Ann Rehabil Med.  2022 Apr;46(2):97-107. 10.5535/arm.22010.

Early Return to Play After Anterior Cruciate Ligament Reconstruction: Is It Worth the Risk?

• Török L
• Jávor P
• Török K
• Rárosi F
• Hartmann P

• KMID: 2529510
• DOI: http://doi.org/10.5535/arm.22010

Abstract

Objective
To compare the outcomes of a 6-month-long accelerated rehabilitation with a 12-month-long rehabilitation. There is no consensus on the optimal duration of rehabilitation after anterior cruciate ligament reconstruction (ACLR). Trends in the past decades have shifted towards accelerated programs, often resulting in a return to play (RTP) at 4–6 months, postoperatively. However, longer rehabilitation cycles have recently experienced renaissance due to a greater understanding of graft remodeling.
Methods
Adult athletes who underwent ACLR between 2015 and 2018 by the same surgeon were included and followed-up prospectively for 24 months. Participants were allocated into two groups based on their RTP (6 months vs. 12 months) and compared with graft elongation, reoperation rate, and sports career (quit or continue) outcomes.
Results
Fifty-four patients underwent accelerated rehabilitation and 92 completed conventional rehabilitation. The accelerated rehabilitation was significantly associated with graft elongation—the accelerated rehabilitation group (n=9) and the conventional rehabilitation group (n=0), p<0.001—and need for reoperation—the accelerated rehabilitation group (n=5) and the conventional rehabilitation group (n=1), p=0.026. Although the relationship between rehabilitation time and quitting competitive sports did not reach significance at 0.05 level (p=0.063), it was significant when p<0.1, thereby showing a clear trend.
Conclusion
Accelerated rehabilitation increased graft elongation risk. Knee laxity ≥3 mm measured at 6 months after ACLR should be accompanied by RTP time frame re-evaluation. Arthrometry checkups or routine magnetic resonance imaging shortly after RTP may be considered in cases of accelerated rehabilitation.

Keyword

Anterior cruciate ligament; Ligaments; Wounds and injuries; Return to sport; Rehabilitation

Figure

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  Fig. 1. Diagram showing patient enrolment. Between 2015 and 2018, 326 patients underwent ACLR performed by the same orthopedic trauma surgeon. The one-patellar tendon-bone technique was used in 169 patients. After excluding patients who did not compete in sports, 146 athletes were included in the analysis. The decision for accelerated rehabilitation was made in 54 cases, and the remaining 92 patients completed a 12-month-old recovery schedule. ACLR, anterior cruciate ligament reconstruction; BPTB, bone-patellar tendon-bone.

• 

  Fig. 2. Primary outcomes in the study groups. The distribution of graft elongation, reoperation, and quitting sports careers among the study groups are presented. Black indicates the conventional rehabilitation cohort, while white represents the accelerated rehabilitation group. Most importantly, graft elongation without rupture occurred only in the patients who completed the accelerated program. Furthermore, there was a notable difference in the reoperation rates and terminating sports careers between the study groups. *p=0.0261, ***p<0.001 (Fisher exact test).

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  Fig. 3. Relationship of patient age with graft failure. Receiver operating characteristic (ROC) curve demonstrated a relationship between age and graft failure. Despite being confirmed as a risk factor for graft failure in several studies, patient age was not significantly associated with graft failure in our patient population.

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