Paediatric Anterior Cruciate Ligament (ACL) reconstruction rehabilitation pathway

Purpose

Decreased activity levels as well as earlier sport specialism in paediatric populations are leading to an increase in number of patients with traumatic ACL rupture. ACL repairs are preferred due to evidence of adverse long term outcomes with conservative management. Therefore, the demand for ACL reconstruction rehabilitation is increasing. Additionally, high re-injury rate (29%) in adolescents post reconstruction surgery has been documented. In order to provide optimal evidence based rehabilitation and prevent re-injury in these patients the ACL Pathway was created. This service evaluation investigates the effectiveness of the pathway since it was implemented 18 months ago.

Approach

Every patient referred to paediatric outpatient physiotherapy team pre or post ACL reconstruction followed the pathway. The pathway included prehabilitation and phased rehabilitation followed at home +/- weekly classes. Objective markers and outcome measures were assessed every six weeks during one-to-one assessment. Objective markers included range of movement, muscle length and muscle strength using Oxford Scale. Outcome measures included Limb Symmetry Index (LSI) for hop tests (single hop, triple hop, crossover hop, six-meter timed hop), Star Excursion Balance Test (SEBT) and The Knee injury and Osteoarthritis Outcome Score for children (KOOS-Child). Additionally, return to running assessment was completed. The data was analysed using secure Microsoft Office Excel software.

Outcomes

Seven patients followed the initial pathway. No patients were referred to physiotherapy pre-operatively. Five patients completed the pathway. Two patients were discharged without completing the full pathway due to poor compliance. Five patients who completed full year of rehabilitation improved in all outcome measures including >95% LSI in all hop tests and SEBT. All patients returned to sport. Currently, seven patients referred pre-operatively are starting the ACL pathway. Ā 

Increasing need for ACL reconstruction in paediatric population has been identified. Comprehensive ACL pathway was created to prevent further injury, promote post-operative return to sport and ensure the injury is not preventing adolescents from establishing active life habits. This service evaluation was completed to evaluate the effectiveness of the ACL pathway. At present there is limited data. Five patients who completed rehabilitation achieved optimal outcome and have returned to sport. There were multiple challenges identified that prevented efficient implementation of the pathway including lack of opportunity to discuss post-operative expectations, limited space for high-level rehab, patients not attending appointments despite multiple attempts of communication and lack of long-term follow up.

Implications

Despite limited data, service evaluation showed positive outcomes. Since the development of the ACL pathway the paediatric physiotherapy team are able to deliver more effective rehabilitation as shown by the outcomes. These results have been shared with the orthopaedic surgeons leading to an increase in pre-operative referrals. Additionally, completing this review allowed for identification of improvements required for more efficient implementation of the pathway including creating a booklet with high level exercises, a spreadsheet to facilitate ongoing data collection, and objective measurement of high level function for many patients returning to sport with asymmetrical injury.

Fund acknowledgements

Guys and St ThomasĀ“ NHS Trust.

Additional notes

This work was presented at Physiotherapy UK 2019