Post-operative rehabilitation of anterior cruciate ligament reconstruction in the skeletally immature child: a systematic review of the literature

Abstract

Background: The rate of surgically managed anterior cruciate ligament (ACL) ruptures in the skeletally immature population is increasing rapidly, and the functional and clinical outcomes are often poor compared with the adult population. There are currently no clear rehabilitation guidelines for this unique group.

Objectives: To systematically review the literature on skeletally immature individuals that have undergone ACL reconstruction surgery, extract the rehabilitation strategies used and the functional outcomes, rate the overall evidence base, and identify themes to create best-practice guidelines for rehabilitation in this age group.

Methods: A search was made of appropriate electronic databases to identify relevant studies. Inclusion criteria were: Participants had confirmed complete ACL rupture repaired surgically; Confirmed skeletal immaturity (SI); Clear description of rehabilitation stages; Reported functional outcome. Papers were excluded if they were expert reviews, single case studies or non English text; did not describe exclusively SI patients; did not describe rehabilitation protocols. Included studies were rated by two independent reviewers using the modified Downs and Black checklist for methodological quality.

Results: The literature search identified 429 studies of relevance. Ten studies met the inclusion criteria. All studies were observational in nature, with eight being case series reports and two being cohort studies. Five studies were rated to be of moderate methodological quality, and five studies were rated as having limited methodological quality. The overall evidence base provided conflicting results regarding functional outcomes following ACL reconstruction and rehabilitation.

Conclusions: The current evidence base for rehabilitation of skeletally immature ACL reconstructed subjects is conflicting, with low methodological quality and inconsistent outcomes. The review identified some emerging themes that can guide future research directed at the development of maturity-specific protocols, including early graft protection, appropriately supervised neuromuscular programmes and criteria-based progression and return to activity.

Keywords:

• Anterior cruciate ligament reconstruction
• Paediatric
• Rehabilitation
• Skeletally immature
• Systematic review