jump.

CONCLUSION

Forty-eight out of 57 (84.2%) athletes managed to RTS. Half of the athletes managed to successfully RTP. Most of the ACL injuries occurred during competition, in the rear court backhand side and during landing after a jump.

LEVEL OF EVIDENCE

Level III.

Nonoperative Anterior Cruciate Ligament Injury Treatment

This article outlines the key points in the nonoperative treatment of an anterior cruciate ligament (ACL) injury. Initial evaluation and treatment of an acute knee injury, often performed by a physician with limited experience in the treatment of an ACL injury, follow the basic diagnostic workup that lead to the diagnosis. The principles of rehabilitation after ACL injury have changed from time based to criteria based, and the different phases based on physical criteria are described.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Effects of clamshell exercises in terminal extension lag after ACL reconstruction

BACKGROUND

Terminal extension lag (TEL) is common following anterior cruciate ligament reconstruction (ACLR). Clamshell exercises have been suggested as a potential intervention to address TEL, but limited research has been conducted in this area.

OBJECTIVE

This study aimed to determine the effects of Clamshell exercises in terminal extension lag after anterior cruciate ligament reconstruction.

METHODS

This randomized controlled trial included 40 participants with a history of ACLR between 1 and 3 years prior. Participants were randomly assigned to either the experimental group (Group A) or the control group (Group B). Group A received conventional exercises along with isolated hip strengthening rehabilitation, while Group B received conventional exercises without specific hip strengthening. The primary outcomes were pain levels (Numeric Pain Rating Scale), knee function (International Knee Documentation Committee scores, (IKDC)), range of motions (goniometer) and strength (sphygmomanometer).

RESULTS

In between the group comparison shows that all outcome measures (NPRS, IKDC, Goniometer, Sphygmomanometer) show significant results (p < 0.05). Within-group comparisons (paired sample t-test) show that there was a significant difference (p < 0.05) in all outcome measures of both groups.

CONCLUSION

The addition of Clamshell exercises to the rehabilitation program resulted in a significantly greater reduction in TEL compared to the control group. These findings suggest that Clamshell exercises were found to be an effective intervention for addressing TEL after ACLR.

Associations of patient characteristics, rate of torque development, voluntary activation of quadriceps with quadriceps strength, and knee function before anterior cruciate ligament reconstruction

Good preoperative knee function (KF) and quadriceps strength (QS) relate to good prognoses after anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate the associations between patient characteristics, rate of torque development (RTD), voluntary activation (VA) of the quadriceps against preoperative KF and QS. A cross-sectional study was conducted. Forty patients with a primary, unilateral ACL injury who had finished the preoperative rehabilitation and scheduled for an ACLR were included. KF was evaluated using the International Knee Documentation Committee score. QS was measured by maximal voluntary isometric contractions. RTD was divided into the early (RTD0-50) and the late (RTD100-200) phases. Quadriceps VA was measured using the superimposed burst technique. Our results showed that patients with poor preoperative KF    had more deficits in RTD0-50 (P = 0.025), higher BMI(P = 0.043), and more meniscus injuries (MI) (P = 0.001) than those with good KF. Patients with asymmetrical QS   showed lower BMI (P = 0.020) and shorter time from injury (TFI) (P = 0.027) than those with symmetrical QS. Additionally, a higher pre-injury Tegner score combined with greater RTD100-200 contributed to greater QS on the injured limb (R2 = 0.357, P = 0.001). To conclude, BMI, TFI, concomitant MI, pre-injury physical activity level, and quadriceps RTD are related to QS and KF before ACLR.

Preoperative Rehabilitation Enhances Mental and Physical Well-Being in Anterior Cruciate Ligament-Injured Individuals: A Mixed Methods Study

CONTEXT

Rehabilitation after an anterior cruciate ligament injury is recommended to be started soon after the injury. When surgery is required, research supports the delivery of physiotherapy before anterior cruciate ligament reconstruction (prehabilitation) to optimize recovery and positive outcomes. Individuals attending prehabilitation have never been questioned regarding their adherence to prehabilitation, perception of utility in meeting needs, upcoming events, or anticipated recovery goals.

DESIGN

Mixed methods cross-sectional study: Methods: 25 individuals before anterior cruciate ligament reconstruction (43% of eligible individuals from 12 clinics during the delivery period) were surveyed on their mindset and recovery expectancies. Semistructured interviews conducted in 9 of 25 participants assessed their lived experience of prehabilitation.

RESULTS

Participants reported that preventing a reinjury (96% of responses) and feeling confident during daily activities about their knee (92%) were the higher rating expectations at this stage of their treatment course. Three themes were developed from the interviews and analyses. (1) Participants reported that prehabilitation was a period full of challenges with memories of the injury and uncertainties. (2) They viewed prehabilitation as a step to move forward by finding support and self-motivating. (3) They believed that prehabilitation would have positive impacts on the treatment outcomes. Participants were confident that prehabilitation would accelerate the recovery of muscle volume (88%) and strength (84%).

CONCLUSION

Participants had positive experiences of prehabilitation, aligning with the findings on functional outcomes in the existing literature on prehabilitation.

Current views on preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia: An online-based cross-sectional survey

Preoperative rehabilitation is an important stage to both physically and mentally prepare patients for anterior cruciate ligament reconstruction (ACLR) and postoperative rehabilitation. This study aimed to investigate the current preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia. This was an online-based cross-sectional survey. A total of 114 physical therapists completed the survey. The survey consisted of 16 mandatory questions about management strategies, prescribed exercises, patients' physical and psychological concerns, and discussions about nonoperative management. The majority of the respondents used the following preoperative interventions: education (89.5%), closed kinetic chain exercises (66.7%), stretches (63.2%), open kinetic chain exercises (61.4%), proprioceptive exercises (59.6%), cold (56.1%), and activity modification advice (52.6%). More than half of the respondents would recommend patients awaiting ACLR to complete the exercises 2 to 4 times weekly (56.1%) for up to 8 weeks (80.7%) before ACLR. The respondents (73.7%) reported that patients awaiting ACLR did not receive preoperative rehabilitation due to 2 primary factors: the orthopedic team did not refer patients to rehabilitation specialists, and there was a lack of awareness about preoperative rehabilitation. Most therapists (86%) would discuss conservative management if a patient returned to their preinjury level of function before surgery. The surveyed physical therapists reported using various interventions and preoperative rehabilitation lengths with patients awaiting ACLR. The majority of the therapists indicated that patients awaiting ACLR did not receive preoperative rehabilitation. Future studies are needed to establish a consensus on the optimal preoperative rehabilitation program.

Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report

INTRODUCTION

Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR.

METHODS

Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented.

RESULTS

Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively.

CONCLUSION

We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.

Functional Outcome of ACL Reconstruction Following Pre-reconstruction Rehabilitation vs. None Rehabilitation: A Systematic Review and Meta-analysis

Objective  The aim of this study is to analyse the needs for pre-operative rehabilitation in patients undergoing ACL reconstruction. Methods  The database reports were searched within 2018 to 2023, using PubMed, Cochrane library database, Medline, and other published trials. A statistical analysis was made from Review Manager. Results  Pre-operative rehabilitation group shows significantly higher 2 years post-operative KOOS score in all subscore and the total mean of the score, pain (p < 0. 0001), symptoms (p < 0. 0001), ADL (p < 0. 0001), sports and recreations (p < 0. 0001), QoL (p < 0. 0001), and the total mean of the KOOS score (p < 0.0001). In contrary, pre-operative rehabilitation group shows insignificantly higher score on 3 months post-operative Lysholm score (p = 0.12). Conclusion  This meta-analysis conclude pre-operative rehabilitation may provide better long-term post-operative outcome, however it may not provide much of a short-term outcome. It is recommended to add pre-operative rehabilitation as a guideline for ACL injury management to improve long-term outcome of patients with ACL injury undergoing ACL reconstruction procedure.

Sex Differences in Quadriceps Atrophy After Anterior Cruciate Ligament Tear

BACKGROUND

Female athletes lag behind their male counterparts in recovery from anterior cruciate ligament (ACL) injury. Quadriceps muscle size and strength are crucial factors for regaining function after ACL injury, but little is known about how these metrics vary due to biological sex.

HYPOTHESIS

Female patients have reduced vastus lateralis fiber cross-sectional area (CSA) and lower quadriceps strength after ACL injury than male patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 60 participants with recent ACL tear were evaluated for vastus lateralis muscle fiber CSA, isometric quadriceps peak torque, and quadriceps rate of torque development. Linear mixed models were fit to determine differences across sex and limb for each variable of interest.

RESULTS

The female group averaged almost 20% atrophy between limbs (P < 0.01), while the male group averaged just under 4% (P = 0.05). Strength deficits between limbs were comparable between female and male groups.

CONCLUSION

Immediately after ACL injury, female patients have greater between-limb differences in muscle fiber CSA but between-limb strength deficits comparable with those of male patients.

CLINICAL RELEVANCE

These results indicate that the underpinnings of strength loss differ based on biological sex, and thus individual patients could benefit from a sex-specific treatment approach to ACL injury.

[Current approach in the follow-up treatment of joint-preserving operations on the knee joint in German-speaking countries]

INTRODUCTION

Postoperative follow-up after joint-preserving knee surgery involves conventional physiotherapy as well as other approaches and devices such as CPM and CAM splints, TENS devices, BFR exercise, prehabilitation, and digital health applications. The aim of this survey was to investigate current standards, trends and control methods in postoperative care to identify fields of concern and to compare them with the current literature.

MATERIAL AND METHODS

We conducted a structured anonymous online survey of specialists in orthopaedics and trauma surgery listed by the German-speaking Society for Arthroscopy and Joint Surgery (AGA). The questionnaire included 36 closed-ended questions on the follow-up of joint-preserving surgery of the knee joint.

RESULTS

Questionnaires from 528 participants with long-term professional experience (86.6% with more than 10 years) were analysed. Standardised post-treatment schemes are used by 97.2% and their evidence is estimated to be high (59.1%) / very high (14.8%). Problems of rehabilitation are seen in 10-20% of cases by 87.3% (persistent muscular atrophy 30.9%). After reconstructive surgery, CPM splints (70.1%), CAM splints (42.1%), orthoses (85.0%) and TENS devices (40.0%) are prescribed. More potent approaches for the treatment of postoperative muscle deficits are desired by 89.4%. BFR exercise is known by 41.7% and is used regularly by 8%. Communication with treating physiotherapists is infrequent (written: 27.5%). Digital rehabilitation management would be supported by 83.3%; 22.7% are not aware of digital health applications. 87.9% of participants believe that prehabilitation can affect postoperative outcomes.

CONCLUSION

Follow-up of knee joint-preserving surgeries is usually standardised and regularly reviewed for up-to-date evidence. The evidence for recommendations made is considered high. Orthoses are usually used after reconstructive surgery, persistent muscle atrophy is a major problem, BFR training is only known to a limited extent, and there is currently a lack of standardised training protocols. Communication with physiotherapists needs to be improved. Digital rehabilitation management is rarely used but would be supported by the majority of surgeons.

[Exercise-Based Prehabilitation In Orthopaedics, Cardiology And Oncology]

Prehabilitation (prehab) aims to prepare patients for surgery, to reduce perioperative complications and to improve postoperative recovery. Pre-operative interventions depend on the indication and the specific patient characteristics and life circumstances. In orthopaedics, the focus is on preoperative improvement of physical performance, function and muscle strength through specific strength, mobility and sensomotoric training. In cardiology, endurance training and respiratory therapy are used in the preoperative phase, as well as coordination and strengthening exercises and occupational therapy to improve physical fitness and performance and reduce cardiovascular risk factors. In oncology, prehab is used preoperatively and also in addition to chemotherapy or radiotherapy to reduce medical side effects and to increase tolerance to cancer therapies (e. g. surgery, chemotherapy, radiotherapy). Exercise interventions in oncology differ according to the type of cancer (e. g. combined strength and endurance training, respiratory therapy, high-intensity interval training and walking). Study results often show positive effects on health resources using prehab. However, further high-quality clinical intervention studies are needed to confirm the clinical benefits of prehab for implementation in routine care.

Bilateral impairments of quadriceps neuromuscular function occur early after anterior cruciate ligament injury

The study aimed to investigate the impairments in quadriceps neuromuscular function, including strength, rate of torque development (RTD) and activation failure (QAF) early after an ACL injury. A cross-sectional study was conducted. Thirty physically active patients with a primary ACL injury within three months, aged 18 to 40 years old, and who were scheduled for ACL reconstruction were included. Thirty matched healthy controls were also recruited. All the outcomes were measured on an isokinetic dynamometer with knee flexion at 45°. Quadriceps strength was measured by maximal voluntary isometric contractions (MVIC). Early (RTD0-50) and late (RTD100-200) phases of RTD were retrieved from the MVIC test from 0 to 50 ms and 100-200 ms, respectively. QAF was quantified by the central activation ratio (CAR) measured by superimposed burst technique. The results of Mann-Whitney U test showed that compared with the healthy limbs, the injured limbs of the ACL group showed lower quadriceps strength (P < 0.001), RTD0-50 (P < 0.001) and RTD100-200 (P < 0.001); the uninjured limbs showed lower quadriceps strength (P = 0.009), RTD0-50 (P = 0.006) as well as greater QAF (P = 0.010). To conclude, bilateral quadriceps suffered from neuromuscular impairments early after an ACL injury.

Effects of exercise prehabilitation before anterior cruciate ligament reconstruction on functional outcomes during pre- and postoperative rehabilitation - protocol for a single-blinded randomised controlled trial

BACKGROUND

Although a benefit of preoperative training prior to anterior cruciate ligament (ACL) reconstruction is likely, there is no consensus on the optimal content (criteria-based programme), supervision (one-on-one guidance or self-administered training) and general setting of preoperative training after ACL injuries. The purpose of this trial is to investigate the efficacy of an individually adaptive, guided, structured and criteria-based preoperative rehabilitation programme in comparison to a non-guided and self-administered home training programme.

METHODS

The planned single-blinded randomised controlled trial study was approved by the ethics committee of the German Sport University on June 14, 2022 (ethics application no. 093/2022) and prospectively registered (DRKS-ID: DRKS00030312; date of registration: 26.09.2022). N = 114 participants between 16 and 60 years of age with a unilateral ACL rupture and scheduled ACL reconstruction with a hamstring or quadriceps tendon autograft will be randomly (block-randomisation, 1:1 allocation) and blinded assigned to one of two groups: intervention group (structured, criteria-based, guided prehabilitation training) and comparator group (non-guided, self-administered home training). After surgical reconstruction, patients of both groups participate in the same standard, functional measurement-guided, postoperative rehabilitation programme. Stepwise increasing the functional requirements of the assessments, all participants participate in testing at the day of anamnesis (t1), 1-7 days before surgical reconstruction (t2), day of surgical reconstruction (t3) and 30 (t4), 60 (t5), 90 (t6) and 180 (t7) days post-reconstruction. The primary outcome is the overall self-reported knee condition, assessed by the sum score of all sub-scales of the Knee injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include functional outcomes (range of motion, knee flexors and extensors and plantar flexors strength/torque, functional postural control, jumping ability), workability and return to sport (RTS) (psychological readiness, RTS success).

DISCUSSION

The planned study targets to fill a gap in the evidence regarding effective designs of prehabilitation training before surgical ACL reconstruction. Potential difficulties that could affect the conduct of the study are lack of treatment adherence of the patients and high dropout.

TRIAL REGISTRATION

German Register of Clinical Trials DRKS-ID: DRKS00030312 . Registered on 26 September 2022.

Update on Current Concepts of Blood Flow Restriction in the Perioperative Period of Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament tears or ruptures are common orthopedic injuries. Anterior cruciate ligament reconstruction (ACLR) is an orthopedic procedure allowing for earlier return to sports, improved maintenance of lifestyle demands, and restored knee stability and kinematics. A perioperative rehabilitative adjunct recently gaining interest is blood flow restriction (BFR), a method in which temporary restriction of blood flow to a chosen extremity is introduced and can be used as early as a few days postoperative. There has been increasing investigation and recent literature regarding BFR. This review synthesizes current concepts of BFR use in the ACLR perioperative period. [Orthopedics. 2023;46(6):e333-e340.].

Kinesiophobia Is Negatively Associated With Psychological Readiness to Return to Sport in Patients Awaiting Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify the factors associated with anterior cruciate ligament return to sport after injury (ACL-RSI) scores in patients awaiting ACL reconstruction (ACLR).

METHODS

This was a retrospective cross-sectional observational study conducted at a single clinical center. We recruited patients scheduled for primary ACLR, aged 16-45 years, and with modified Tegner activity scale scores ≥5 before ACL injury. The main outcome was psychological readiness to return to sport (RTS), as measured using the ACL-RSI scale. Participants' personal and injury-related information were obtained, and their psychological status (Tampa Scale for Kinesiophobia [TSK] and athletic identity measurement scale) and knee functions (effusion, range of motion, joint stability, and knee flexion angle during a single-leg squat) were examined. All variables were assessed the day before the surgery.

RESULTS

A total of 105 patients (median [interquartile range]: age, 20.0 [9.0] years; body mass index, 22.8 [4.3] kg/m2; days from injury to surgery, 63.0 [65.0] days; 44% female) were enrolled. Univariate analysis indicated that only the TSK score was associated with the ACL-RSI scores (r = -0.305; P = .02). Multiple regression analysis of factors, including sex, preinjury Tegner activity scale score, and days from injury to surgery, further showed that only the TSK score was associated with the ACL-RSI scores (P = .002; 95% confidence interval -1.738 to -0.394).

CONCLUSIONS

In patients awaiting ACLR, kinesiophobia was moderately negatively associated with psychological readiness to RTS, while other factors were not.

LEVEL OF EVIDENCE

Level III, retrospective cross-sectional observational study.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review

BACKGROUND

Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction.

METHODS

Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB).

CONCLUSION

Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR.

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO: CRD 42020222567.

Patients With Low Resilience Scores Have Significantly Worse Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction Than Patients With Normal or High Resilience Scores

Purpose

To evaluate the relationship between patient resilience and patient-reported outcome measures (PROMS) after primary anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent an ACL reconstruction by a single surgeon between January 2012 and June 2020 were identified by an institutional query using Current Procedural Terminology codes. Patients were included if they (1) underwent a primary ACL reconstruction and (2) had a minimum of 2 years' follow-up. Data were retrospectively collected regarding demographics, surgical details, visual analog scale (VAS) scores, and 12-item short form survey (SF-12) scores. Resilience scores were obtained via the Brief Resilience Scale questionnaire. Stratification into low (LR), normal (NR), and high resilience (HR) was based on standard deviation from mean Brief Resilience Scale score to determine differences in PROMS between groups.

Results

One-hundred eighty-seven patients were identified by the institutional query. Of the 187 patients, 180 met inclusion criteria. Seven patients underwent revision ACL reconstruction and were excluded from the study. One-hundred three patients (57.2%) completed the postoperative questionnaire and were included. Patients in the NR group and HR group had significantly greater postoperative SF-12 scores (P < .001) and lower postoperative VAS pain scores (P < .001) when compared with those of the LR group. This trend was again shown with breakdown of the SF-12 into physical and mental aspects, each of which were significantly greater in either the NR group or HR group when compared with the LR group (P < .001). Overall, 97.9% and 99.0% of patients had changes in their SF-12 total and VAS pain scores respectively that exceeded the minimal clinically important difference for the cohort.

Conclusions

Patients with lower resilience scores have worse PROMs and increased pain than patients with greater resilience at a minimum of 2-year follow-up after ACL reconstruction.

Level of Evidence

Level IV, prognostic case series.

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.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient

PURPOSE

The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process.

METHODS

For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement.

RESULTS

During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus.

CONCLUSIONS

This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient.

LEVEL OF EVIDENCE

Level V.

ACL Reconstruction: Which Additional Physiotherapy Interventions Improve Early-Stage Rehabilitation? A Systematic Review

Despite the restoration of the mechanical stability of the knee joint after ACL reconstruction (ACLR), patients often experience postoperative limitations. To our knowledge, there are no systematic reviews analyzing additional physiotherapy interventions implementing standard rehabilitation programs in the early postoperative phase after ACLR. The objective of this study was to analyze the additional physiotherapy interventions implemented in standard rehabilitation programs that improve early-stage ACLR rehabilitation. For this systematic review, we followed the PRISMA guidelines. In March 2022 we conducted a literature review using electronic databases. Primary outcomes were pain, edema, muscle strength, ROM, and knee function. The risk of bias and scientific quality of included studies were assessed with the RoB 2, ROBINS-I and PEDro scale. For the review, we included 10 studies that met the inclusion criteria (total n = 3271). The included studies evaluated the effectiveness of Kinesio Taping, Whole-body vibration, Local Vibration Training, Trigger Point Dry Needling, High Tone Power Therapy, alternating magnetic field, and App-Based Active Muscle Training Program. Most of the additional physiotherapy interventions improved pain, edema, ROM, knee muscle strength, or knee function in early-stage postoperative ACL rehabilitation. Except for one study, no adverse events occurred in the included studies, which demonstrates the safety of the discussed physiotherapy interventions. Further in-depth research is needed in this area.

Mechanical strain drives exosome production, function, and miRNA cargo in C2C12 muscle progenitor cells

Mesenchymal stem cells (MSCs) have been proven to promote tissue repair. However, concerns related to their clinical application and regulatory hurdles remain. Recent data has demonstrated the proregenerative secretome of MSCs can result in similar effects in the absence of the cells themselves. Within the secretome, exosomes have emerged as a promising regenerative component. Exosomes, which are nanosized lipid vesicles secreted by cells, encapsulate micro-RNA (miRNA), RNA, and proteins that drive MSCs regenerative potential with cell specific content. As such, there is an opportunity to optimize the regenerative potential of MSCs, and thus their secreted exosome fraction, to improve clinical efficacy. Exercise is one factor that has been shown to improve muscle progenitor cell function and regenerative potential. However, the effect of exercise on MSC exosome content and function is still unclear. To address this, we used an in vitro culture system to evaluate the effects of mechanical strain, an exercise mimetic, on C2C12 (muscle progenitor cell) exosome production and proregenerative function. Our results indicate that the total exosome production is increased by mechanical strain and can be regulated with different tensile loading regimens. Furthermore, we found that exosomes from mechanically stimulated cells increase proliferation and myogenic differentiation of naïve C2C12 cells. Lastly, we show that exosomal miRNA cargo is differentially expressed following strain. Gene ontology mapping suggests positive regulation of bone morphogenetic protein signaling, regulation of actin-filament-based processes, and muscle cell apoptosis may be at least partially responsible for the proregenerative effects of exosomes from mechanically stimulated C2C12 muscle progenitor cells.

Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade

Purpose

To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts.

Results

Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts.

Conclusions

Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft.

Clinical Relevance

As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.

The Effects of a Combined Pre- and Post-Operative Anterior Cruciate Ligament Reconstruction Rehabilitation Program on Lower Extremity Muscle Imbalance

This study examined whether the 5-week pre-operative progressive exercise rehabilitation program with weekly monitoring contributed to a significantly lower muscle activity imbalance in the treatment group, both before and immediately after anterior cruciate ligament reconstruction (ACLR), as well as during the next 5 weeks in comparison to the control group. Twelve professional soccer players took part in the study (from among the top three Polish levels of competition) (age: 26 ± 5 years, body mass: 73 ± 7 kg, stature: 180 ± 6 cm, training experience: 15 ± 4 years). The participants were randomly assigned to the treatment group (n = 6) or to the control group (n = 6). Both groups performed the same pre- and post-operative progressive exercise rehabilitation program, while the rehabilitation of the treatment group was extended by supplementary body-weight functional stabilization training. The three-way repeated-measures ANOVA revealed a statistically significant interaction for muscle × group × time (p < 0.0001; F = 24.897; η2 = 0.806). The post-hoc analysis for the interaction effect of muscle × group × time indicated a significantly higher muscle activity imbalance for every measured muscle in the control group at any time point than in the treatment group (from p = 0.036 to p < 0.0001). The muscle activity imbalance was significantly higher from the 1st to 4th weeks than in the last week before surgery for quadriceps (p < 0.016 for all) and hamstrings (p < 0.001). However, in the case of gluteal muscles’ activity imbalance, it was significantly higher at every time point of the post-operative phase than in the last week before surgery (p < 0.001). The results of this study showed that the 5-week pre-operative rehabilitation program with weekly monitoring influenced outcomes of the post-operative phase. Nevertheless, performing both pre- and post-ACLR rehabilitation significantly reduced the muscle activity imbalance of lower limbs, but in the case of the quadriceps muscles, not to a sufficient level.

The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy

BACKGROUND

The unique anatomy of the human hand makes it possible to carefully manipulate tools, powerfully grasp objects, and even throw items with precision. These apparent contradictory functions of the hand, high mobility for manual dexterity vs high stability during forceful grasping, imply that daily activities impose a high strain on a relatively instable joint. This makes the hand susceptible to joint disorders such as osteoarthritis. Both systemic (eg, genetics, hormones) and mechanical factors (eg, joint loading) are important in the development of osteoarthritis, but the precise pathomechanism remains largely unknown. This paper focuses on the biomechanical factors in the disease process and how hand therapists can use this knowledge to improve treatment and research.

CONCLUSION

Multiple factors are involved in the onset and development of osteoarthritis in the hand. Comprehension of the biomechanics helps clinicians establish best practices for orthotics intervention, exercise, and joint protection programs even in de absence of clear evidence-based guidelines. The effect and reach of hand therapy for OA patients can be expanded substantially when intervention parameters are optimized and barriers to early referrals, access reimbursement, and adherence are addressed. Close and early collaboration between hand therapists and primary care, women's health, rheumatology, and hand surgery providers upon diagnosis, and with hand surgeons pre and postoperatively, combined with advances in the supporting science and strategies to enhance adherence, appear to be a promising way forward.

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.

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction

Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.

The effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction: A systematic review

OBJECTIVES

to evaluate the effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction.

DESIGN

Systematic review.

METHODS

a systematic review was undertaken, included studies were evaluated using the Modified Downs and Black checklist which is appropriate for determining the quality of randomised and non-randomised studies. Scientific databases searched included PubMED, EBSCO Health, CINAHL, Medline, and Cochrane Library databases from inception to March 2021.

RESULTS

Ten studies met the inclusion criteria. There were six randomised studies and four prospective studies. The level of evidence is categorised as 'limited' due to heterogenicity and only six studies reported quadriceps strength increases. Five studies demonstrated preoperative exercise of 4-16 weeks duration can significantly increase preoperative quadriceps strength. One study demonstrated preoperative OKC exercise produced significantly stronger preoperative quadriceps compared to CKC exercise. One study showed no between group (intervention vs control) quadriceps strength difference pre or 12 weeks postoperatively.

CONCLUSIONS

4-16 weeks of preoperative exercise could increase quadriceps strength preoperatively but any persistent postoperative strength benefit from undertaking a standardised preoperative intervention is unclear. There is considerable variation and methodological limitations across the included studies and the composition of optimal preoperative ACLR exercise is currently unknown.

Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

OBJECTIVES

To evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online survey.

SETTING

Survey platform.

PARTICIPANTS

Greek physiotherapists.

OUTCOME MEASURES

The survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.

RESULTS

Significant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.

CONCLUSION

Current ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.