Fifty-five percent return to competitive sports following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors
Ardern CL, Taylor NF, Feller JA, & Webster KE. Br J Sports Med. Published online first August 25, 2014. doi: 10.1136/bjsports-2013-093398 http://bjsm.bmj.com/content/early/2014/08/24/bjsports-2013-093398.short
Take Home Message: Only 55% of athletes returned to competitive sport following anterior cruciate ligament (ACL) reconstruction. The debate continues as to whether hamstring or patellar tendon autograft is better. However, factors that may favor return to competitive sport include younger age, male gender, elite sport, and a positive psychological response.
Return to sport participation following anterior cruciate ligament (ACL) reconstruction is often considered a measure of surgery success. Unfortunately, we don’t have a good estimate of how often athletes successfully return to activity rates after an ACL reconstruction and which factors (individual and external) may affect return to activity. Therefore, Ardern and colleagues conducted a meta-analysis to determine the return to sport rate after an ACL reconstruction and which factors favored returning to play. This meta-analysis included 69 articles and reported on 7556 participants with an average age of 26 years, 66% male, and 34% received a hamstring graft while 61% received a patellar tendon graft. Eight one percent who had ACL surgery returned to any sport, 65% returned to their preinjury level of sport, and 55% returned to competitive level of sport. Key factors that favored successful return to preinjury level of sport were being younger in age, male, an elite athlete, less fearful of reinjury, and of greater psychological readiness. Graft selection continues to be inconclusive. Participants who received hamstring grafts had better odds of returning to any sport or competitive level sport, while participants who received patellar grafts had better odds of returning to preinjury levels of sport. The average follow-up was 40 months (range = 12 to 156 months) but the length of follow-up did not influence the return to play results.
While there is a high rate of return to any sport (81%), the number of participants who return to preinjury or competitive levels of sport is relatively low. There were some factors that favored successful return to preinjury levels; however, there are few that we can modify. Important findings of this meta-analysis further emphasize that it would be advantageous for clinicians to dedicate time during the recovery process to address psychological readiness and fears of the participant. The authors of this study updated an earlier study, which focused on research conducted before 2010, and showed that there was an increase in the return to competitive sport rate in this current study. It is interesting to see that male elite athletes are more likely to return to competitive sport. Future studies may benefit from determining timing of the participant’s knee injury. For example, if an athlete suffers a knee injury at the end of their college career, there are very limited options for them to return to competitive sport. Especially if an athlete is a female, there may not be as many options for them to continue to participate competitively. A better understanding is needed of the athlete’s desired or attainable level of participation versus what they actually succeed in returning to. The graft analysis results should be interpreted with caution as there were twice as many patellar tendon grafts as there were hamstring grafts. Lastly, it would be very interesting to see this type of study replicated in younger aged groups (high school and college) as there are more opportunities for successful return to competitive sport. However, I still caution clinicians to not look at return to competitive sport as the only criteria for success. Following these participants into middle-aged and older adulthood would be very interesting to see if whether they returned to competitive level or not affected their risk for early osteoarthritis development.
Questions for Discussion: What do you think the younger aged population would look like in terms of return to competitive sport? Are there any strategies that you utilize during your rehabilitation process to address fear of reinjury and psychological readiness?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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