Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group

Abstract

Background: Anterior cruciate ligament (ACL) injuries are among the most common knee injuries sustained in elite sport, and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. ACL graft rupture is a career-threatening event for elite athletes. Purpose/Hypothesis: 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 lateral extra-articular procedure (LEAP) would experience significantly lower rates of graft rupture in comparison with those who underwent isolated ACLR. Study design: Cohort study; Level of evidence, 3. Methods: Professional athletes who underwent primary ACLR with a minimum follow-up of 2 years were identified from the Santy database. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Further ipsilateral knee injury, contralateral knee injury, and any other reoperations or complications after the index procedure were identified by interrogation of the database and review of the medical notes. Results: A total of 342 athletes with a mean follow-up of 100.2 ± 51.9 months (range, 24-215 months) were analyzed. Graft failures totaling 31 (9.1%) were reported, requiring revision surgery because of symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% vs 6.0%; P = .0105) and in athletes aged 21 years or younger (13.8% vs 6.6%; P = .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 = .0164) when compared with those undergoing a combined ACLR with a LEAP. Additionally, athletes aged ≤21 years were also at >2-fold risk of graft failure (HR, 2.381 [1.313; 5.463]; P = .0068) than those aged >21 years. Sex, sport, and graft type were not found to be significant risk factors for graft failure. Conclusion: Professional athletes undergoing isolated ACLR and aged ≤21 years are at >2-fold greater risk of graft failure. Orthopaedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction

“…Fabbriciani et al [10] and Takazawa et al [27] both reported no re‐ruptures, but this may have been due to the small number (12) of cases studied. An 8% re‐rupture rate in rugby was reported by Hopper et al as part of their multisport study [15]. The re‐rupture rate in NFL(6.9% [16] and 18% [25]) and Australian football (30% [20]), which are sports that are comparable to rugby, are similar or higher than those shown in rugby players in the present study.…”

“…Graft re‐rupture is widely reported in studies of elite athletes after primary ACL‐R and ranges between 3 and 19% [2, 9, 11, 14, 15, 19, 20, 24, 25, 29]. Hopper et al [15] in a multi‐sport study found that the re‐rupture rate was not affected by the type of sport played.…”

Though five‐strand hamstring autografts demonstrate greater graft diameter, postoperative outcomes are equivocal to four‐strand hamstring autograft preparations: a systematic review and meta‐analysis of level I and II studies

“…This is corroborated by retrospective cohort studies in the literature that compared five‐ and four‐strand autografts and found no significant differences in rupture and instability rates [2, 5, 16]. Failure of ACLR is not only attributed to graft diameter, with medial and lateral meniscus deficiency, non‐anatomic femoral tunnel positioning, and younger patient age all being reported to play a role [14, 27, 28, 34]. In addition, bone morphological risk factors such as increased tibial slope and intercondylar notch stenosis have also been shown to be associated with failure [7, 10, 12, 31].…”

ALL Repair and Reconstruction: Techniques From the SANTI Study Group

“…Firstly, we describe a combined ACL reconstruction and double-bundle ALL reconstruction. 4,7,9,11 Appropriate landmarks are identified and marked including the joint line, Gerdy tubercle, fibular head, and lateral epicondyle. Three stab incisions are made in preparation for the ALL reconstruction.…”