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P. LANDREAU
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previous questions generate this one: When
will the risk of re-injury be at the lower possible
level in order to authorize the player to return
to sport?
WHAT DOES IT MEAN
“RETURN TO PLAY” AND
WHAT IS THE ACTUAL
RATE?
In their meta-analysis, Arden
et al.
(Forty-eight
studies evaluating 5770 participants at a mean
follow-up of 41.5 months were included for
review) demonstrated that while 82% of
patients returned to some form of sports
participation following ACL reconstruction
surgery, only 63% of patients were able to
return to their pre-injury level and only about
half of patients returned to competitive sport
after ACL reconstruction surgery [2].
In another study, the same group showed that
while two-thirds of patients had attempted
some form of sport by 12 months following
their surgery, only one-third had returned to
their pre-injury level of competitive sport
participation [3].
In a more selected population, including
motivated professional athletes, it is probable
that the rate of return to same level and
competition should be better but the patient
must be informed about the actual rate in order
to fit his/her expectations.
WHICH FACTORS SHOULD
BE TAKEN INTO CONSIDE
RATION TO CONDUCT THE
CUSTOMIZED RETURN TO
PLAY PROCESS?
Different factors must be taken into account to
allow the patient to move from one step to
another during his rehabilitation and return to
play: the biology (fixation, integration and
maturation of the graft according to the type of
graft) the neuromuscular control and the
psychological factors.
The biology
The fixation and the maturation of the graft
should be considered.
Even if there are some controversies in li
terature, it seems that there is no evidence that
one graft shouldbe superior to another concerning
return to sport and risk of re-rupture [4].
However, the consolidation of the bone plugs
in the tunnels has been shown to be faster than
the tendon tunnel integration. Therefore,
prudence is advised especially after hamstrings
reconstruction.
The development of the fixation systems have
facilitated the modern rehabilitation protocols
allowing immediate weight bearing, less knee
immobilization, early and unrestricted range of
motion, early recovery of neuromuscular
function and therefore, early return to physical
activity. The bone integration is different
according to bone-tendon-bone graft or tendon
grafts. It can take up to 4-6 months before
complete bone integration; then a minimum of
4-6 months should be respected before to return
to play only according to the bone integration.
The maturation of the graft has been studied on
animals. The three phases of healing and their
approximate timelines in animal models are
remodeling (first 4 weeks postoperatively),
maturation (weeks 4-12), and ligamentization
(from 12 weeks). It has been demonstrated that
there are substantially reduced mechanical
properties of the graft in the first 8-12 weeks.
This notion has not been demonstrated in
human population and appears to contradict
the successful clinical outcomes reported
after accelerated rehabilitation programs.
Additionally, there are some controversy
concerning the properties of the tendon graft in
human population. This graft could undergo a
process of adaptation rather than a
ligamentization or restoration of native ACL
[5]. We miss further research to accurately