Sports Medicine Research: In the Lab & In the Field: Older Males or Patients with an Allograft ACL Reconstruction Have Short-Term Faster Returns (Sports Med Res)

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Wednesday, August 29, 2018

Older Males or Patients with an Allograft ACL Reconstruction Have Short-Term Faster Returns

Examination of Early Functional Recovery After ACL Reconstruction: Functional Milestone Achievement and Self-Reported Function

Obermeier MC, Sikka RS, Tompkins M, Nelson BJ, & Chmielewski TL.  Sports Health. 2018 10(4): 345-354. DOI: 10.1177/1941738118779762

Take Home Message: After an anterior cruciate ligament reconstruction, patients report significant improvements during the first month after surgery. Many important milestones often occur during the first 15 days after surgery (e.g., return to school, work, driving). Higher age, male sex, allograft selection, and lower body mass index (BMI) are associated with achieving functional milestones earlier than their peers.

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Anterior cruciate ligament (ACL) injuries and decisions to have these surgically repaired are common among physically active Americans.  While we often focus on the medium- to long-term outcomes after an ACL reconstruction (e.g., return to sport), early functional recovery is also important.  If clinicians knew early functional milestones then it could help patients set realistic expectations and provide them feedback on progress, which may improve a patient’s experience and treatment adherence.  These authors prospectively followed 182 participants who had primary ACL reconstruction to determine the time to early functional milestones over the first 12 weeks after an ACL reconstruction. They also sought to determine patient characteristics that may be related to early functional outcomes. The authors selected participants without concomitant complicated procedures (i.e., meniscus repair, microfracture, multi-ligament reconstruction) and assessed them prior to and at 1, 2, 4, 8, and 12 weeks post-surgery.  The researchers focused on self-reported functional milestones such as medication discontinuation; progression to non-assisted ambulatory status; and return to work, school, or driving. The authors also assessed self-reported function as scored by the Short Musculoskeletal Functional Assessment questionnaire.  Participants showed functional improvements over the 12 weeks post-surgery, with the greatest improvements during the first month after surgery. The median times to functional milestones are described below. No demographic predictors were not found to be associated with self-reported function scores changes over time. 

Functional Milestone
Median Time to Milestone
(day by which half the people met it)
Factors related  to achieving the milestone earlier
Return to school
7 days
none
Discontinue pain medications
9 days
allograft
Return to work
11 days
Higher age, males, lower BMI, light occupational demands
Return to driving
11 days
Higher age, males, left knee reconstruction
Discontinue crutches
15 days
none

These researchers followed patients longitudinally after an ACL reconstruction and linked certain predictors to short-term functional milestone achievements.  This study is a good addition to the field because it gives us an idea of timeframes to achieve functional milestones, as well as the modifiable and nonmodifiable factors that may be linked to these achievements.  It was interesting, yet not surprising, to see that allograft reconstructed patients tended to discontinue their pain medication use faster than autograft patients.  As a clinician, these results may help us educate our patients on what to expect based on their graft selection.  It would be interesting to continue to follow these patients out longer to see if their graft selection caused any different long-term outcomes (e.g., failure rates, osteoarthritis), as many researchers have investigated these differences.  The fact that higher age was a predictor of return to work and drive was fascinating to me.  We often think that our younger patients tend to be more resilient, so I wonder if there were other factors such as the inability to miss work or other societal demands that incentivized this faster return compared with younger patients.  But, we need to ask ourselves whether a faster return is necessarily better.  Ultimately, continuing to follow these patients over time to determine their self-reported function, as well as their clinical outcomes (such as, strength, limb symmetries, and possible clearance) would help clarify the long-term benefits or consequences of meeting these milestones faster.  Clinically, we can use this information to educate our patients and help ourselves recognize what we might be able to control and expect post ACL reconstruction. 

Questions for Discussion:  What are the relatively short-term functional outcomes that you are interested in seeing in your patients?  Are there any other functional outcomes that you might find interesting (perhaps past 12 weeks) in the physically active population?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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