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Meta-Analysis
. 2016 Jul;44(7):1861-76.
doi: 10.1177/0363546515621554. Epub 2016 Jan 15.

Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Amelia J Wiggins  1 , Ravi K Grandhi  2 , Daniel K Schneider  3 , Denver Stanfield  4 , Kate E Webster  5 , Gregory D Myer  6
Affiliations
Meta-Analysis

Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Amelia J Wiggins et al. Am J Sports Med. 2016 Jul.

Abstract

Background: Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL are disastrous outcomes after successful ACL reconstruction (ACLR), rehabilitation, and return to activity. Studies reporting ACL reinjury rates in younger active populations are emerging in the literature, but these data have not yet been comprehensively synthesized.

Purpose: To provide a current review of the literature to evaluate age and activity level as the primary risk factors in reinjury after ACLR.

Study design: Systematic review and meta-analysis.

Methods: A systematic review of the literature was conducted via searches in PubMed (1966 to July 2015) and EBSCO host (CINAHL, Medline, SPORTDiscus [1987 to July 2015]). After the search and consultation with experts and rating of study quality, 19 articles met inclusion for review and aggregation. Population demographic data and total reinjury (ipsilateral and contralateral) rate data were recorded from each individual study and combined using random-effects meta-analyses. Separate meta-analyses were conducted for the total population data as well as the following subsets: young age, return to sport, and young age + return to sport.

Results: Overall, the total second ACL reinjury rate was 15%, with an ipsilateral reinjury rate of 7% and contralateral injury rate of 8%. The secondary ACL injury rate (ipsilateral + contralateral) for patients younger than 25 years was 21%. The secondary ACL injury rate for athletes who return to a sport was also 20%. Combining these risk factors, athletes younger than 25 years who return to sport have a secondary ACL injury rate of 23%.

Conclusion: This systematic review and meta-analysis demonstrates that younger age and a return to high level of activity are salient 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. The high rate of secondary injury in young athletes who return to sport after ACLR equates to a 30 to 40 times greater risk of an ACL injury compared with uninjured adolescents. These data indicate that activity modification, improved rehabilitation and return-to-play guidelines, and the use of integrative neuromuscular training may help athletes more safely reintegrate into sport and reduce second injury in this at-risk population.

Keywords: ACL injury; ACL revision; knee injury; knee injury prevention.

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Conflict of interest statement

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Figures

Figure 1
Figure 1
Flow chart of literature search and review process.
Figure 2
Figure 2
Pooled (A) ipsilateral anterior cruciate ligament (ACL) reinjury rate from 14 studies, (B) contralateral ACL injury rate and (C) secondary ACL injury rate from 7 studies. Five studies,,,, were excluded from these calculations, as their populations were included in other studies.
Figure 3
Figure 3
Pooled reinjury rates for subjects <25 years old. (A) Ipsilateral anterior cruciate ligament (ACL) reinjury rate from 11 studies. Four studies,,, were excluded from the calculations, as their populations were included in other studies. (B) Contralateral ACL injury rate and (C) secondary ACL injury rate from 6 studies. Two studies, were excluded from the calculations in (B) and (C), as their populations were included in other studies.
Figure 4
Figure 4
Pooled reinjury rates for subjects who returned to sports. Two studies, in were excluded from these calculations, as their populations were included in other studies. (A) Ipsilateral anterior cruciate ligament (ACL) reinjury rate from 7 studies and (B) contralateral ACL injury rate and (C) secondary ACL injury rate from 6 studies.
Figure 5
Figure 5
Pooled reinjury rates for subjects <25 years old who returned to sports from 5 studies. One study was excluded from these calculations, as its population was included another study. (A) Ipsilateral anterior cruciate ligament (ACL) reinjury rate, (B) contralateral ACL injury rate, and (C) secondary ACL injury rate.
Figure 6
Figure 6
Pooled secondary anterior cruciate ligament injury rates from respective patient groups.
See this image and copyright information in PMC

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