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 https://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

Related Posts:

Return to High School- and College-Level Football After Anterior Cruciate Ligament Reconstruction



Ardern, C., Taylor, N., Feller, J., & Webster, K. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors British Journal of Sports Medicine DOI: 10.1136/bjsports-2013-093398