Summary

Professional athletes undergoing isolated ACLR and aged 21 or younger are at >2-fold risk of graft failure. Orthopedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship

Abstract

Anterior cruciate ligament (ACL) injuries are amongst the most common knee injuries sustained in elite sport and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. Multiple studies have reported predictors for ACLR failure, including age, activity level, graft size, graft choice, increased posterior tibial slope and meniscal deficiency. However, no studies are specific to professional athletes and include the addition of a lateral extra-articular procedures (LEAP).

The purpose of this study was to determine the risk factors for graft failure in professional athletes undergoing ACLR. It was hypothesized that athletes who underwent combined ACLR with a LEAP would experience significantly lower rates of graft rupture in comparison to those who underwent isolated ACLR

Professional athletes who underwent primary ACLR using autograft by the senior author (BSC) between January 2003 and January 2020 with a minimum follow-up of 2 years were considered for study inclusion. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Patient notes were reviewed by an investigator, independent of the primary surgeons, to determine if they had sustained a further ipsilateral knee injury, sustained a contralateral knee injury or had undergone any reoperations or complications after the index procedure. Key demographics and additional secondary surgery were also documented.

A total of 420 professional athletes underwent ACLR during the study eligibility period. After application of the exclusion criteria, 342 athletes were identified as eligible for final inclusion with a mean follow-up of 100.2 +/- 51.9 months (range, 24 - 215 months). 31 graft failures (9.1%) were reported, all requiring revision surgery due to symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% v 6.0%, p = 0.0105) and in younger athletes (13.8% v 6.6%, p = 0.0290). A multivariate analysis was performed using the Cox model and demonstrated that athletes undergoing an isolated ACLR were at >2-fold risk of ACL graft rupture (Hazard Ratio (HR) = 2.678 (1.173;4.837), p = 0.0164) when compared to a combined ACLR with a LEAP. Additionally, athletes aged 21 or younger were also at >2-fold risk of graft failure (HR = 2.381 (1.313;5.463), p = 0.0068). Gender, sport and graft type were not found to be significant risk factors. Secondary surgery on the ipsilateral knee took place in 62 athletes (18.1%). Additionally, 42 athletes (13.2%) had a subsequent ACL rupture of the contralateral knee.

The main finding of this study was that professional athletes who underwent isolated ACLR had a >2-fold higher graft failure rate than when ACLR was combined with a LEAP. Additionally, athletes aged 21 or younger also had a >2-fold higher graft failure rate when compared to older athletes. To the knowledge of the authors, this is the first study to specifically analyze risk factors for ACL graft failure in elite athletes of all sports including the addition of a LEAP. Orthopedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship