Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen stereophotogrammetric analysis.
Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011 Sep 27.
A few years ago Beynnon et al published the results of a pilot randomized clinical trial (n = 22) that suggested accelerated (19 week) and nonaccelerated (32 week) rehabilitation after an anterior cruciate ligament (ACL) reconstruction lead to similar results in anterior knee laxity, clinical assessments, patient satisfaction, functional performance. Patients in both groups had abnormal cartilage turnover at least one year after surgery. That pilot study inspired the current randomized double-blind trial which included more patients and more outcome measures. The purpose of this paper was to describe the influence of 2 rehabilitation programs (19-week accelerated or 32-week nonaccelerated) after a bone-patellar tendon-bone autograft reconstruction on 6-degrees of freedom laxity values (instead of the previous trial which only evaluated anterior-posterior laxity). Knee laxity was evaluated using roentgen stereophotogrammetric analysis (based on x-ray techniques) at the time of surgery, 3-months, 6-months, 12-months, and 24-month after surgery. The authors also evaluated clinical, functional, and patient-oriented outcome measures at the same time points. During the recruitment period (1998 to 2001) a total of 390 patients (average age ~ 30 years; range 16 to 48 years of age) were evaluated for an ACL tear by two orthopaedic surgeons. Patients were excluded for a variety of reasons including if they had cartilage lesions that exposed bone or needed a meniscal repair. Patients were randomized to a rehabilitation program after surgery to ensure the surgeon and evaluators were unaware of the patient’s group assignment. The authors provide a detailed outline of the rehabilitation programs with their article (rehabilitation was administered by one physical therapist). Overall, 42 patients were enrolled (24 patients receiving accelerated and 18 receiving nonaccelerated) and 85% of patients made it through the 2 year follow-up period. Compliance to the rehabilitation programs were good with 47% and 29% of those in the accelerated and nonaccelerated groups, respectively, completing at least 75% of the exercises during their program. Immediately after surgery, overall knee laxity was restored compared to the contralateral (normal) knee. Patients in both groups had similar increases in overall knee laxity (e.g., anterior-posterior, medial-lateral, rotational) over 2-years. At 3 months after surgery the accelerated group had better isokinetic knee extensor muscle strength than the nonaccelerated group but at all of the subsequent evaluations the two groups had similar strength. Two years after surgery both groups had similar clinical assessments, patient satisfaction, function (one-legged hop test), proprioception (threshold to detect passive knee movement), and isokinetic thigh muscle strength (knee extensor and flexor). Interestingly, patient-reported knee-related quality of life scores did not return to what has been previously defined as “normal” suggesting that at 2-years post-operative both groups sill reported lower impaired quality of life.
This study provides a comprehensive comparison of an accelerated and nonaccelerated rehabilitation program that indicated that both programs lead to similar increases in knee laxity as well as improvements in clinical outcomes, functional performance, proprioception, and thigh muscle strength. Unfortunately, patient-reported quality of life did not return to normal. The authors suggest that these findings indicate that the accelerated program should be used for rehabilitation after ACL reconstructions with bone-patellar tendon-bone autografts. However, it’s important to note that they did not include individuals with meniscal repairs or full thickness cartilage defects. Furthermore, the study, as well as the pilot trial the authors performed, should raise an important question: If patients in both groups are not reporting “normal” quality of life 2-years after surgery and have prolonged signs of cartilage turnover is our current standard of care for ACL tears enough?
Written by: Jeffrey Driban
Reviewed by: Stephen Thomas
Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, & Nichols CE (2011). Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen stereophotogrammetric analysis. The American Journal of Sports Medicine, 39 (12), 2536-48 PMID: 21952714