Orthopaedics & Traumatology: Surgery & Research 107 (2021) 103065

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Original article

Early postoperative practices following anterior cruciate ligament

reconstruction in France
Hasan Basri Sezer a , Thibaut Noailles b , Cécile Toanen c , Nicolas Lefèvre a , Yoann Bohu a ,
Jean-Marie Fayard d , Alexandre Hardy a,∗ , the Francophone Arthroscopy Society (SFA)e
a
Clinique du Sport Paris V, 36, Boulevard Saint Marcel, 75005 Paris, France
b
Département de Chirurgie Orthopédique, Polyclinique de Bordeaux Nord, 15, Rue Claude-Boucher, 33000 Bordeaux, France
c
Service de Chirurgie Orthopédique et Traumatologique, CHD Vendée, Boulevard Stéphane Moreau, 85925 La Roche-Sur-Yon, France
d
Centre Orthopedique Santy, 24, Rue Paul Santy, 69008 Lyon, France
e
15, Rue Ampère, 92500 Rueil Malmaison, France

i n f o a r t i c l e A b s t r a c t

Historique de l’article : Introduction. – The early postoperative period after anterior cruciate ligament reconstruction (ACL) is cri-
Reçu le 20 juin 2021 tical for optimal functional recovery. Despite an abundance of literature, there is no consensus regarding
Accepté le 28 juillet 2021 good practices. This period is often under-considered by orthopedic surgeons. The aim of this study was
to identify early postoperative practices after ACL reconstruction in France.
Hypothesis. – The hypothesis was that there was a discrepancy between validated data in the literature
and the current practices of orthopedic surgeons in France.
Material and methods. – In 2019, a questionnaire was sent to all the members of the French Arthro-
scopy Society to investigate their postoperative practices after ACL reconstruction. Two hundred
sixty-nine members responded. Surgeons were divided into two groups of experienced (n = 137) and
less experienced (n = 132) surgeons, according to the number of ACL reconstructions performed per year
(< or ≥ 50/year). Outpatient management, effusion prevention measures, and rehabilitation instructions
and goals were collected. Overall responses were analyzed after multiple linear logistic regression and
the responses of the two groups were compared.
Results. – ACL reconstruction was performed as an outpatient procedure in 72.9% of cases. This rate
increased with surgical experience (p = 0.009 × 10−3 ). Among measures to prevent effusion, cryotherapy
was recommended in 97.8% of cases. The experienced group more often used compressive cryotherapy
devices (p = 0.004). Rehabilitation was started immediately in 75.5% of cases, with as main objective reco-
very of full extension (89.6%). Weight-bearing was allowed in 98.5% of cases and a brace was prescribed
in 69.9% of cases. In the experienced group, braces were less frequent (p = 0.02) and self-rehabilitation
was preferred (p = 0.0006).
Conclusion. – Early postoperative practices after ACL reconstruction in France are related to surgical
experience. The greater the surgical experience, the greater the role of joint effusion prevention and self-
rehabilitation. Despite recommendations in the literature, a quarter of the French orthopedic surgeons
who responded to this survey did not perform this procedure on an outpatient basis and more than
two-thirds prescribed braces.
Level of Evidence. – IV.
© 2021 Les Auteurs. Publié par Elsevier Masson SAS. Cet article est publié en Open Access sous licence
CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction In the early postoperative period, rehabilitation is essential for

Anterior cruciate ligament (ACL) reconstruction techniques and
postoperative rehabilitation protocols are ever more numerous [1].
∗ Corresponding author.
Adresse e-mail : alexandre.hardy@me.com (A. Hardy).
rapid functional recovery [2], and later is essential to prevent repeat
trauma in either the ipsi- or the contra-lateral knee [3]. However,
there is little consensus on rehabilitation after ACL reconstruction
[4,5], and its importance is often underestimated by orthopedic
surgeons [6]. Although practices vary between surgeons, various
guidelines have been drawn up [7–11]. The main aim is rapid
recovery of complete extension, by resumption of weight-bearing,

https://doi.org/10.1016/j.otsr.2021.103065
1877-0568/© 2021 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
H.B. Sezer, T. Noailles, C. Toanen et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 103065

Table 1
Questionnaire sent to SFA member.

Topics Questions

Number of procedures 1. On average, how many ACL reconstructions do you perform per year?
Do you systematically suggest outpatient surgery?
Outpatient management 3. What percentage of ACL reconstructions do you perform on an outpatient basis?
Prevention of bleeding 4. Do you fit an intra-articular redon drain?
Do you use electrocoagulation?
Cryotherapy 6. Do you recommend applying ice to the knee at home?
Do you prescribe cryotherapy devices?
Bracing 8. Do you prescribe postoperative bracing?
9. What type of brace do you prescribe?
How long do you apply bracing?
Weight-bearing 11. Do you authorize postoperative weight-bearing in isolated ACL reconstruction?
12. Do you authorize postoperative weight-bearing in ACL reconstruction with meniscal suture?
13. Do you recommend crutches?
How long do you recommend crutches for?
Rehabilitation 15. When do you start rehabilitation?
16 What do you think are the essential points in successfully starting rehabilitation?
Self-rehabilitation 17. Do you propose self-rehabilitation?
If so, with what support?
Postoperative consultation 19. When do you first see your patients for postoperative consultation?

SFA: French Arthroscopy Society (Société Francophone d’Arthroscopie); ACL: Anterior cruciate ligament.

mobilization and early neuromuscular reinforcement. Recent stu-
dies showed bracing to be ineffective [12–14], or even prejudicial
[8].
Moreover, global management of ACL reconstruction has pro-
gressed in recent years. The growth of outpatient surgery has
optimized overall care [15,16], for both patient and surgeon, and
reduced the patient’s level of stress without increasing postope-
rative pain [17,18]. Cryotherapy and compressive devices have
improved management of pain and postoperative effusion [19,20],
and contribute to rapid functional recovery.
The main aim of the present study was to determine the cur-
rent practices of members of the French Arthroscopy Society (SFA)
regarding the first month following ACL reconstruction. The study
hypothesis was that there is a discrepancy between validated data
in the literature and the current practices of orthopedic surgeons in
France regarding early postoperative course after ACL reconstruc-
tion.
2. Material and methods
An on-line questionnaire was sent to the 1,600 active mem-
bers of the SFA, assessing current practices during the first month
after ACL reconstruction. Two hundred sixty-nine members (16.8%)
responded to the whole questionnaire (Table 1). The questionnaire
was sent once only, in September 2019, from the SFA board ano-
nymized e-mail address. Responses were anonymous and took the
form of simple declarations. No personal information was reques-
ted.
The questionnaire basically focused on global postoperative
management after ACL reconstruction: outpatient management,
effusion prevention, and rehabilitation instructions and objectives.
However, some surgical data (associated meniscal procedures, ite-
rative reconstruction) were requested, to assess their impact on
use of bracing, resumption of weight-bearing and rehabilitation
protocol.
Outpatient management was, arbitrarily, deemed frequent
when it represented more than 80% of the surgeon’s annual pro-
cedures. The surgeon’s annual number of ACL reconstructions was
collected. For statistical reasons, a cut-off of 50 procedures per
year was chosen to define the surgeon’s experience, constituting
2 groups: “experienced”, with 50 or more procedures per year
(n = 137), or “less experienced” with less than 50 (n = 132).
Data were collected and analyzed by an independent inves-
tigator, using MATLAB® software (MATLAB® Version R2019b;
MathWorks, Natick, Massachusetts, USA). There were no missing
data. Questionnaire data were mainly nominal and ordinal rather
than quantitative, and were therefore analyzed by logistic regres-
sion. Association with surgeon’s experience was assessed for all
study variables. The significance threshold was set at p < 0.05.
The study design did not require review board approval.
3. Results
In 72.9% of cases, primary reconstruction was performed on an
outpatient basis. Day surgery was frequent (> 80% of procedures) for
58.4% of surgeons (n = 157) and less frequent (0 to 80%) for 41.6%
(n = 112). Seventy-three of the 269 respondents (27.1%) never per-
formed ACL reconstruction as day surgery and 106 (39.4%) did not
in case of associated meniscal suture or iterative ACL reconstruc-
tion. Outpatient management was more frequent for experienced
surgeons (p = 0.009 × 10−3 ).
Fig. 1 shows intraoperative measures to prevent effusion. Drai-
nage or electrocoagulation was more frequent for less experienced
surgeons, the difference being non-significant in the case of drai-
nage (p = 0.068) and significant for electrocoagulation (p = 0.005).
Outpatient surgery was significantly associated with drainage
(p = 0.003), but not with electrocoagulation (p = 0.14). Fig. 2 shows
use of postoperative cryotherapy. Compressive cryotherapy was
more frequent for experienced surgeons (p = 0.004). Outpatient
management showed no association with any form of cryotherapy.
In rehabilitation, weight-bearing was authorized by 98.5% of
surgeons in isolated ACL, either completely (68%) or partially
(30.5%). In case of associated meniscal suture, practices varied
depending on the type of lesion (Table 2). Resumption of weight-
bearing was unrelated to the surgeon’s experience or to outpatient
management.
Crutches were recommended by 100% of surgeons, for variable
periods, either predetermined (22.3% for 15 days, 17.8% for 30 days)
or according to functional recovery (34.9% until quadriceps locking,
24.9% at the physical therapist’s discretion).
Immobilization braces were prescribed by 188 surgeons (69.9%),
and systematically by 158 (58.7%). These were equally extension
braces (n = 97) or articulated braces (n = 91). Table 2 shows dura-
tion of use. Bracing was less frequent for experienced surgeons
(p = 0.02), and was unrelated to outpatient management.
Rehabilitation was initiated immediately by 75.5% of surgeons
(Table 3). Time to initiation of rehabilitation was unrelated to the
surgeon’s experience or to outpatient management. Table 3 shows

2
H.B. Sezer, T. Noailles, C. Toanen et al.
Fig. 1. Intraoperative effusion prevention in ACL reconstruction. * Significant difference between groups.
Fig. 2. Recommendation for postoperative cryotherapy after ACL reconstruction. * Significant difference between groups.
early postoperative rehabilitation objectives. For 89.6% of surgeons,
recovery of extension was an essential objective, and was in fact the
sole objective for 19.3%. Experience and outpatient management
were unrelated to any rehabilitation objective.
Self-rehabilitation was recommended by 124 surgeons (46.1%).
Instructions were delivered in writing (58.9%), orally by the surgeon
(13.7%) or the physiotherapist (5.6%), or via an application or web-
site (12.1%). Self-rehabilitation was more frequently recommended
by experienced surgeons (p = 0.0006).
4. Discussion
The present study found that early postoperative practices
after ACL reconstruction in France were related to the surgeon’s
level of experience: the greater the experience, the greater the
use of outpatient management, measures to limit effusion and
self-rehabilitation, and the less frequent the prescription of immo-
bilization braces, however common they may still be in France.
Outpatient surgery for ACL reconstruction has shown efficacy in
terms of costs and complications [21]. Despite its many advantages
3
Orthopaedics & Traumatology: Surgery & Research 107 (2021) 103065
and improved patient satisfaction, it was not systematic for all
respondents. This depended on both the surgeon and the health-
care structure. In 2012 in France, 41,122 ACL reconstructions were
performed, and only 3% were performed on an outpatient basis [16].
During the last decade, day surgery has spread rapidly in orthope-
dics [22]. In the present study, in 2019, 72.9% of surgeons performed
the procedure on an outpatient basis, with a positive association
with the surgeon’s experience. The use of outpatient management,
however, did not significantly affect early rehabilitation protocols.
Joint effusion can significantly impair quadriceps recovery
after ACL reconstruction [23]. The first step in prevention is to
control intra-articular bleeding. In the present series, this was
done systematically by about 20% of surgeons, and less frequently
by experienced surgeons. However, the efficacy of arthrosco-
pic electrocoagulation and intra-articular drainage in preventing
hemarthrosis has never been demonstrated [24]. The second step
consists in controlling early postoperative effusion. In the present
study, 97.8% of surgeons recommended cryotherapy and 68.8%
prescribed compressive cryotherapy. Compressive cryotherapy
was more frequently prescribed by experienced surgeons. The
H.B. Sezer, T. Noailles, C. Toanen et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 103065

Table 2
Postoperative practices after ACL reconstruction: rehabilitation instructions.

Rehabilitation instructions Whole series Experienced surgeons Less experienced surgeons p

n = 269 n = 137 n = 132

Weight-bearing (isolated ACL)

Yes 265 (98.5%) 137 (100%) 128 (97%) NS
Full 183 (68%) 86 (62.8%) 97 (73.5%)
Partial 82 (30.5%) 51 (37.2%) 31 (23.5%)
No 4 (1.5%) 0 (0%) 4 (3%) NS
WB (ACL + meniscal suture)*
Yes
Always 149 (55.4%) 83 (60.6%) 66 (50%) NS
No
Never 36 (13.4%) 12 (8.8%) 24 (18.2%) NS
If vertical lesion 28 (10.4%) 10 (7.3%) 18 (13.6%) NS
If horizontal lesion 6 (2.2%) 3 (2.2%) 3 (2.3%) NS
If radial lesion 57 (21.2%) 31 (22.6%) 26 (19.7%) NS
If root lesion 57 (21.2%) 29 (21.2%) 28 (21.2%) NS
Brace
Yes 188 (69.8%) 84 (61.3%) 104 (78.8%) 0.02
Always 158 (58.7%) 69 (50.4%) 89 (67.4%)
If meniscal suture 23 (8.6% 11 (8%) 12 (9.1%)
If iterative ACL 7 (2.6%) 4 (2.9%) 3 (2.3%)
No 81 (30.1%) 53 (38.7%) 28 (21.2%) 0.02
Type of brace
Extension 97 (36.1%) 41 (29.9%) 56 (42.4%) NS
Articulated 91 (33.8%) 43 (31.4%) 48 (36.4%) NS
None 81 (30.1%) 53 (38.7%) 28 (21.2%) NS
Brace duration
15 days 67 (24.9%) 37 (27%) 30 (22.7%) NS
21 days 56 (20.8% 23 (16.8%) 33 (25%) NS
30 days 31 (11.5%) 11 (8%) 20 (15.2%) NS
45 days 21 (7.8%) 5 (3.6%) 16 (12.1%) NS
Not specified 13 (6.9%) 8 (5.8%) 5 (3.8%) NS
No brace 81 (30.1%) 53 (38.7%) 28 (21.2%) NS

ACL: Anterior cruciate ligament reconstruction; WB: weight-bearing; NS: non-significant. Qualitative variables reported as number and percentage. Comparison of 2
experience groups, with p-value.
*
More than 1 answer possible.

Table 3
Postoperative practices after ACL reconstruction: rehabilitation.

Rehabilitation Whole series Experienced surgeons Less experienced surgeons p

n = 269 n = 137 n = 132

Start
Immediate 203 (75.5%) 99 (72.3%) 104 (78.8%) NS
Day 7 42 (15.6%) 26 (19%) 16 (12.1%) NS
Day 15 16 (5.9%) 8 (5.8%) 8 (6.1%) NS
Later 8 (3%) 4 (2.9%) 4 (3%) NS
Objectives*
Combat flexion contracture 241 (89.6%) 121 (88.3%) 120 (90.9%) NS
Restore flexion 64 (23.8%) 31 (22.6%) 33 (35%) NS
Proprioception 25 (9.3%) 11 (8%) 14 (10.6%) NS
Quadriceps strengthening 106 (39.4%) 47 (34.3%) 59 (44.7%) NS
Reduce effusion 143 (53.2%) 73 (53.3%) 70 (53%) NS
Self-rehabilitation
Yes 124 (46.1%) 77 (56.2%) 47 (35.6%) 0.0006
No 145 (53.9%) 60 (43.8%) 85 (64.4%) 0.0006

ACL: Anterior cruciate ligament reconstruction; NS: non-significant. Qualitative variables reported as number and percentage. Comparison of 2 experience groups, with
p-value.
*
More than 1 answer possible.

American Physical Therapy Association (APTA) and the Royal Dutch
Society for Physical Therapy (KNGF) recommend compressive cryo-
therapy in the early postoperative period after ACL reconstruction
[10,11]. Although there is no consensus on the contribution to
prevention of effusion, an analgesic effect is well established
[19,25,26].
Many scientific societies [10,11] and groups [7,8] recommend
early resumption of weight-bearing. It is considered safe after
isolated ACL reconstruction without meniscal or multi-ligament
lesions [5]. In the present study, 98.5% of surgeons authorized early
resumption of weight-bearing, completely and immediately for
68%.
No restriction on joint motion is specified in clinical guidelines.
However, the guidelines of the MOON (Multicenter Orthopedic
Outcomes Network) and MARS (Multicenter ACL Revision Study)
warn against limiting knee motion in the early postoperative period
after ACL reconstruction [7,8]. Recent studies reported inefficacy for
immobilization braces [12–14], or even harmful impact on range
of motion and recovery of strength [8]. Naik et al. also showed that
rehabilitation without bracing after ACL reconstruction reduced the
risk of retear [27]. Bracing may, however, be useful later, when
resuming certain sports activities [28,29]. Despite the abundant
literature, in the present study more than two-thirds of surgeons
prescribed early postoperative bracing, systematically for more

4
H.B. Sezer, T. Noailles, C. Toanen et al.
than half of them. There was, however, an inverse relation between
bracing and the surgeon’s experience.
In the present series, rehabilitation was initiated immediately
in 75.5% of cases and early in 21.5%; only 3% of respondents pre-
ferred a later start. The more experienced surgeons more often
recommended functional self-rehabilitation, mainly via written
instructions (59.9%); online applications were little used (12.1%).
In the literature, functional scores are identical or better after self-
rehabilitation compared to rehabilitation by a physical therapist
[30,31]. However, there is no consensus as to the type of rehabili-
tation in the non-French clinical practice guidelines [7,9–11].
In the present study, the main aims of early rehabilitation were,
for 89.6% of surgeons, to restore complete extension and reinforce
the quadriceps; restoring extension was indeed the sole aim for
almost 20% of respondents. This is in line with the literature. After
ACL reconstruction, “arthrogenic muscle inhibition” may arise and
needs to be prevented [32]. It induces hamstring contracture and
inactivation of the quadriceps, leading to loss of full extension due
to lack of an intra-articular mechanical factor. Moreover, hamstring
contracture is associated with increased risk of cyclops syndrome
[33]. In a recent literature review, Filbay et al. [34] described 3
objectives for early rehabilitation:
• absence of effusion;
• full active and passive ranges of motion;
• and active extension maintained without dead angle.
Although not included in clinical practice guidelines, proprio-
ception was one of the main objectives for 9% of surgeons in the
present study. However, after ACL reconstruction, patients tend to
overshoot target knee extension; early proprioceptive rehabilita-
tion of complete extension is then crucial, although usually only
dealt with later [35].
The main limitation of the present study was the low response
rate, with only 16.8% of SFA members answering the question-
naire. However, it is likely that knee specialists mainly responded,
and that the response rate for this specialty was higher. Respon-
dents were, surgically and scientifically, active members of a large
and influential French Society. Another limitation was the arbi-
trary threshold of 50 procedures per year defining “experience”.
This definition took no account of the surgeon’s age, which can be
a factor in surgical experience. Moreover, the subjective nature of
the data, inherent to this type of survey, was an important bias.
On the one hand, responses were simple declarations; and on the
other hand, the results may have been limited by certain questions
that were not asked: surgical technique, tourniquet time and perio-
perative analgesia all influence early postoperative care after ACL
reconstruction. However, the questions that were actually asked
give a good picture of postoperative practices being used in France
after ACL reconstruction.
5. Conclusion
Surgical experience seemed to be the main factor influencing
French orthopedic surgeons’ early postoperative practices after
ACL reconstruction. With growing experience, surgeons focus more
on preventing effusion, and start rehabilitation earlier, favoring
self-rehabilitation. Despite clinical practice guidelines published
outside France, a quarter of French orthopedic surgeons do not
perform this procedure on an outpatient basis, and two-thirds pres-
cribe an immobilization brace. Drawing up French guidelines would
promote progress and harmonization in practices.
5
Orthopaedics & Traumatology: Surgery & Research 107 (2021) 103065
Review board
Not required.
Disclosure of interest
AH: consultant for Medacta Corporate and Medacta France.
JMF: consultant for Arthrex, consultant receiving royalties from
Newclip Technics, and royalties from XNov.
The other authors declare that they have no competing interest.
Funding
None.
Author contribution
SHB: statistical analysis, article writing.
TN: study design, data collection, article writing.
CT: study design, data collection, article writing.
NL: supervision, re-editing.
YB: supervision, re-editing.
JMF: study design, coordination, re-editing.
AH: study design, data collection, article writing.
Acknowledgments
The French Arthroscopy Society (SFA) for distributing the ques-
tionnaire to all members.
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