Summary

Current preoperative rehabilitation (prehabilitation) practices in the context of anterior cruciate ligament reconstruction emphasize impairment resolution, range of motion restoration, and neuromuscular exercises, and are shown to help patients surpass previously established patient acceptable symptom state thresholds and return to sports criteria without additional risk of complication.

Abstract

Background

The primary foci of postoperative rehabilitation protocols for anterior cruciate ligament reconstruction (ACLR) are to regain full range of motion (ROM), improve extensor and flexor strength, and improve neuromuscular and proprioceptive control. Inclusion of preoperative rehabilitation (prehabilitation) programs have been shown to expedite this process, while further facilitating postoperative impairment resolution. Therefore, the purpose of this review is to provide a comprehensive report of the postoperative outcomes and complication profiles and rates following ACLR supplemented with prehabilitation.

Hypothesis

Clinical and functional postoperative outcomes following ACLR supplemented with prehabilitation will meet corresponding patient acceptable symptoms state (PASS) thresholds, and complication profiles and rates will be comparable to those of literature-reported values of patients undergoing ACLR only.

Methods

A systematic search of Embase, Medline, Cochrane and PubMed was conducted from inception to June 1, 2024. All studies reporting outcomes and/or complications following ACLR supplemented with prehabilitation in at least one treatment arm were included. All study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion.

Results

Thirty-three studies with 2,244 patients that had completed prehabilitation and ACLR were included. Weighted means of included studies were reported for extension and flexion limb symmetry index (LSI; 89.5% and 91.9%, respectively), IKDC subjective score (84.3), side-to-side laxity under Manual Maximum displacement (2.7mm), KOOS Activities of Daily Living, Pain, Symptoms, Sports, Quality of Life, and Activities of Daily Living subscores (97.0, 92.1, 86.4, 82.2, and 74.7, respectively), 6m-timed hop, crossover-hop, triple-hop, and one-leg hop LSIs (98.3%, 97.7%, 96.0%, and 94.9%, respectively), Lysholm score (88.8), KOS-ADLS (96.4), and Global Rating Scale (96.3). Negative pivot-shift and Lachman grades were achieved in 80.7% and 64.6% of patients, respectively. Major postoperative complications included graft failure (4.8%), contralateral ACL rupture (1.0%), surgical site infection (0.7%), deep infection requiring lavage (0.4%), non-ACL ligament injury (5.1%), reoperation for hardware removal (0.3%), muscle rupture (0.1%), patellar subluxation (0.1%) and patellar rupture (0.1%).

Conclusion

Current prehabilitation practices in the context of ACLR emphasize impairment resolution, ROM restoration, and neuromuscular exercises. Clinical outcomes of patients undergoing prehabilitation were shown to meet and surpass previously established PASS thresholds, suggesting that prehabilitation can be used as a safe and effective intervention for moderate- to long-term benefits. Further, the safety of current prehabilitation practices is supported by similar complication profiles and rates reported in this review compared to literature-reported values in patients undergoing standard care. Nevertheless, substantial heterogeneity exists in the level of detail reported for prehabilitation protocols across current studies, making other clinical results difficult to extrapolate to the general ACLR population. There is a need for further high-quality randomized trials and prospective cohort studies to compare and quantify the effect of prehabilitation on postoperative outcomes, and delineate a standardized prehabilitation protocol for most patients undergoing ACLR.

Level of Evidence: Level II.