|Year : 2022 | Volume
| Issue : 3 | Page : 167-172
The effect of preoperative rehabilitation on the outcome of anterior cruciate ligament reconstruction
S Srinivasalu1, Anoop Pilar1, Sandesh G Manohar1, Jobin Joseph2, M Madan Mohan1, Rajkumar S Amaravathi1
1 Department of Orthopaedics, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
2 Department of Orthopaedics, Christuraj Hospital, Kannur, Kerala, India
|Date of Submission||07-Mar-2022|
|Date of Decision||20-Mar-2022|
|Date of Acceptance||21-Apr-2022|
|Date of Web Publication||1-Sep-2022|
M Madan Mohan
Department of Orthopaedics, St. John's Medical College Hospital, Sarjapur Road, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objectives: Internal knee injuries account for nearly 45% of sports-related injuries, with anterior cruciate ligament (ACL) injury being the most prevalent. ACL injury is associated with pain, instability of the joint, muscle weakness, functional limitation, poor quality of life, and an increased risk of knee-related osteoarthritis. Preoperative exercise rehabilitation physiotherapy program is often performed to prepare the knee for reconstruction surgery and to maximize the outcomes of rehabilitation. The objective of our study was to evaluate the effects of preoperative rehabilitation on the outcome of ACL reconstruction (ACLR) using the International Knee Documentation Committee (IKDC) score, Tegner Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), patients' symptoms, including tenderness, effusion, and range of motion limitations. Materials and Methods: Thirty patients with ACL injury were included in this study after obtaining informed consent and followed up till 12 months. A detailed history and evaluation were done. All patients who met the inclusion criteria were randomly allocated into two groups, one receiving a course of preoperative rehabilitation of 12 weeks, and one who were taken up for surgery without preoperative rehabilitation. Pre- and postsurgery, each of these groups was assessed at 3-, 6-, and 12-month intervals using the IKDC, KOOS, and Tegner Lysholm scores. Results: On analysis, it was found that the mean IKDC, KOOS, and Tegner Lysholm scores increased significantly for all patients from preoperative to postoperative 12 months. There was a statistically significant difference between the prehab and non-prehab groups, in each of these scores, with the prehab group having better functional scores. Conclusion: It was found that in individuals with ACL tear, arthroscopic ACLR improved the functional outcome, and among these patients, it was found that individuals who received preoperative rehabilitation fared better in terms of functional score assessment.
Keywords: Anterior cruciate ligament tear, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, reconstruction, rehabilitation, Tegner Lysholm score
|How to cite this article:|
Srinivasalu S, Pilar A, Manohar SG, Joseph J, Mohan M M, Amaravathi RS. The effect of preoperative rehabilitation on the outcome of anterior cruciate ligament reconstruction. J Orthop Dis Traumatol 2022;5:167-72
|How to cite this URL:|
Srinivasalu S, Pilar A, Manohar SG, Joseph J, Mohan M M, Amaravathi RS. The effect of preoperative rehabilitation on the outcome of anterior cruciate ligament reconstruction. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 6];5:167-72. Available from: https://jodt.org/text.asp?2022/5/3/167/355243
| Introduction|| |
Internal knee injuries account for nearly 45% of sports-related injuries, with anterior cruciate ligament (ACL) being the most commonly involved. ACL injury is associated with pain, instability of the joint, muscle weakness, functional limitation, poor quality of life, and an increased risk of knee-related osteoarthritis.,
Typically, the recommendation of ACL reconstruction (ACLR) surgery is for unstable knee following ACL rupture to restore mechanical stability at the knee and subsequently enable a return to functional activities, including participation in sports.
During the 1980s, Noyes et al. first suggested the potential of preoperative physiotherapy to restore knee function. Preoperative rehabilitation (PreHab) is often performed to prepare the knee for reconstruction surgery and to maximize the outcomes of surgery and rehabilitation.
Even though there are multiple clinical trials that have investigated the effectiveness of preoperative rehabilitation on the outcomes (pain, quality of life, range of motion [ROM], muscle strength, and function) of treatment following ACL injury, there is a lack of unanimity in these findings.,
Eitzen et al. demonstrated that patients with ACL injury, who initially have poor knee function, demonstrate good potential for functional improvement after rehabilitation, with preoperative quadriceps strength as the single most important factor predicting knee function 2 years after ACLR. Carter et al., in a recent systematic review, found low-quality evidence of prehabilitation offering a small benefit to quadriceps strength and single-leg hop scores 3 months post-ACLR compared with no prehabilitation. Another systematic review conducted by Giesche et al. indicated low-to-moderate quality evidence of the positive impact of prehabilitation on preoperative and postoperative functional performance.
Still, sparsity of evidence-based protocols for early-stage ACL injury management, including detailed descriptions of the rehabilitation programs and evaluation of outcome, exists. As a result, little is known about the tolerance for, and potential benefit from, short-term progressive exercise therapy programs in the early stage after ACL injury.
The aim of the present study was to evaluate the role of preoperative rehabilitation on the outcome of ACLR using clinical examination and standardized scoring systems and to assess whether it enhances the postoperative outcome of ACLR.
| Materials and Methods|| |
This is a prospective study involving 30 patients belonging to the age group of 18–60 years with ACL (partial or complete) injury. Approval of the institutional ethical review board has been taken prior to initiation of the study. After obtaining written informed consent they were included in the study and followed up for at least 12 months. A detailed history was elicited and clinical evaluation was done. The diagnosis was confirmed with standard clinical tests and using magnetic resonance imaging (Sigma HDxT-GE 1.5 Tesla).
Patients were randomly assigned to one of the two groups, one receiving preoperative rehabilitation and one not receiving preoperative rehabilitation. The group receiving preoperative rehabilitation was subjected to a 12-week course of hospital-based physiotherapy before surgery. The second group was taken up for ACLR without preoperative physiotherapy.
Preoperatively and postoperatively data were functionally analyzed with the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm Tegner scores. The scores of both time points were expressed as mean + or– standard deviation the normality of the data was examined. If the scores follow normal distribution, it was compared between pre- and postoperative time points using paired sample t-test. All statistical analyses were considered significant at P < 0.05 level of significance.
IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp and R Core Team (2021). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/ were used for the analysis of the data.
| Results|| |
Of the 30 patients who underwent ACLR, majority (67%) were in the age group 20–40, with male predominance (83.3%). The right knee was more commonly affected as compared to the left. Road traffic accidents (RTA) were the most common mechanism of injury, amounting to 43% of the cases, followed by sports injuries, and self-fall.
It was found that the incidence of sports-related injuries was significantly higher among the group that had received prehab, and the incidence of RTA as a mechanism of injury was more common among the group that did not receive prehabilitation.
Concomitant meniscal injury was seen in 65% of patients with medial meniscal more commonly involved in both the groups.
To compare pre- and postoperative scores between the prehab and no prehab groups repeated measure analysis of variance is used. All the variables were approximately normally distributed.
Tegner Lysholm score
Different time points (preoperative, postoperative 3 months, postoperative 6 months, and postoperative 12 months) had significant effect on Tegner Lysholm score (F , 26 = 40.6, P < 0.001). The simultaneous effect of time points and use of prehab had a significant effect on Tegner Lysholm score (F , 26 = 8.5, P < 0.001). The score differed significantly across preoperative, postoperative-3 months, postoperative-6 months, and postoperative-12 months (Greenhouse-Geisser corrected F 2.0, 61.5 = 68.62, P < 0.001) and also there was a significant difference in average Tegner Lysholm score between the prehab and no prehab groups (F , 28 = 19.1, P < 0.001) [Table 1] and [Figure 1].
|Figure 1: Estimated marginal means of Tegner Lysholm score. PREHAB: Preoperative rehabilitation|
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International Knee Documentation Committee score
IKDC score also showed that different time points had significant effect on IKDC score (F , 26 = 247.0, P < 0.001). There was a significant effect on IKDC score (F , 26 = 65.5, P < 0.001) of the simultaneous effect of time points and the use of prehab. There was a significant increase in average IKDC score between all pairs of time points with P < 0.001, and the difference in average IKDC score between the prehab and no prehab groups was significant (F , 28 = 89.86, P < 0.001) [Table 2].
Knee Injury and Osteoarthritis Outcome Score
KOOS was affected significantly at different time points (F , 26 = 75.13, P < 0.001), use of prehab had a significant effect on KOOS (F , 26 = 16.81, P < 0.001) [Table 3] and [Figure 2]. Average KOOS between the prehab and no prehab groups showed significant difference (F , 28 = 7.0, P < 0.013), and there was a significant increase in average KOOS between all pairs of time points with P < 0.001.
|Figure 2: Estimated marginal means of KOOS. KOOS: Knee Injury and Osteoarthritis Outcome Score, PREHAB: Preoperative rehabilitation|
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Maximum range of motion
The average of maximum ROM differed significantly across preoperative, postoperative-3 months, postoperative-6 months, and postoperative 12 months (F [3, (84)] = 124.9, P < 0.001). Prehab had significant effect on maximum range of movement (F , 26 = 92.1, P < 0.001) at different time points [Table 4] and [Figure 3].
|Figure 3: Estimated marginal means of maximum of ROM. ROM: Range of motion, PREHAB: Preoperative rehabilitation|
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Comparison of all scores between time points
All scores showed a significant difference in median score between the time points for duration 1 and 3 months and 3–6 months [Table 5],[Table 6],[Table 7].
|Table 5: Comparison of International Knee Documentation Committee score between time points|
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|Table 7: Comparison of Knee Injury and Osteoarthritis Outcome Score between time points|
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| Discussion|| |
It is a known fact that ACL is the predominant restraint to anterior tibial displacement, and it accepts 75% of anterior force at full extension and approximately 85% at 30° and 90° of flexion. Discontinuity of the ACL inevitably results in knee kinematics alterations, as transfer of loads can be effective only if the joint is mechanically stable. The sequelae seen after ACL injury involve quadriceps strength deficits, neuromuscular dysfunction, and biomechanical maladaptation and is associated with the development of knee osteoarthritis.,
The goals of ACLR in athletes are to restore normal knee joint stability and function and allow a return to sports activities. However, even with modern operative techniques and rehabilitation programs, there is strong evidence that deficits in balance, proprioception, muscle strength, and neuromuscular control exist for many months postoperatively. Preoperative quadriceps muscle strength deficits have previously been assessed from isokinetic measurements to be between 7% and 17%.
The mean IKDC, KOOS, and Tegner Lysholm scores increased among all 30 patients, in comparison to the preoperative values. In each category (with and without prehab), it was found that the mean IKDC, KOOS, and Tegner Lysholm scores improved substantially, in comparison to the preoperative values. These values gradually increased at the first follow-up, which was at 3 months postoperative, followed by steady increases with the highest postoperative. Value attained at the 12th month postoperatively. These were true for each of the three functional scores. As an additional part of the assessment, it was found that all of the 30 patients exhibited a significant increase in the range of movement of the affected knee postoperatively, in comparison to the preoperative values.
Alshewaier et al., in their systematic review of eight studies, analyzing the effects of preoperative physiotherapy found significant improvements in function and physical performance in the intervention group following preoperative physiotherapy compared to the control group. Five of these studies found significant improvements in the prehab group compared to the control group in a range of outcomes, including function, strength, and reflex hamstring contraction latency.
Based on the analysis, it was found that, of the 30 patients included in the study, 15 patients in the prehab group reported better functional scores as compared to the 15 from the non-prehab group. There was a statistically significant relation between prehabilitation and better functional scores. Moreover, the preoperative rehabilitation group was found to exhibit a faster recovery of ROM as compared to the nonpreoperative rehab group, similar to the findings elicited by Shaarani et al. They found that following 6 weeks of exercise intervention, the single-legged hop test results improved significantly in the exercise-injured limb compared with baseline. Knee function was also shown to have improved in these subjects based on the single-legged hop test and self-reported assessment using the modified Cincinnati score.
Palmieri-Smith et al., concluded that individuals with good preoperative quadriceps activation demonstrated better postoperative activation. Similarly, individuals with good preoperative strength demonstrated greater postoperative strength. Clinicians should utilize therapies targeting both quadriceps activation and strength before ACLR to maximize these factors post-ACLR. These correlate with the findings in our study, which concludes that preoperative physiotherapy administered to patients awaiting ACL surgery improved not only the functional scores but also the range of movement and consequently the return to normal activity.
Eitzen et al. in their study of 100 patients included in a 5-week progressive exercise therapy program, within 3 months after injury., showed improved knee function in the early stage after ACL injury. Their results indicate a positive role for preoperative physiotherapy in ACL injured patients awaiting surgery for a better postoperative functional outcome, thus complementing the findings of our study.
Kim et al. demonstrated significant improvement the single-leg hop distance in randomly assigned 80 male patients, scheduled for reconstruction surgery, to two equal groups, the preoperative exercise group and a no preoperative exercise group. The result indicated that preoperative exercises not only prevented quadriceps weakness but also has many positive effects postreconstruction surgery, including accelerated recovery of knee extensor strength and quicker adaption to the rehabilitation environment.
Keays et al. in a masked controlled study comprising two matched groups of 12 chronically ACLD patients awaiting reconstruction and a group of 12 matched uninjured control subjects, concluded physiotherapy plays a significant role in reversing majority of the key deficits resulting from ACL injury.
Failla et al. compared outcomes after an ACL rupture in an international cohort (Delaware-Oslo ACL Cohort [DOC]) treated with extended preoperative rehabilitation, including neuromuscular training, to data from the multicenter orthopedic outcomes network cohort, which did not undergo prehabilitation. The DOC cohort had better functional outcomes and return to sports 2 years after ACLR. They recommended prehab as an additional consideration in the standard of care to enhance functional outcomes after ACLR.
The main clinical implication of this finding is that ACLD patients awaiting surgery, electing to postpone surgery or to manage without surgery, should be referred for a physiotherapy program. Deficits can be reversed, even in the chronic stages of injury, and they can be reversed using an individualized 6-week home-based program. These findings concur with the implications of our study and support the use of routine preoperative physiotherapy in all patients awaiting ACLR surgery, further going on to imply that patients with chronic ACL tears would also benefit from a similar program.
In summary, arthroscopic ACLR was found to improve the knee function significantly, as assessed by the IKDC, KOOS, and Tegner Lysholm questionnaires.
It was also found that preoperative rehabilitation is a simple and effective method of ensuring a better postoperative outcome as measured by range of movement and functional score assessment for patients with ACL tears.
The shortcomings of the study include the period of follow-up, which is 1-year. Further follow-up is needed to assess the long-term implications of our findings. Furthermore, the prehab and non-prehab samples are not matched with respect to the mechanism of injury.
| Conclusion|| |
Arthroscopic ACLR offers a good outcome in terms of functional score assessment in individuals with ACL tears. Preoperative rehabilitation before ACLR surgery enhances the postoperative outcomes as measured up to a period of 1 year postoperative.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc 2013;45:462-9.
Friel NA, Chu CR. The role of ACL injury in the development of posttraumatic knee osteoarthritis. Clin Sports Med 2013;32:1-12.
Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol 2019;33:33-47.
Wilk KE, Arrigo CA. Preoperative phase in the rehabilitation of the patient undergoing anterior cruciate ligament reconstruction. Oper Tech Sports Med 2016;24:12-20.
Barber SD, Noyes FR, Mangine R, DeMaio M. Rehabilitation after ACL reconstruction: Function testing. Orthopedics 1992;15:969-74.
Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: A systematic review. Clin Rehabil 2017;31:34-44.
Giesche F, Niederer D, Banzer W, Vogt L. Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review. PLoS One 2020;15:e0240192.
Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med 2009;43:371-6.
Carter HM, Littlewood C, Webster KE, Smith BE. The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: A systematic review. BMC Musculoskelet Disord 2020;21:647.
Lepley LK, Palmieri-Smith RM. Pre-operative quadriceps activation is related to post-operative activation, not strength, in patients post-ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2016;24:236-46.
Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 2011;27:1697-705.
Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med 2008;27:405-24, vii-ix.
Bruhn S, Kullmann N, Gollhofer A. Combinatory effects of high-intensity-strength training and sensorimotor training on muscle strength. Int J Sports Med 2006;27:401-6.
Shaarani SR, O'Hare C, Quinn A, Moyna N, Moran R, O'Byrne JM. Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. Am J Sports Med 2013;41:2117-27.
Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther 2010;40:705-21.
Kim DK, Hwang JH, Park WH. Effects of 4 weeks preoperative exercise on knee extensor strength after anterior cruciate ligament reconstruction. J Phys Ther Sci 2015;27:2693-6.
Keays SL, Bullock-Saxton JE, Newcombe P, Bullock MI. The effectiveness of a pre-operative home-based physiotherapy programme for chronic anterior cruciate ligament deficiency. Physiother Res Int 2006;11:204-18.
Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, et al.
Does extended preoperative rehabilitation influence outcomes 2 years after ACL reconstruction? A comparative effectiveness study between the MOON and Delaware-Oslo ACL Cohorts. Am J Sports Med 2016;44:2608-14.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]