Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1065–1073 | Cite as

No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review

  • Ciaran Thrush
  • Tabitha J. Porter
  • Brian M. Devitt
Knee
  • 248 Downloads

Abstract

Purpose

Anterior cruciate ligament (ACL) rupture commonly occurs in conjunction with articular cartilage injury. However, there is no consensus on the most appropriate rehabilitation which should be carried out for ACL reconstruction (ACLR) and the surgical management of articular cartilage lesions of the knee. The purpose of this study was to systematically review the literature to investigate the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment.

Methods

Two reviewers independently searched five database for randomised controlled trials (RCTs), non-randomised comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the postoperative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black’s checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilisation, continuous passive motion (CPM), and return to play criteria. Secondary outcomes included patient-reported outcomes. A best evidence synthesis was performed.

Results

The review yielded six studies which reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques utilised and especially the rehabilitation regimes. No consensus was found on weight-bearing status, postoperative immobilisation, the use of CPM, or return to play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions.

Conclusion

This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. A list of specific rehabilitation protocols based on the cartilage restoration technique is provided.

Level of evidence

IV.

Keyword

Anterior cruciate ligament reconstruction Articular cartilage lesions Rehabilitation 

Introduction

Anterior cruciate ligament (ACL) rupture is a common injury, which may occur in isolation or in conjunction with other intra-articular knee pathology [1, 2, 3, 4, 5]. Associated articular cartilage injury is a frequent finding in patients undergoing ACL reconstruction (ACLR), with some studies suggesting the presence of severe chondral damage in up to 46% of cases [6]. ACLR followed by postoperative rehabilitation is commonly recommended and performed for the management of a patient with a symptomatic, unstable knee following ACL rupture. However, the suggested treatment for concurrent cartilage injury is less clear cut; some experts advocate no treatment [5, 7] while other propose using various techniques of cartilage restoration [8, 9, 10].

Another area of controversy is the advised rehabilitation following treatment of an articular cartilage injury, particularly in the setting of a concurrent ACLR. The type of rehabilitation following ACLR alone is highly variable [11]. In recent times methods have become more accelerated compared to the conservative recommendations of the past, which included prolonged periods of immobilisation and restricted weight-bearing [12, 13, 14, 15]. However, the situation becomes increasingly more complex in the context of concurrent chondral injuries where there might be a greater temptation to offload the damaged area. Therefore, there is a distinct risk that the outcome of a combined injury may be compromised by being either too aggressive with the postoperative rehabilitation, which may compromise the cartilage restoration, or not aggressive enough which can impact the ACLR. Currently, no consensus exists in the literature to provide guidelines on the recommended rehabilitation following the surgical management of a combined articular cartilage and ACL injury [11, 16].

Therefore, the purpose of this study was to systematically review the literature to investigate the recommended rehabilitation regimes in a patient undergoing ACLR with concurrent articular cartilage injury. A secondary aim was to perform a best evidence synthesis with a view to provide guidelines on the optimal rehabilitation following concurrent treatment of chondral lesions and ACLR.

Materials and methods

This study was undertaken as a review of the current literature, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [17].

Search strategy

A search was undertaken on 25th September 2017, utilising the Pubmed, Embase, Cinahl, Cochrane Central Register of Controlled trials and AusportMed databases. Search terms were entered into the database under three concepts: Concept One: “anterior cruciate ligament” OR “ACL” AND “reconstruction” AND “knee.” Concept Two: “rehabilitation” AND “knee.” Concept Three: “knee” AND “cartilage.” The results from each concept were then combined with the “AND” operator to produce the search strategy and the final yield. To supplement the electronic database search, the reference list of all relevant papers was crosschecked, and forward citation tracking via the Web of Science electronic database was conducted. Publication details from all studies was identified in the literature search were exported to bibliographic software (Endnote X8). Duplicate titles were excluded and the remaining articles were assessed for suitability.

Selection criteria

The following inclusion criteria were applied to the final yield:

  • Published peer-reviewed study: either randomised controlled trial (RCT), case–control study (CCS) or cohort studies (CS).

  • Studies describing the management of concurrent ACLR and articular cartilage injury.

  • Description of the postoperative rehabilitation protocols.

The exclusion criteria were as follows:

  • ACLR performed in isolation.

  • Articular cartilage surgery performed in isolation.

  • Cases with more than two surgically treated knee ligaments.

  • ACLR combined with alignment knee surgery.

  • Reports on guidelines, technical notes, reviews, or systematic reviews.

  • Non-English language articles with no available translation.

Selection was undertaken initially by assessing the article titles and abstracts. If a resource appeared suitable or it was not clear as to the suitability based on the abstract, the full text article was obtained and further analysis was undertaken to decide suitability. Two reviewers applied the selection criteria independently (CT and BMD). Consensus was used to resolve any disagreements between reviewers, with a third reviewer was consulted if consensus could not be reached.

Quality appraisal

The modified Downs and Black tool was used to methodological quality and was applied to the included articles by two independent reviewers (CT and BMD) [18]. The modification of this tool uses a maximum score of 16, with scores ≥ 12 regarded as high quality, 10 or 11 to be moderate quality, and ≤ 9 low quality. This was applied to assess the quality of the studies overall, before examining their specific approaches to rehabilitation. Each article had a level of evidence assigned using the Oxford Centre for Evidence-Based Medicine guidelines and was assessed using the Cochrane Collaboration’s tool for risk of bias in randomised trials [19].

Data extraction

Two independent reviewers extracted data using a data extraction form specifically designed for this review. The primary outcome of interest was details regarding postoperative rehabilitation with concurrent ACLR and articular cartilage injury. The following data were extracted from the papers: study-type, number of patients, sex, age, time from injury to surgery, primary/revision procedure, type of ACLR, grade of cartilage injury, type of cartilage procedure if any, and specific rehabilitation protocols. The secondary outcomes were clinical, objective, subjective, functional, and radiographic outcomes.

Data synthesis and analysis

The heterogeneity of the outcome scores used in the different studies and the results reported in them precluded a meta-analysis. The primary outcome was postoperative rehabilitation techniques and data from the individual studies were summarized and categorized according to the following headings: postoperatively immobilisation, weight-bearing status, the use of continuous passive motion (CPM), strength training, and return to sport decision making. The secondary outcomes, including failure rate, clinical and radiological outcomes and surgical technique of each treatment modality were assessed. No statistical synthesis of results was possible and, as such, no measures of consistency were calculated.

Best-evidence synthesis

To assist with evaluating the outcome findings that could not be assessed through meta-analysis due to the limited availability of homogenous data, a best-evidence synthesis was performed. The method, proposed by Van Tulder et al [20] and adapted by Steultjens et al. [21] was used to ascribe levels of evidence of effectiveness, taking into consideration study design, methodological quality, and statistical significance of the findings (Appendix 1).

Results

Database searches revealed 621 articles, and an additional article was found after reference checks. After elimination of duplicates, 349 titles and abstracts were screened. Three-hundred and nine were eliminated based on this screening, and therefore, 40 full-text articles were obtained. Thirty-four articles were removed for the following reasons: no description of postoperative rehabilitation protocols (n = 16), concurrent ACLR and articular cartilage injury was not described in the study (n-16), and no English-language version of the study available (n = 2). This left six articles which were suitable for analysis (Fig. 1).

Fig. 1

Prisma flow diagram

Methodological quality

Table 1 illustrates the assessment of methodological quality according to the Downs and Black criteria. The methodological score was poor in all studies with values ranging from 6 to 8 out of a maximum possible score of 16. All studies were lacking in sample size calculation, consideration of selection bias, power analysis, accounting for selection bias, assessment of confounding factors and provision of a comparative group to assess the effectiveness of rehabilitation protocols. There were no RCTs. All of the studies were cohort studies, with two reaching levels of evidence according to the Oxford Centre for Evidence-based Medicine [19] of grade 2b [22, 23] and the others reaching grade 4 [7, 8, 10, 24].

Table 1

Quality assessment tool: modified Downs & Black

Paper

Aim

Patient

Sample

Bias

Comparison

Outcomes

Valid

Blinding

Findings

Shelbourne

1

1

1

0

1

1

1

0

1

Nakamura

1

1

1

0

0

1

1

0

1

Klinger

1

1

1

0

0

1

1

0

1

Gaweda

1

1

0

0

1

1

1

0

1

Cox

1

1

1

0

0

1

1

0

1

Alfredson

1

1

1

0

0

1

1

0

1

Paper

Random

Statistics

Confounders

Adjustment

Sample calc.

Power

Total

Quality

Shelbourne

0

1

0

0

0

0

8

Low quality

Nakamura

0

1

0

0

0

0

7

Low quality

Klinger

0

0

0

0

0

0

6

Low quality

Gaweda

0

0

0

0

0

0

6

Low quality

Cox

0

1

0

0

0

0

7

Low quality

Alfredson

0

0

0

0

0

0

6

Low quality

Aim aim of study, Patient patient characteristics, Sample sample is representative, Bias selection bias present, Comparison comparison group identified, Outcomes clearly described outcomes, Valid measures are valid and reliable, Blinding attempt to blind measurers, Findings main findings of study, Random estimates of random variability, Statistics statistical tests used, Confounders clearly described distributions of principle cofounders, Adjustment adequate adjustment for cofounding, Sample calc. reported sample size calculation, Power sufficient power in study, ≥ 12 high quality, 10 to 11 moderate quality, ≤ 9 low quality

Postoperative rehabilitation

There was considerable variation in not only the operative techniques for ACLR and cartilage restoration but also the postoperative rehabilitation protocols described (Table 2). Commonly described aspects of rehabilitation included the use of immobilisation, weight-bearing status and the use of continuous passive motion. Strengthening protocols and decision-making on return to play were inconsistently reported.

Table 2

Study description, ACL reconstruction technique, chondral restoration technique and postoperative rehabilitation regimen

Study

Type of study

ACLR type

Cartilage injury treatment

Grade

Location

Shelbourne [7]

Retrospective cohort

BTB autograft

No intervention

3 or 4

Med 60, lat 65

Nakamura [24]

Prospective cohort

Hamstring, double bundle-ish (two femoral sockets, one tibial)

Nil intervention. Second look arthroscopy average 18months post-op

Mixed

 

Klinger [10]

Prospective cohort

BTB autograft

OATS

 

Full thickness, MFC > 2 cm × cm

Gaweda [23]

cohort

BTB and hamstrings

OATS one stage with ACLR

 

MFC in 19, LFC in 1, both in 1. 1.52 cm × cm average

Cox [22]

Prospective cohort

Mixed allo and auto, some revisions

Mixed

  

Alfredson [8]

cohort

BTB autograft

Periosteum transplant

Range 1-12.5 cm × cm

MFC

Study

Weightbearing

ROM

Immobilisation

CPM

Strength

Proprioception

Running

Return to Play

Shelbourne [7]

FWB

Full

No

No

    

Nakamura [24]

NWB 3 weeks, PWB until 5 weeks

Immobilised 20 deg flexion, active and PROM after 1 week

Immobilised 20° flexion

No

  

3–4 months

8 months

Klinger [10]

NWB 3 weeks, PWB 3 weeks then FWB

 

Hinge knee brace for 3 weeks

Yes

Closed chain Day 1

Day 1

 

9 months

Gaweda [23]

NWB 7–14 days, progress to FWB by 6 weeks

 

0–30°

Yes

Closed chain Day 1

From 6 week

  

Cox [22]

FWB

  

No

    

Alfredson [8]

PWB 3 weeks, progressing to FWB under supervision

 

ROM brace 0–90° 3 weeks

Yes for 7 days (epidural for 5)

3 weeks on

   

Weight-bearing

Weight-bearing status was described in all six articles. Cox et al. and Shelbourne et al. allowed full weight-bearing immediately. Alfredson et al. commenced with partial weight-bearing for three weeks followed by full weight-bearing which was progressed under supervision. Gaweda et al., Klinger et al. and Nakamura et al. initially used non-weight-bearing for one to three weeks, followed by partial weight-bearing for a further two or three weeks to progression to full weight-bearing at the six week point.

Immobilisation

Immobilisation to some extent was reported in four studies [10, 23, 24]. The amount of knee range of motion permitted postoperatively varied considerably. Nakamura et al. immobilising on 20° of flexion, Klinger et al. allowing free range of motion in a brace, Gaweda et al. allowing up to 30° of flexion and Alfredson et al. 90° of flexion. The duration ranged from 1 week [24] to 3 weeks [8, 10].

Continuous passive motion

The use of postoperative continuous passive motion was reported in three studies [8, 10, 23]. However, the details describing the duration of use was only listed in one study by Alfredson et al. [8], where it was used for 7 days; this period included an epidural for the first 5 days to facilitate pain-free motion.

Strengthening and neuromuscular control

Three studies described the use of postoperative strengthening, with two [10, 23] implementing closed chain exercises immediately and the other beginning at the third week [8]. Proprioception was introduced immediately [10] or at 6 weeks [23].

Return to play

Return to play was allowed at eight months [24] or nine months in two studies [10]. No details were described on the criteria required to return to sport.

Best evidence synthesis

Given the quality of the studies there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions.

Secondary outcomes

A variety of patient reported outcomes were used to assess the postoperative clinical outcome (Table 3).

Table 3

Secondary outcome: postoperative clinical outcome summary

Study

Follow-up

ROM

Tegner

Modified lysholm

Lysholm

L&G (groups)

IKDC

KOOS

Marx

Marshall (groups)

VAS

Modified noyes

Symp

Pain

ADL

Sport/Rec

Knee QOL

    

Alfredson [8]

31.3 months

Full

4

98

Cox [22]

6 years

Median 86

89

94

99

85

75

7

Gaweda [23]

17.1 months

Full

Study 89.19 ± 3.65

Control 93.84 ± 2.87

-

-

-

-

-

-

-

Study 43.24 ± 1.79

Control 44.81 ± 2.4

Klinger [10]

38 months

Full

6.1

90

A—24%

B—57%

C—19%

D—0%

2

Nakamura [24]

18 months

Shelbourne [7]

8.7 years

Full

MC

LC

Significantly lower results in the defect group both for MC and LC

Defect

A—72%

B—24%

C—4%

Control

A—80%

B—4%

C—16%

Defect

A—74%

B—22%

C—4%

Control

A—85%

B—15%

C—0%

L&G Lysholm and Gillquist Score, IKDC International Knee Documentation Committee, A normal, B nearly normal, C abnormal, D severely abnormal, MC medial compartment, LC lateral compartment, KOOS Knee Injury and Osteoarthritis Outcome Score, Symp symptoms, Knee QOL knee-related quality of life, ADL activities of daily living, Marshall Functional Marshall Score

Discussion

The main finding of this systematic review is that studies describing postoperative rehabilitation protocols with concurrent ACLR and articular cartilage injury demonstrate very little uniformity. Given the small numbers of articles describing rehabilitation protocols, the quality of evidence of each of the individual studies, and the fact that none specifically addressed the sole question of rehabilitation of the knee with concurrent ACLR and cartilage injury, it is not possible to make strong recommendations regarding the most appropriate rehabilitation in this scenario. In terms of clinical usefulness, this study demonstrates that in the setting of concurrent ACLR with cartilage injury the use of aggressive rehabilitation protocols with early weight-bearing, no immobilisation and immediate range of motion exercises did not compromise outcomes compared to more conservative protocols.

The concomitant presence of chondral lesion in the setting of ACLR presents a challenge in terms of defining the most appropriate rehabilitation regimen. Mithoefer et al. in a review of rehabilitation following knee articular cartilage asserted that the postoperative rehabilitation is a critical component of the treatment process for athletic articular cartilage injury and should take into consideration the biology of the cartilage repair technique, cartilage defect characteristics, and each athlete’s sport-specific demands to optimize functional outcome [16]. The authors recommended a systematic, step-wise rehabilitation with criteria-based progression. Further, Peterson et al. in a long-term study of ACI stated that failures were linked to premature exposure to shear forces by noncompliance with prescribed rehabilitation regimes [25]. In the studies examined in this systematic review, the treatment of the cartilage injury ranged from autologous periosteal transplantation [8] to osteochondral transplantation [10, 23] to no specific treatment for the cartilage itself [7] or a variety of techniques [22]. Given that the characteristics of the chondral lesions and the treatment techniques differed greatly, it is not surprising then so too did the rehabilitation protocols that were undertaken.

The treatment of chondral lesion concurrently with ACLR represents a different clinical environment. It is well recognised that rigorous rehabilitation following ACLR is necessary for a successful surgical outcome [11]. To this end, accelerated rehabilitation has become more commonplace in isolated ACLR and does not appear to be harmful [11]. Moreover, Hjermundrud et al. determined that the combination of a full-thickness cartilage lesion and an ACL rupture did not result in inferior knee function at the time of ACLR as evaluated by the Knee injury and Osteoarthritis Outcome Score [9]. Allowing for the fact that ACLR by itself will inevitably result in some self-protective responses, it is probably not unreasonable to treat patients with untreated chondral lesions at the time of ACLR like any other ACLR patient. Indeed, the findings of the study of the natural history of the outcome of untreated articular cartilage lesions by Shelbourne et al., contained within this review, would support this argument [7]. The authors determined that although there was a statistically significant difference in subjective outcomes between those patients with and without chondral defects at the time of ACLR at a mean of 8.7 years follow-up, most patients had very few symptoms. However, the question remains does the same argument apply when chondral treatment has been undertaken?

In the original technique of microfracture for the treatment of articular cartilage defects, Steadman et al. prescribed a strict regimen of rehabilitation afterwards, which is commonly cited as the gold-standard for cartilage rehabilitation [26, 27, 28]. Their protocol includes the use of CPM initially, and touchdown weight-bearing for 6–8 weeks. The argument put forward to support this relates to the fact that microfracture relies on the influx of marrow products to form a fibrin clot, which is slowly remodelled into fibrocartilage; it is thought less durable initially, and therefore, requires prolonged protection prior to initiating activities [29, 30, 31, 32]. However, weight-bearing following autologous osteochondral transplantation appears to have no adverse effect when examined at second-look arthroscopy [33]. Moreover, Ebert et al. in a randomised control study of two groups undergoing matrix-induced ACI found no difference in functional radiographic outcomes following 2 years comparing an accelerated weight-bearing protocol to the conventional 8-week non-weight-bearing regimen [34]. Yet, full weight-bearing following ACLR is now recommended [13, 35]. Wright et al. in a systematic review of RCTS with level I and II evidence determined that there was no harm in weight-bearing following ACLR [14]. The studies examined in this systematic review report mixed usage of protected weight-bearing. Therefore, it is difficult to make definitive conclusions on the most appropriate postoperative weight-bearing regime, given the heterogeneity and paucity of evidence. As regards the use of CPM, while there is basic science evidence to support the use in rehabilitation following articular cartilage intervention [36, 37], there is little clinical evidence to substantiate its use [38]. Similarly, a systematic review of the use of CPM following ACLR suggested that there is limited evidence to support its clinical effectiveness [14].

The use of bracing following standard ACLR has become less common with the development of accelerated rehabilitation protocols, with few adverse effects reported [35, 39, 40]. Kruse et al. in a level I and II systematic review, determined that bracing was neither necessary nor beneficial following ACLR and adds to the cost of the procedure [11]. Functional bracing has been shown to have conflicting effects on knee kinematics in normally aligned knees, limiting their usefulness in the rehabilitation of isolated cartilage injuries of the tibiofemoral joint [41]. Therefore, the decreased use of bracing for ACL rehabilitation, along with its limited usefulness in cartilage regeneration would suggest that the use of bracing for a combined injury has little scientific basis and may not be required.

There are a number of limitations to this study. First, the quality of information that this systematic review was poor and contained heterogeneous data which precluded meta-analysis. In addition, given the lack of randomised studies or studies with relevant statistical significance pertaining to rehabilitation techniques, there was no evidence to support one method of rehabilitation over another. A further confounding factor was the heterogeneity not only of chondral lesions being treated but also the method of treatment.

Conclusion

This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. Ultimately, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available.

Notes

Compliance with ethical standards

Conflict of interest

None of the authors declare that they have any conflict of interest related to this work.

Ethical approval

This manuscript is a systematic review and does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.

Supplementary material

167_2018_4882_MOESM1_ESM.docx (13 kb)
Supplementary material 1 (DOCX 13 KB)

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Ciaran Thrush
    • 1
  • Tabitha J. Porter
    • 1
  • Brian M. Devitt
    • 1
  1. 1.OrthoSport Victoria Research UnitEpworth HealthcareMelbourneAustralia

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