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In the literature, it is notable that there is no
relationship can be found between the rate
of returning to the pre-injury level of sports
participation and knee function, as
measurements were conducted by the
International Knee Documentation Committee
(IKDC) knee evaluation form. [3].
Psychological factors
Some authors have suggested that psychological
factors may also contribute to the return-to-
sport outcomes, as fear and motivation [7].
Other factors can influence the return to play
and its quality, like family situation and work
involvement.
RISK OF NEW INJURY
(GRAFT
RUPTURE AND CONTRALATERAL
ACL INJURY)
After RTS the risk of re-injury (graft rupture)
ranges in the literature from 6% to 25%
whereas the risk of contralateral ACL injury
ranges from 2 to 20.5%.
Wright
et al.
[8] conducted a systematic review
of six level I or II prospective studies that
evaluated the graft rupture and contralateral
ACL injury rates in patients at least 5 years
following ACL reconstruction surgery, using
either a patellar tendon or hamstring tendon
autograft. The results demonstrated that, the
ipsilateral ACL graft rupture rate ranged from
1.8 to 10.4%, with a pooled percentage of 5.8%.
The contralateral injury rate ranged from 8.2 to
16.0%, with a pooled percentage of 11.8%.
They concluded that the risk of ACL tear in the
contralateral knee (11.8%) was double the risk
of ACL graft rupture in the ipsilateral knee
(5.8%). However, most studies do not clearly
separate graft rupture and graft deficiency that
may have been present from the early
postoperative period. This may in turn influence
the factors that are identified as predictors of
graft rupture as opposed to failure.
Young age is a factor of re-injury. Shelbourne
et al.
[9] demonstrated that young patients
(<18 years) had the highest risk of graft rupture
and they have also been shown to be up to seven
times more likely to sustain a contralateral ACL
injury than patients aged greater than 18 years.
Wiggins
et al.
[10] in a systematic review,
showed that athletes younger than 25 years
who returned to sport have a secondary ACL
injury rate of 23%. This systematic review and
meta-analysis demonstrates that younger age
and a return to high level of activity are
predominant factors associated with secondary
ACL injury. These combined data indicate that
nearly 1 in 4 young athletic patients who
sustain an ACL injury and return to high-risk
sport will go on to sustain another ACL injury
at some point in their career, and they will
likely sustain it early in the return-to-play
period. Andernord
et al.
[11] in a cohort study
of 16,930 patients with 2-year follow-up,
demonstrated that soccer players and
adolescents are predictors for a high risk of
revision surgery.
CONCLUSION
Most athletes can return to sport after an ACL
reconstruction but the rate of return to previous
sports level and competition can be more
disappointing. The time to return to sport in
practice goes from 4 months to 18 months.
The elements which influence the time and
quality of return to play are multifactorial and
the return-to-sport decision should be
individualized and objective (goal), rather than
based on time.
The maturation of the human ACL graft should
not be the only factor to be considered. Meeting
specific objective discharge criteria can reduce
the relative risk of sustaining an ACL graft
rupture. Nevertheless, careful attention to
athletes achieving an appropriate hamstring to
quadriceps strength ratio before discharge after
ACL reconstruction, may help to reduce the
likelihood of ACL graft rupture.
The young age and high level of sports must
make return to sport discharge even more
prudent.