Sports Medicine Research: In the Lab & In the Field: Survival of the ACL Graft and the Contralateral ACL at a Minimum of 15 Years (Sports Med Res)
Friday, September 21, 2012

Survival of the ACL Graft and the Contralateral ACL at a Minimum of 15 Years

Survival of the Anterior Cruciate Ligament Graft and the Contralateral ACL at a Minimum of 15 Years

Bourke HE, Salmon LJ, Waller A, Patterson V, Pinczewski LA. Am J Sports Med. 2012 Aug 6. [Epub ahead of print]

Anterior cruciate ligament injury is devastating to the athletic career of an athlete, but it is also potentially only the beginning of knee problems for an athlete.  ACL reconstruction likely follows, which can restore static stability (but not prevent the development of arthritis or guarantee a return to sports), but we know that there is at least some risk for suffering a graft injury or a contralateral ACL injury. However, like many aspects of function after ACL injury, we don’t have sample sizes large enough with adequate follow-up to determine the true prevalence or risk factors for these re-injuries.  The purpose of this investigation was to do just that.  To achieve this objective patients undergoing ACLR at a minimum of 15 years prior were contacted to complete the IKDC2000 Subjective Knee Form and a telephone interview to determine their self-reported function, activity level, and any injury to either the ACL graft or the contralateral ACL (CACL). Of 755 eligible subjects, 673 completed the follow-up, 23% of whom had sustained an injury to either ACL.  Risk factors for an ACL graft rupture included being a male and having a positive family history of ACL rupture.  Risk factors for a contralateral ACL rupture included being 18 or younger at the time of surgery, returning to sport and having a positive family history of ACL rupture.  The period of greatest risk for a graft rupture was in the first two years after reconstruction and between one and four years post reconstruction for the CACL.

Patients are clearly at risk for injury to the graft or contralateral ACL in the post-operative period, as indicated here and in a 5 year follow-up from Shelbourne et al.  The risk-factors identified consistently include young athletes (18 or younger at the time of reconstruction) which return to high level activities.  However, as pointed out in the discussion of this paper, it may simply be due to greater exposure to injurious situations.  Regardless, as a medical professional, this is something we must consider when preparing our young athletes for returning to sports.  Interestingly, the only risk factors discussed in this report are largely non-modifiable from a rehabilitation standpoint (one could argue that returning to sport is modifiable, however, to many patients this is not an option). Further research is needed to identify if the high risk period between one and two years after ACLR is due to inadequate rehabilitation and poor movement patterns, structural predisposition to injury, or some combination of both. We know that time from injury doesnt adequately identify functional deficits after ACLR. But as previously mentioned, objective return to sport criteria are lacking in predicting failure.  What do you tell your patients about their likelihood of re-injury when returning to sport after ACLR? Do you implement a systematic injury prevention program for your younger patients?  Are there any criteria that you find to be predictive of future injury that are potentially modifiable?

Written by:  Andrew Lynch
Reviewed by:  Stephen Thomas

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Bourke HE, Salmon LJ, Waller A, Patterson V, & Pinczewski LA (2012). Survival of the Anterior Cruciate Ligament Graft and the Contralateral ACL at a Minimum of 15 Years. The American Journal of Sports Medicine, 40 (9), 1985-92 PMID: 22869626

3 comments:

Jake Marshall ATC CES said...

It would ber awsome to be able to implement injury prevention programs in the younger population. However, as one who works at a high school, I can say that is much easier said than done. Time for individual rehab is minimal and there are always more athletes that need individual attention than I have time to give. Also, being responsible for 5 sports, most with 3 levels, makes it very difficult to coordinante with coaches to train them to be able to effectively incorporate one of the many specific injury prevention programs into their daily practice. Many of the injury prevention programs require a constant vigilance of form and execution in order to truely establish a new, functionaly improved movement pattern. They would vbe best initially implemented during off season or pre season training which I am either not around for or I am dealing with in season sports. Trying to get most of these students to do these things in their off time is like asking a fish to breath out of the water. They just simply wont do it.

All of that being said, there has to be a way to make it happen. My first step has been trying to identify the one sport with the highest acl injury rate. Once I indentify that team I wiull begin speaking to the coaches about finding a way to implement one of the ACL prevention programs into either their warm up or as conditioning. To prove that the program works there will need to be a huge amount of dedicated testing done before the program is implemented and after a couple of set time frames to create the evidence that its working and worth doing.

All considered it is a HUGE task to do by myself, I am the only trainer here, while still fulfiling the rest of my duties. Suggestions would be appreciated.

Andrew Lynch said...

Jake, I think you have clearly stated the problem that most people are seeing and struggling to deal with. I think the key to getting coaches to buy in is, as you said, demonstrating value. This value can be of two possible realms - improved performance and decreased injury rates. Obviously, the improved performance requires the extensive dedicated testing of which you mentioned. However, the injury prevention may not require as much testing. You may be able to strike a chord with coaches when you ask them if they have ever lost their star player to an ACL injury - it has more than likely happened more than once. Offer these training programs as one thing they can easily do to help reduce that risk. Something like the F-MARC 11+ for soccer has some inherent value as it comes right from FIFA, so I might start there. And if you can get the coach to do it once a week, you are improving some aspect of injury prevention. In addition, it may not be a bad idea to start your own basic injury surveillance system for discussion with the coaches.

Andrew Lynch said...

When it comes to the necessity of individual attention, we need better indicators of risk factors and faulty mechanics so we can pull those participants out for additional training. This also would require extensive testing. Until that time, basic education for coaches will have to suffice for things that don't "look right" to the relatively untrained eye. Also having the strength and conditioning coach (if there is one) pulling people out for individual screening is another potential avenue for identifying these subjects.

But, overall, any training - even if not monitored for perfect form - can still be beneficial. Unless they get hurt doing it...

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