Factors Influencing Return to Play and Second Anterior Cruciate Ligament Injury Rates in Level 1 Athletes After Primary Anterior Cruciate Ligament Reconstruction: 2-Year Follow-up on 1432 Reconstructions at a Single Center

Abstract

Background: Despite the importance of return-to-play (RTP) rates, second anterior cruciate ligament (ACL) injury rates, and patient-reported outcomes of athletes returning to sports after ACL reconstruction (ACLR), these outcomes have not been evaluated together across a single cohort nor the pre- and intraoperative factors influencing outcomes explored.

Purpose: To prospectively report outcomes after ACLR relating to RTP, second ACL injury, and International Knee Document Committee (IKDC) scores in a large cohort of athletes at a single center to examine the influence of pre- and intraoperative variables on these outcomes.

Design: Cohort study; Level of evidence, 3.

Methods: A consecutive cohort of 1432 athletes undergoing primary ACLR by 2 orthopaedic surgeons was followed up prospectively more than 2 years after surgery. Pre- and intraoperative findings were reported with outcomes at follow-up relating to RTP, second ACL injury, and IKDC. Between-group differences for each outcome were reported and the predictive ability of pre- and intraoperative variables relating to each outcome assessed with logistic regression.

Results: There was >95% follow-up 2 years after surgery. The RTP rate was 81%, and of those who returned, 1.3% of those with patellar tendon grafts and 8.3% of those with hamstring grafts experienced ipsilateral rerupture (hazard ratio, 0.17). The contralateral ACL injury rate was 6.6%, and the IKDC score at follow-up was 86.8, with a greater proportion of patients with patellar tendon grafts scoring <80 on the IKDC (odds ratio, 1.56; 95% CI, 1.15-3.12). There was no relationship between time to RTP and second ACL injury, and there was a moderate correlation between ACL-Return to Sport After Injury score and RTP at follow-up (P < .001, rho = 0.46). There were a number of differences in pre- and intraoperative variables between groups for each outcome, but they demonstrated a poor ability to predict outcomes in level 1 athletes at 2-year follow-up.

Conclusion: Findings demonstrated high overall RTP rates, lower reinjury rates with patellar tendon graft after 2-year follow-up in level 1 athletes, and no influence of time to RTP on second ACL injury. Despite differences between groups, there was poor predictive ability of pre- and intraoperative variables. Results suggest pre- and intraoperative variables for consideration to optimize outcomes in level 1 athletes after ACLR, but future research exploring other factors, such as physical and psychological recovery, may be needed to improve outcome prediction after ACLR.

Registration: NCT02771548 (ClinicalTrials.gov identifier).

Keywords: anterior cruciate ligament reconstruction; athletes; reinjury; return to play.

Figures

Figure 1.

Flowchart of participant inclusion in analysis. ACLR, anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee; RTP, return to play.

Figure 2.

Kaplan-Meier survival analysis for ipsilateral vs contralateral anterior cruciate ligament (ACL). The dot indicates the first month that a difference in survival was detected between groups. CONTRA, contralateral ACL injury; IPSI, ipsilateral ACL injury; KME, Kaplan-Meier estimate.

Figure 3.

Kaplan-Meier survival analysis for bone–patellar tendon–bone vs hamstring tendon graft. The dot indicates the first month that a difference in survival was detected between groups. KME, Kaplan-Meier estimate.