Advertisement

Preoperative Patient and Injury Factors of Successful Rehabilitation After Anterior Cruciate Ligament Reconstruction With Single-Bundle Techniques

      Purpose

      The aim of this systematic review was to determine which patient determinants and injury factors, before anterior cruciate ligament reconstruction by arthroscopic single-bundle techniques, affect postoperative rehabilitation.

      Methods

      A search of PubMed, Embase, and the Cochrane Database of Clinical Trials was performed up to February 2013. After application of our inclusion criteria, a final selection was made based on studies' methodologic score assessed with the Newcastle-Ottawa Scale. Meta-analysis was planned for each prognostic factor when data were considered clinically and statistically homogeneous.

      Results

      Meta-analysis showed that male patients have better functional outcomes. Qualitative synthesis from 18 high-quality studies showed that patients operated on before 30 years of age reach higher activity levels. Patients with high baseline body mass index have lower activity levels after surgery. Smoking results in more symptoms and lower activity levels and subjective scores. Reconstruction before 3 months results in higher activity levels. Preoperatively, a less than 20% quadriceps strength difference, 50° of tibial external rotation or less, absence of flexion deficits, low knee influence on the patient's activity level, and less anterior knee pain result in higher functional scores. Preoperative anterior laxity difference does not predict functional scores. The prognostic value of preoperative activity and competition level for postoperative functional outcome is controversial. Patients with concomitant meniscal injuries have worse functional outcomes. The prognostic value of concomitant chondral pathology for postoperative functional outcome is controversial. Collateral ligament injury could predict functional scores or activity level.

      Conclusions

      Male gender, patient age younger than 30 years, reconstruction before 3 months, and high baseline activity level contribute to better functional outcomes. Smoking, high body mass index, quadriceps strength, and range-of-motion deficits affect rehabilitation negatively. Preoperative anterior laxity does not influence rehabilitation. The role of preoperative prognostic injury factors remains unclear because of limited evidence.

      Level of Evidence

      Level III, systematic review of Level II and III studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hewett T.E.
        • Di Stasi S.L.
        • Myer G.D.
        Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2013; 41: 216-224
        • Kvist J.
        Rehabilitation following anterior cruciate ligament injury: Current recommendations for sports participation.
        Sports Med. 2004; 34: 269-280
        • Ardern C.L.
        • Webster K.E.
        • Taylor N.F.
        • Feller J.A.
        Return to sport following anterior cruciate ligament reconstruction surgery: A systematic review and meta-analysis of the state of play.
        Br J Sports Med. 2011; 45: 596-606
        • Thomeé R.
        • Kaplan Y.
        • Kvist J.
        • et al.
        Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1798-1805
      1. Te Wierike SC, van der Sluis A, van den Akker-Scheek I, Elferink-Gemser MT, Visscher C. Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: A systematic review. Scand J Med Sci Sports. 4 November, 2012. [Epub ahead of print.]

        • Thomeé P.
        • Währborg P.
        • Börjesson M.
        • Thomeé R.
        • Eriksson B.I.
        • Karlsson J.
        Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 118-127
      2. Wells GA, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed December 13, 2012.

      3. Oxford Centre for Evidence-Based Medicine. OCEBM levels of evidence system. Available from: http://www.cebm.net/index.aspx?o=5653. Accessed December 13, 2012.

        • Higgins J.P.T.
        • Green S.
        Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011].
        The Cochrane Collaboration, 2011 (Available from: http://www.cochrane-handbook.org. Accessed February 12, 2013.)
      4. McPheeters ML, Kripalani S, Peterson NB. Quality improvement interventions to address health disparities. Closing the quality gap: Revisiting the state of the science. Evidence Report No. 208. AHRQ Publication No. 12-E009-EF. Rockville, MD: Agency for Healthcare Research and Quality, 2012. Available from: http://www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed December 13, 2012.

        • Kowalchuk D.A.
        • Harner C.D.
        • Fu F.H.
        • Irrgang J.J.
        Prediction of patient-reported outcome after single-bundle anterior cruciate ligament reconstruction.
        Arthroscopy. 2009; 25: 457-463
        • Osti L.
        • Papalia R.
        • Del Buono A.
        • Leonardi F.
        • Denaro V.
        • Maffulli N.
        Surgery for ACL deficiency in patients over 50.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 412-417
        • Heijne A.
        • Ang B.O.
        • Werner S.
        Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction.
        Scand J Med Sci Sports. 2009; 19: 842-849
        • Melikoglu M.A.
        • Balci N.
        • Samanci N.
        • et al.
        Timing of surgery and isokinetic muscle performance in patients with anterior cruciate ligament injury.
        J Back Musculoskelet Rehabil. 2008; 21: 23-28
        • Salmon L.J.
        • Refshauge K.M.
        • Russell V.J.
        • Roe J.P.
        • Linklater J.
        • Pinczewski L.A.
        Gender differences in outcome after anterior cruciate ligament reconstruction with hamstring tendon autograft.
        Am J Sports Med. 2006; 34: 621-629
        • Ahldén M.
        • Sernert N.
        • Karlsson J.
        • Kartus J.
        Outcome of anterior cruciate ligament reconstruction with emphasis on sex-related differences.
        Scand J Med Sci Sports. 2012; 22: 618-626
        • Dunn W.R.
        • Spindler K.P.
        • MOON Consortium
        Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): A Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study.
        Am J Sports Med. 2010; 38: 2040-2050
        • Spindler K.P.
        • Huston L.J.
        • Wright R.W.
        • et al.
        The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: A population cohort study.
        Am J Sports Med. 2011; 39: 348-359
        • Barber-Westin S.D.
        • Noyes F.R.
        • Andrews M.
        A rigorous comparison between the sexes of results and complications after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1997; 25: 514-525
        • Brandsson S.
        • Kartus J.
        • Larsson J.
        • Eriksson B.I.
        • Karlsson J.
        A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction.
        Arthroscopy. 2000; 16: 178-182
        • Karim A.
        • Pandit H.
        • Murray J.
        • Wandless F.
        • Thomas N.P.
        Smoking and reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Br. 2006; 88: 1027-1031
        • Ahlén M.
        • Lidén M.
        A comparison of the clinical outcome after anterior cruciate ligament reconstruction using a hamstring tendon autograft with special emphasis on the timing of the reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 488-494
        • Karlsson J.
        • Kartus J.
        • Magnusson L.
        • Larsson J.
        • Brandsson S.
        • Eriksson B.I.
        Subacute versus delayed reconstruction of the anterior cruciate ligament in the competitive athlete.
        Knee Surg Sports Traumatol Arthrosc. 1999; 7: 146-151
        • Raviraj A.
        • Anand A.
        • Kodikal G.
        • Chandrashekar M.
        • Pai S.
        A comparison of early and delayed arthroscopically-assisted reconstruction of the anterior cruciate ligament using hamstring autograft.
        J Bone Joint Surg Br. 2010; 92: 521-526
        • Sterett W.I.
        • Hutton K.S.
        • Briggs K.K.
        • Steadman J.R.
        Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction.
        Orthopedics. 2003; 26: 151-154
        • Eitzen I.
        • Holm I.
        • Risberg M.A.
        Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction.
        Br J Sports Med. 2009; 43: 371-376
        • Hamada M.
        • Shino K.
        • Horibe S.
        • Mitsuoka T.
        • Miyama T.
        • Toritsuka Y.
        Preoperative anterior knee laxity did not influence postoperative stability restored by anterior cruciate ligament reconstruction.
        Arthroscopy. 2000; 16: 477-482
        • Kim S.J.
        • Choi D.H.
        • Mei Y.
        • Hwang B.Y.
        Does physiologic posterolateral laxity influence clinical outcomes of anterior cruciate ligament reconstruction?.
        J Bone Joint Surg Am. 2011; 93: 2010-2014
        • Shelbourne K.D.
        • Foulk D.A.
        Timing of surgery in acute anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft.
        Am J Sports Med. 1995; 23: 686-689
        • Howell S.M.
        • Deutsch M.L.
        Comparison of endoscopic and two-incision techniques for reconstructing a torn anterior cruciate ligament using hamstring tendons.
        Arthroscopy. 1999; 15: 594-606
        • Kongtharvonskul J.
        • Attia J.
        • Thamakaison S.
        • Kijkunasathian C.
        • Woratanarat P.
        • Thakkinstian A.
        Clinical outcomes of double- vs single-bundle anterior cruciate ligament reconstruction: A systematic review of randomized control trials.
        Scand J Med Sci Sports. 2013; 23: 1-14
        • Tiamklang T.
        • Sumanont S.
        • Foocharoen T.
        • Laopaiboon M.
        Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults.
        Cochrane Database Syst Rev. 2012; 11: CD008413
        • Mohtadi N.G.H.
        • Chan D.S.
        • Dainty K.N.
        • Whelan D.B.
        Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults.
        Cochrane Database Syst Rev. 2011; : CD005960
        • Deeks J.J.
        • Dinnes J.
        • D'Amico R.
        • et al.
        Evaluating non-randomised intervention studies.
        Health Technol Assess. 2003; 7 (iii-x, 1-173)
        • Harner C.D.
        • Irrgang J.J.
        • Paul J.
        • Dearwater S.
        • Fu F.H.
        Loss of motion after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1992; 20: 499-506
        • Jerre R.
        • Ejerhed L.
        • Wallmon A.
        • Kartus J.
        • Brandsson S.
        • Karlsson J.
        Functional outcome of anterior cruciate ligament reconstruction in recreational and competitive athletes.
        Scand J Med Sci Sports. 2001; 11: 340-342
        • Kim S.J.
        • Moon H.K.
        • Kim S.G.
        • Chun Y.M.
        • Oh K.S.
        Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction?.
        Clin Orthop Relat Res. 2010; 468: 1136-1141
        • Laxdal G.
        • Kartus J.
        • Ejerhed L.
        • et al.
        Outcome and risk factors after anterior cruciate ligament reconstruction: a follow-up study of 948 patients.
        Arthroscopy. 2005; 21: 958-964
        • Sakai H.
        • Hisatada H.
        • Yashiki M.
        Gravity-assisted pivot-shift test can predict the function of the reconstructed anterior ligament.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 572-578
        • Sgaglione N.A.
        • Del Pizzo W.
        • Fox J.M.
        • Friedman M.J.
        Arthroscopically assisted anterior cruciate ligament reconstruction with the pes anserine tendons.
        Am J Sports Med. 1993; 21: 249-256
        • Tambe A.D.
        • Godsiff S.
        • Mulay S.
        • Joshi M.
        Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes.
        Int Orthop. 2006; 30: 104-109
        • Wiger P.
        • Brandsson S.
        • Kartus J.
        • Eriksson B.I.
        • Karlsson J.
        A comparison of results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes.
        Scand J Med Sci Sports. 1999; 9: 290-295
        • Ferrari J.D.
        • Bach B.R.
        • Bush-Joseph C.A.
        • Wang T.
        • Bojchuk J.
        Anterior cruciate ligament reconstruction in men and women: an outcome analysis comparing gender.
        Arthroscopy. 2001; 17: 588-596
        • Marcacci M.
        • Zaffagnini S.
        • Iacono F.
        • Neri M.P.
        • Petitto A.
        Early versus late reconstruction for anterior cruciate ligament rupture.
        Am J Sports Med. 1995; 23: 690-693
        • McHugh M.P.
        • Tyler T.F.
        • Browne M.G.
        • Gleim G.W.
        • Nicholas S.J.
        Electromyography predictors of residual quadriceps muscle weakness after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2002; 30: 334-339
        • Ott S.M.
        • Ireland M.L.
        • Ballantyne B.T.
        • Willson J.D.
        • McClay Davis I.S.
        Comparison of outcome between males and females after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2003; 11: 75-80
        • Wu W.H.
        • Hackett T.
        • Richmond J.C.
        Effects of meniscal and articular surface status on knee stability, function, and symptoms after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2002; 30: 845-850
        • Asano H.
        • Muneta T.
        • Shinomiya K.
        Evaluation of clinical factors affecting knee pain after anterior cruciate ligament reconstruction.
        J Knee Surg. 2002; 15: 23-28
        • de Jong S.N.
        • van Caspel D.R.
        • van Haeff M.J.
        • Saris D.B.F.
        Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions.
        Arthroscopy. 2007; 23: 21-28
        • Mauro C.S.
        • Irrgang J.J.
        • Williams B.A.
        • Harner C.D.
        Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria.
        Arthroscopy. 2008; 24: 146-153
        • Yüksel H.Y.
        • Erkan S.
        • Uzun M.
        Factors affecting isokinetic muscle strength before and after anterior cruciate ligament reconstruction.
        Acta Orthop Belg. 2011; 77: 339-348
        • McHugh M.P.
        • Tyler T.F.
        • Gleim G.W.
        • Nicholas S.J.
        Preoperative indicators of motion loss and weakness following anterior cruciate ligament reconstruction.
        J Orthop Sports Phys Ther. 1998; 27: 407-411