Early Weight-Bearing Rehabilitation Protocol After Anterior Cruciate Ligament Reconstruction
Summary
Based on the safety and feasibility, this article presents an early weight-bearing rehabilitation protocol after anterior cruciate ligament reconstruction. The protocol is clear and easy to operate, which is helpful to promote its use in clinical practice and accelerate the functional recovery of patients.
Abstract
Anterior cruciate ligament (ACL) injury is one of the common sports injuries. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment for ACL injury, aiming to regain normal anatomical structure and stability of the knee joint and promote the patient’s return to sports. Under the guidance of the concept of enhanced recovery after surgery, early weight-bearing rehabilitation (EWB) is an important factor affecting patient function and quality of life. However, there is no consensus on whether EWB rehabilitation can be performed after ACL surgery.
This study aims to explore the safety and feasibility of EWB after ACL surgery. The study implemented a gradual EWB rehabilitation program in the experimental group, including weight-shifting training, balance training, and gait training on the affected lower limb, and assessed wound healing and stability of the knee joint. The study found that EWB after ACLR is safe and feasible. EWB rehabilitation not only does not pose a negative effect on the patient’s knee pain, swelling, wound healing, and stability, but also helps to improve knee active flexion and quality of life faster and better. The EWB program in this study is simple, safe, and effective, and it provides strong theoretical guidance and practical demonstration for accelerated rehabilitation after ACLR.
Introduction
Enhanced Recovery after Surgery (ERAS) is a concept that promotes the early initiation of postsurgery rehabilitation care units, particularly after orthopedic operations, when conditions are appropriate1. This approach seeks to shift the clinical focus from treating the disease to functional rehabilitation promptly with the goal of reducing hospital stays, minimizing postoperative complications, improving patient prognosis and satisfaction, and enhancing overall rehabilitation outcomes. Since the introduction of ERAS, Chinese orthopedic rehabilitation specialist, Zhou Mouwang, has advocated for the active application of accelerated recovery protocols to further progress perioperative rehabilitation practices within the realm of Chinese orthopedics2. Internationally recognized consensus guidelines have also been established to facilitate enhanced surgical recovery for orthopedic conditions such as joint replacement and spine surgery3. Nonetheless, while considerable advancements have been made in implementing ERAS in recent years, the primary application has been in major operations, such as joint replacement surgeries4. As a result, there is a pressing need to further investigate and expand the application of ERAS within the rehabilitation of other orthopedic conditions.
The anterior cruciate ligament (ACL) plays a pivotal role in maintaining knee joint stability. ACL injuries are among the most prevalent sports-related injuries, with approximately 2 million cases occurring worldwide annually5. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment approach, aiming to restore normal knee anatomy and stability, prevent secondary injuries, and enable patients’ return to sport. Rehabilitation following ACL injury has been an active research area. It is widely accepted that post ACLR rehabilitation is integral for optimizing surgical outcomes and facilitating patients’ recovery of sports-related function6,7. However, early weight-bearing (EWB) rehabilitation protocols after ACLR remain understudied, leading to a lack of consensus among clinicians.
The latest research in 2021 supports allowing immediate weight-bearing and full knee range of motion within tolerance after ACL autograft reconstruction surgery7. However, a consensus has not yet been reached in clinical practice. The authoritative British Journal of Sports Medicine published in 2016 also advocates for immediate weight-bearing post ACLR, finding it does not increase knee joint laxity. If gait is proper without increased pain or effusion during/after walking, immediate weight-bearing is considered acceptable6. In contrast, a review in 2022 summarizes that accelerated weight-bearing rehabilitation following ACLR may increase risks of knee joint laxity and bone tunnel widening compared to delayed weight-bearing protocols, advising cautious selection of postoperative regimens8. Additional concerns with EWB include knee pain, swelling, effusion, wound healing, and fall risks after ACLR. Although substantial literature endorses EWB after ACLR, clinical practices still vary. A study in 20209 found that surgeon experience influences post ACLR weight-bearing timelines in France; more experienced surgeons were more likely to favor EWB rehabilitation.
Under the guidance of the ERAS concept, EWB is an important factor affecting patient function and quality of life. However, whether the EWB program could impair wound healing, increase pain and swelling, or impact knee stability remains a key concern for orthopedic and rehabilitation clinicians. In view of the current dilemma of clinicians and inconsistent research results, this study aims to explore the safety and feasibility of EWB after ACLR.
Protocol
Representative Results
Discussion
This study protocol contains details of the EWB rehabilitation after ACLR. Its process is clear and not complicated, and because only simple rehabilitation equipment is needed for the implementation of the EWB rehabilitation program, it is clinically feasible and convenient. In addition, safety is an important consideration in this study protocol. The EWB rehabilitation program not only adds protective measures to prevent iatrogenic sports injury but also follows the step-by-step principle. Therefore, the results of this…
Divulgations
The authors have nothing to disclose.
Acknowledgements
This research was supported by two grants from the research project grant from Shanghai First People's Hospital (grant number: SYYG20221007) and the Medical Innovation Research Special Project in the Science and Technology Innovation Action Plan of the Shanghai Science and Technology Committee (grant number: 22Y11912100).
Materials
| Elastic band | JOINFIT | 10722038422 | |
| Electronic body weightometer | China's Xiaomi Technology (W0LONOW) | 100021480693 | |
| Movable mirror | Guangzhou Compaq Medical Equipment Co. LTD | 10073735389717 | |
| SPSS 21.0 | statistical analysis |
References
- Kehlet, H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 78 (5), 606-617 (1997).
- Zhou, M. W., Li, T. Jiji kaizhan jiasu kangfu waike gongzuo,cujin woguo guke weishouqi kangfu de fazhan[To carry out the work of accelerating rehabilitation surgery actively and promote the development of perioperative rehabilitation of orthopedics in our country]. Zhongguo kangfu yixue zazhi. 35 (7), 769-770 (2020).
- Yun, S. C., Tae, W. K., Moon, J. C., Seung, B. K., Chong, B. C. Enhanced recovery after surgery for major orthopedic surgery: a narrative review. Knee Surg Relat Res. 34 (1), 8 (2022).
- Bertrand, D., et al. 34;Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations". Spine J. 21 (5), 729-752 (2021).
- Renstrom, P. A. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport:recent evidence and a personal reflection. Br J Sports Med. 47 (6), 367-372 (2013).
- Nicky, V. M., et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 50 (24), 1506-1515 (2016).
- Kaycee, E. G., et al. Anterior cruciate ligament reconstruction recovery and rehabilitation: a systematic review. J Bone Joint Surg Am. 104 (8), 739-754 (2022).
- Fan, Z. Y., et al. Delayed versus accelerated weight-bearing rehabilitation protocol following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Rehabil Med. 54, (2022).
- Hasan, B. S., et al. Early postoperative practices following anterior cruciate ligament reconstruction in France. Orthop Traumatol Surg Res. 107, 103065 (2021).
- Marianne, J. H., et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 41 (6), 1073-1093 (2011).
- Collin, C., Wade, D. T., Davies, S., Horne, V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 10 (2), 61-63 (1988).
- Butler, D. L., Noyes, F. R., Grood, E. S. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am. 62 (2), 259-270 (1980).
- Zhang, L., Xu, J. W., Huang, L., Tao, G., Liao, M. Quanshen zhendong jiehe yundong xunlian dui qianjiaocha rendai chongjian shuhou huanzhe zaoqi kangfu de yingxiang [Effects of whole-body vibration combined with exercise training on early rehabilitation of patients after anterior cruciate ligament reconstruction surgery]. Zhonghua wuli yixue yu kangfu zazhi. 43 (2), 158-161 (2021).
- Jonas, I., Eva, F., Sveinbjörn, B., Bengt, I. E., Jon, K. Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. Knee Surg Sports Traumatol Arthrosc. 14 (11), 1108-1115 (2006).
- Riccardo, D., Nicola, U., Fabrizio, D. F. Quadrupled semitendinosus anterior cruciate ligament reconstruction without the use of tourniquet and minimal instrumentation: the "Double D" technique. Arthrosc Tech. 12 (9), e1589-e1593 (2023).
- Schmitz, R. J., Kim, H., Shultz, S. J. Effect of axial load on anterior tibial translation when transitioning from non-weight bearing to weight bearing. Clin Biomech. 25 (1), 77-82 (2010).
- Yack, H. J., Riley, L. M., Whieldon, T. R. Anterior tibial translation during progressive loading of the ACL-deficient knee during weight-bearing and nonweight-bearing isometric exercise. J Orthop Sports Phys Ther. 20 (5), 247-253 (1994).
- Joanna, K. Tibial translation in exercises used early in rehabilitation after anterior cruciate ligament reconstruction exercises to achieve weight-bearing. Knee. 13 (6), 460-463 (2006).
- Steven, C., Peter, V., Ramses, F., Johan, B. The "ligamentization" process in anterior cruciate ligament reconstruction:what happens to the human graft? A systematic review of the literature. Am J Sports Med. 39 (11), 2476-2483 (2011).
- Gabriel, D. A., Kamen, G., Frost, G. Neural adaptations to resistive exercise: mechanisms and recommendations for training practices. Sports Med. 36 (2), 133-149 (2006).
- Jakobsen, T. L., Husted, H., Kehlet, H., Bandholm, T. Progressive strength training (10RM) commenced immediately after fast-track total knee arthroplasty:is it feasible. Disabil Rehabil. 34 (12), 1034-1040 (2012).
