compared to those who received only postoperative training. Failla and colleagues (2016) support these findings, as patients who received preoperative rehabilitation including perturbation and progressive quadriceps strength training and postoperative treatments demonstrated statistical and clinical improvements in their IKDC and KOOS scores and a higher rate of return to prein- jury sport activities at 2 years after surgery compared to patients who underwent criterion-based post- operative rehabilitation alone (i.e., without additional, extended pre-operative rehabilita- tion training). Multiple variables contribute to better functional outcomes after surgery. Men achieve superior functional outcomes than women at 1 year follow- up after surgery, regardless of the graft type (van Melick et al., 2016). Use of allograft results in joint laxity and lower knee function outcomes (Hu, Qu, Xu, Zhou, & Lu, 2013; Kan et al., 2016; Zeng et al., 2016). Patients who receive a bone-patellar tendon-bone autograft may take longer to reach important clini- cal milestones than their counterparts with allograft or hamstring autograft (A. Smith et al., 2019). Younger patients return to a higher level of activities within 2 years after surgery compared to older patients. Tobacco consumption, high BMI, quadriceps weakness, and ROM deficit preoperatively have a negative effect on postoperative functional outcomes (de Valk et al., 2013; van Melick et al., 2016). Most studies investigating short-term knee functional outcomes report that the majority of patients improve after ACL reconstruc- tion. Quadriceps strength and activation level has been shown to be lower in the involved limb compared to the non-involved limb and has been shown to persist up to 5 years after both ACL injury and reconstruction surgery (Hart et al., 2010; Petersen et al., 2014). Strength deficit in the reconstructed limb was reported to be be- tween 27% and 39% for knee extensors and 16% and 35% for the knee flexors between 9 and 12 months after surgery. Additionally, impaired performance on counter movement jump and single hop for distance was reported to be 23% and 20% at the same follow- up time point (Larsen, Farup, Lind, & Dalgas, 2015). At 2 years after surgery, Logerstedt and colleagues have reported that normal limb symmetry index (LSI) related to quadriceps strength and single-legged hop performance is restored at 6 months and continues to improve 12 months after ACL reconstruction surgery (Logerstedt et al., 2012). Studies have shown that knee functional performance measured by single- limb hop tests improve at 6 to 12 months (Moksnes & Risberg, 2009) and continue to improve from 2 to 5 years after surgery (Ageberg et al., 2008; Hopper, Strauss, Boyle, & Bell, 2008). Scores on self-reported measures also continue to improve after ACL reconstruction surgery. These outcomes are similar to findings reported in patients with ACL- deficient knees (Grindem et al., 2011; Moksnes & Risberg, 2009). A clinical review study reported that limb-to-limb strength deficits are, on average, 23% (range, 3% to 40%) and 14% (range, 3% to 28%) at 6 and 12 months, respectively, after reconstruction sur- gery (Lepley, 2015). Patients’ self-perceptions of knee function at 6 and 12 months after surgery are 14% and 13%, respectively, while limb symmetry indexes for hop performance are 11% at 6 months and 1.3% at 12 months after surgery (Lepley, 2015). The findings of this clinical review indicate limb-to-limb strength and patients’ self-reported deficits (more than 10%) continue to exist up to 12 months after surgery. (Note that findings among studies vary greatly, perhaps due to different training regimens as well as other factors.) The presence of these deficits might be detrimental at the time of returning to preinjury activities. E. H. Hartigan and colleagues (2010) indicated that individual limb-to-limb strength and hop performance deficits and patients’ self-reported knee function measures improved, on average, to less than 10% at 6 months after surgery. Only 5%, 48%, and 78% of patients score < 10% on a collective of seven objective measures (reported in Table 6) at 3, 6, and 12 months, respectively, after surgery (E. H. Hartigan et al., 2010). Nawasreh and colleagues (2016) reported that 49.5%, 42.5%, and 35% of patients demonstrated deficits more than 10% at objective measures reported in Table 7 at 6, 12, and 24 months,
Early ACL reconstruction surgery has been advocated as the stan- dard of care for youth athletes intending to return to pivoting and cutting sport activities (Marx et al., 2003; McRae, Chahal, Leiter, Marx, & MacDonald, 2011; Mirza, Mai, Kirkley, Fowler, & Amen- dola, 2000; Myklebust & Bahr, 2005). Furthermore, the recon- struction surgery is often performed with the purpose of restoring passive knee stability to prevent damages to the joint surfaces and menisci and to preserve the joint health status (Marx et al., 2003). The time frame between ACL injury and surgical repair did not influence postoperative outcomes. Early reconstruction surgery resulted in clinical, functional, and patient-reported knee function outcome measures similar to those of the delayed surgery (Frobell et al., 2010; T. O. Smith et al., 2010). Furthermore, there were no differences between early or late surgery in regard to the postoperative complication, rate of return to sport, or incidence rates of radiographic knee osteo- arthritis (Frobell et al., 2010; T. O. Smith et al., 2010). However, patients who participated in high preoperative activity level and underwent the reconstruction surgery within 3 months from sur- gery resumed a higher level of activity postoperatively (van Melick et al., 2016). Radiological signs of reconstructed knee osteoarthri- tis were reported 10 and 20 years after surgery in patients who re- constructed their injured ACL when they were adolescents (Mans- son, Sernert, Rostgard-Christensen, & Kartus, 2015). Knee impairments and patients’ physical and psychological status prior to the surgery have been reported to be associated with postoperative patients’ functional recovery and outcomes (de Valk et al., 2013; Eitzen et al., 2009; Grindem et al., 2011; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012, 2013a; van Melick et al., 2016). Preoperative knee impairments related to ROM and quadriceps strength deficits contribute to significant knee compli- cations after surgery (Cosgarea, Sebastianelli, & DeHaven, 1995; Mohtadi, Webster-Bogaert, & Fowler, 1991; Sachs, Daniel, Stone, & Garfein, 1989). Performing a reconstructive surgery on a patient with limited knee ROM is positively associated with the devel- opment of postoperative arthrofibrosis and patellofemoral prob- lems (Cosgarea et al., 1995; Mohtadi et al., 1991; Sachs et al., 1989). Preoperative knee functional status is also predictive of the postoperative patient-reported and knee functional performance measures (de Valk et al., 2013; Eitzen et al., 2009; Grindem et al., 2011; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012, 2013a; van Melick et al., 2016). Preoperative quadriceps strength is predictive of knee function 2 years after surgery and has a posi- tive effect on postoperative quadriceps at the time of return to activity (Lepley & Palmieri-Smith, 2016). Roewer and colleagues (2011) conducted a 2-year follow-up after surgery for a group of patients who received progressive quadriceps strength and neu- romuscular perturbation training. They reported that quadriceps strength continued to improve and most of gait kinematic and kinetic asymmetry resolved. Preoperative training also impacts postoperative function and bio- mechanical movement symmetry. Hartigan and colleagues found that administering progressive quadriceps strength and neuro- muscular perturbation training prior to surgery improves limb-to- limb quadriceps strength and kinematic symmetries compared to abnormal kinematic asymmetries 6 months after surgery com- pared to administering only progressive quadriceps strength (Har- tigan et al., 2009). Apparently, the preoperative patients’ status is crucial for better recovery and functional outcomes after surgery (de Valk et al., 2013; Eitzen et al., 2009; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012; van Melick et al., 2016). This issue highlights the importance of incorporating rehabilitation training to specifically address patients’ impairments and restore a high level of knee functional performance prior to the reconstruction surgery. The effect of administering a preoperative rehabilitation program followed by a postoperative rehabilitation program has resulted in superior functional outcomes when compared to only administering a postoperative rehabilitation program (Failla et al., 2016; Grindem et al., 2015). Grindem and colleagues (2015) reported higher self-reported knee function in patients who re- ceived preoperative and postoperative rehabilitation programs
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