Summary

Post-operative rehabilitation programs in published peer-reviewed articles describing ACL-R for patients with a primary ACL rupture are largely clinically irreproducible.

Abstract

Introduction

Rupture of the anterior cruciate ligament (ACL) is a significant problem in sports medicine. For athletes, ACL reconstruction (ACL-R) has traditionally been the primary management. Post-operative rehabilitation programs substantially influence the outcome of ACL-R, yet they are often poorly described in the literature. Via a scoping review, we sought to evaluate the clinical reproducibility of the published rehabilitation programs in peer-reviewed articles for ACL-R patients with primary ACL rupture.

Methods

We performed a systematic literature search, on 7 July 2022, using the following medical databases: MEDLINE via PubMed, Web of Science, Cochrane Library, and Scopus. Following title, abstract, and full-text screening, 250 studies including 29,216 individuals were identified that satisfied our pre-specified inclusion criteria. Before data extraction, the preliminary domains used to categorize the descriptions of the rehabilitation programs were developed. Eventually, they were adapted based on the characteristics of the extracted data. Additionally, the post-operative programs described in each study were evaluated using the template for intervention description and replication (TIDieR) checklist (12 items) to determine clinical reproducibility; a score of 0 (minimum) to 12 (maximum) was assigned to each study. A mean TIDier score was determined for each domain used to categorize the descriptions of the rehabilitation programs. We arbitrarily assigned the TIDier scores of 0–4 (not clear), 5–8 (somewhat clear), and 9–12 (clear), to classify the clinical reproducibility of the rehabilitation programs.

Results

27 domains were included to categorize the descriptions of the rehabilitation programs. ACL-R via arthroscopy was the most performed surgical procedure (79%). The bone-patellar-tendon-bone graft was the most frequently used graft type (45%). 17% of the studies failed to report the graft type. Concurrent lesions to ACL rupture were reported in 31% of the studies; meniscus lesions were the most common concomitant injury (61%). As many as 47% of the studies did not report the presence/absence of concomitant injuries, consequently, the prevalence of meniscus injuries is likely under-estimated. Across the included studies, there was a substantial degree of heterogeneity in the thoroughness of reporting of ACL-R rehabilitation programs. The highest number of domains described in any study was 20, but only one study (0.4%) achieved this level of reporting. As many as 40 studies (16%) only included 1 ACL-R rehabilitation domain. Considering the number of studies concurring to generate each domain, an average of 75% of studies reported whether the decision-making on interventions was time- or criteria-based, with 89.5% being the first and 10.5% the latter respectively. The domain’s reproducibility in clinical practice, rated with the mean of the TIDieRs of the studies concurring to each domain, resulted unclear (mcTIDieR min-max score = 6.24-7.23/12). Studies often lacked the proper attention to detail on the delivered post-operative interventions and/or progression parameters.

Discussion

Post-operative rehabilitation programs in published peer-reviewed articles describing ACL-R for patients with a primary ACL rupture are largely clinically irreproducible. Most of the included studies lacked critical details about the dose and progression of the interventions. This underscores the need for improved reporting of rehabilitation protocols following ACL-R to foster evidence-informed practice.