Factors Affecting Subjective and Objective Outcomes and Return to Play in Anterior Cruciate Ligament Reconstruction: A Retrospective Cohort Study

Abstract

Purpose To analyze the prognostic factors influencing subjective and objective outcomes and return to play (RTP) after anterior cruciate ligament reconstruction (ACL-R). Methods Primary ACL-Rs using a transtibial technique performed between 2008 and 2012 were included. Data regarding patients, surgery, sports, and rehabilitation, including an on-field rehabilitation (OFR) and duration of the rehabilitation program, were collected. The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms, and the Knee Injury and Osteoarthritis Outcome Score and Lysholm questionnaires were used for the assessment of subjective and objective outcomes. The Subjective Patient Outcome for Return to Sports and ACL–return to sport after injury (RSI) scores were used for RTP evaluation. Several potential predictors of outcome were tested with a univariate analysis. All the variables with p < 0.1 were retested in a logistic regression model to evaluate their association with the outcomes. Results In total, 176 cases were included with an average follow-up of 44.1 months. Of the patients, 92.2% were rated as normal or nearly normal at the IKDC evaluation. In addition, 90.1% of the patients returned to sport, with 57.6% returning to the same preinjury level. Objective outcomes were negatively influenced by late rehabilitation (odds ratio [OR] = 2.75). Performing an OFR phase during the rehabilitation was associated with better subjective outcomes (OR = 2.71). Length of rehabilitation strongly influenced the RTP rate (OR = 13.16). Conversely, higher ACL-RSI score was inversely related to RTP. Objective IKDC score was inversely related to the ACL-RSI (OR = 0.31), whereas subjective score was correlated with both the total ACL-RSI score (OR = 0.15) and the level of activity (OR = 0.20). Conclusion This study confirmed the role of rehabilitation on subjective and objective outcomes and on RTP. Particularly, the complete adherence to a rehabilitation program, including an OFR phase, resulted in better subjective outcomes and higher RTP rate. The relationship between psychological factors, measured through the ACL-RSI score, and RTP was confirmed. Level of Evidence Level III, observational study without a control group.

The Influence, Barriers to and Facilitators of Anterior Cruciate Ligament Rehabilitation Adherence and Participation: a Scoping Review

“…All studies compared a group of patients who completed a shorter duration of supervised rehabilitation (less than 3 or 6 months) to a group of patients who completed six or more months of rehabilitation, including structured agility, gym exercises, landing and on-field rehabilitation in line with current evidence-based recommendations Supervised rehabilitation longer than 6 months was associated with improved outcomes at all assessment time points. Specifically, associations were found between longer supervised rehabilitation and functional symmetry [50,51], a greater likelihood of meeting return to sport criteria and RTS at 12 months [50,51], double leg vertical hop landing symmetry [52,53], knee flexor rate of torque development and symmetry [54], speed and agility [55], knee extensor muscles torque parameters and LSI values [56] and better subjective outcomes [57]. Delaying the start of rehabilitation longer than one month after reconstruction was negatively associated with objective outcomes [57].…”

“…Specifically, associations were found between longer supervised rehabilitation and functional symmetry [50,51], a greater likelihood of meeting return to sport criteria and RTS at 12 months [50,51], double leg vertical hop landing symmetry [52,53], knee flexor rate of torque development and symmetry [54], speed and agility [55], knee extensor muscles torque parameters and LSI values [56] and better subjective outcomes [57]. Delaying the start of rehabilitation longer than one month after reconstruction was negatively associated with objective outcomes [57]. However, the duration of supervised rehabilitation was not associated with one leg vertical hop symmetry [53], knee joint stability, thigh and knee joint circumferences, active range of motion or everyday pain [55].…”

Do Nonsteroidal Anti-Inflammatory Drugs Affect Tissue Healing After Arthroscopic Anterior Cruciate Ligament Reconstruction?

“…Among various treatment options, ACL reconstruction has become the top choice of orthopedics doctors, for ligament reconstruction could help patients re-obtain relatively normal knee function and potentially delay consequent osteoarthritis [ 2 – 4 ]. It has been estimated that there are 329–435 per 1 000 000 person each year from 1994 to 2006 who receive ACL reconstruction in the United States [ 5 ]. Although numerous studies have reported excellent subjective and objective outcomes after ACL reconstruction, satisfactory results require careful postoperative nursing and rehabilitation.…”

Physiotherapy treatment and rehabilitation following anterior cruciate ligament injury in New Zealand: Are we doing enough?

“…Our results suggest New Zealanders are not receiving physiotherapy treatment for an appropriate duration following ACL injury or surgery. Post-ACLR rehabilitation lasting up to 12 months is associated with improved knee flexor/extensor strength (Ageberg, Thomeé, Neeter, Silbernagel, & Roos, 2008;Heijne & Werner, 2007;, greater performance during functional testing , a greater rate of returning to pre-injury activities (Ardern et al, 2014;Della Villa et al, 2012;Edwards et al, 2018;Han et al, 2015;Rosso et al, 2018) and decreased re-injury risk (Grindem, Snyder-Mackler, Moksnes, Engebretsen, & Risberg, 2016). Traditional progressions through ACL rehabilitation have been time based, which may result in sub-optimal outcomes, as time after ACLR is not necessarily related to functional performance (Myer et al, 2012).…”

“…Early physiotherapeutic intervention after ACL injury, including education about the importance of rehabilitation, could positively influence the patient experience and may increase adherence to rehabilitation Risberg et al, 2016;Scott et al, 2018). Increased adherence to rehabilitation is positively associated with functional ability following ACLR (Brewer et al, 2000;Pizzari, Taylor, McBurney, & Feller, 2005;Rosso et al, 2018).…”