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. 2025 Mar 3;13(3):23259671251317490.
doi: 10.1177/23259671251317490. eCollection 2025 Feb.

Survival Analysis of ACL Graft and Contralateral ACL Ruptures in Patients Younger Than 18 Years

Kate E Webster  1 , Julian A Feller  2
Affiliations

Survival Analysis of ACL Graft and Contralateral ACL Ruptures in Patients Younger Than 18 Years

Kate E Webster et al. Orthop J Sports Med. .

Abstract

Background: Although high rates of graft and contralateral anterior cruciate ligament (ACL) ruptures have been reported in younger patients after ACL reconstruction (ACLR), recent evidence suggests that previously reported crude event rates underestimate the actual event risk.

Purpose: To report rates of graft and contralateral ACL rupture after ACLR in a large series of younger patients using survival analysis.

Study design: Cohort study; Level of evidence, 3.

Methods: Patients aged <18 years at the time of primary ACLR were identified from a single-surgeon database over 12 years ending January 2018. Patients with a previous contralateral ACL rupture or bilateral ACL ruptures were excluded. Overall, 388 patients (204 males, 184 females) were included in the final dataset. Bespoke survey data and clinic follow-up data were used to record graft rupture and contralateral ACL rupture events. Rates of graft and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis. Log-rank tests were used to compare survival functions between several subgroups.

Results: According to Kaplan-Meier survival analysis, the cumulative rates at 2, 5, and 10 years for graft rupture were 11%, 17%, and 22%, and the cumulative rates for contralateral ACL injury were 7%, 19%, and 33%. Males had significantly greater rates of graft rupture than females throughout a 10-year follow-up period (P < .001). Contralateral ACL rupture survival functions were not significantly different between the sexes, although rates were higher in females until 5 years postoperatively, after which contralateral ACL ruptures increased in males, with a cumulative rate of 39% at 10 years compared with 29% for females. Survival rates did not vary between different age groups (<16 vs ≥16 years), but females with a graft diameter of <7 mm on the femoral side had significantly greater graft rupture rates than females with grafts ≥7 mm (P = .04).

Conclusion: The present study is one of the largest consecutive series of younger patients, with one of the longest follow-up periods, reporting a high risk for a second ACL injury. Over time, the cumulative risk for contralateral ACL rupture was higher than for graft rupture. In males, the risk for contralateral ACL rupture continued to increase after 5 years.

Keywords: anterior cruciate ligament; athlete; reconstruction; sports injury.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: J.A.F. is a paid associate editor for The Orthopaedic Journal of Sports Medicine. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Histogram of patient age at surgery. Open growth plates were present in 54 patients (14%) and closed/closing growth plates in 334 patients (86%).
Figure 2.
Figure 2.
Kaplan-Meier survival curves of (A) graft rupture and (B) contralateral ACL rupture according to sex in patients having undergone ACLR. ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction.
Figure 3.
Figure 3.
Kaplan-Meier survival curves of graft rupture according to age grouping.
Figure 4.
Figure 4.
Kaplan-Meier survival curves of graft rupture in female patients according to graft diameter on the femoral side.
See this image and copyright information in PMC

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