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Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes Caitlin M. Rugg, Dean Wang, Pamela Sulzicki and Sharon L. Hame Am J Sports Med 2014 42: 959 originally published online February 11, 2014 DOI: 10.1177/0363546513519951 The online version of this article can be found at: http://ajs.sagepub.com/content/42/4/959
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Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes Caitlin M. Rugg,* MS, Dean Wang,* MD, Pamela Sulzicki,y MS, ATC, and Sharon L. Hame,*z MD Investigation performed at the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Background: High school and professional athletes with a history of orthopaedic surgery have decreased career lengths and are at a greater risk for reinjury compared with their peers. It is unknown whether the same risk applies to intercollegiate athletes. Purpose: To determine the effect of prior knee surgery in National Collegiate Athletic Association (NCAA) Division I athletes in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: Division I athletes who began participation in collegiate athletics at a single institution from fall 2003 to spring 2008 were identified. Athletes with a history of orthopaedic surgery were identified through preparticipation evaluation forms. Data on the number of seasons and games played, number of days missed, diagnostic imaging, athletic injuries sustained, and surgical operations during college were collected through medical records and the Sports Injury Monitoring System (SIMS). Results: During the 5-year study period, 456 athletes completed preparticipation evaluation forms. Of these, 104 athletes (22.8%) had a history of orthopaedic surgery (Ortho group). Forty-eight (10.5% of all athletes) had a history of knee surgery (Knee group), 16 (3.5%) had a history of anterior cruciate ligament reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Days missed per season due to any injury and due to knee injury were increased for all surgical groups compared with controls (P \ .016). The rate of knee injury and knee surgery while in college was significantly increased for all surgery groups. Athletes in the Knee and ACL groups were 6.8- and 19.6-fold more likely to sustain a knee injury and 14.4- and 892.9-fold more likely to undergo a knee surgery during their collegiate careers compared with controls (P \ .001). The number of MRIs per season were 0.83 for the Knee group (P \ .001), 1.29 for the ACL (P = .009), and 0.97 for the Multiple group (P \ .001), compared with 0.37 for controls. Average career length and percentage of games played were not significantly different between any of the surgery groups compared with controls. Conclusion: Athletes who had a history of knee surgery before participation in collegiate athletics miss more days due to injury, have increased rates of knee injury and knee surgery, and require more MRIs during their collegiate careers than their peers. Keywords: knee; surgery; collegiate; anterior cruciate ligament; athlete; imaging; prior injury; sports; return
Knee injuries are among the most common injuries sustained by high school and collegiate athletes and can have devastating results for individual athletes and the team.8-10,12,22,24 In the 2005-2006 and 2006-2007 school
years, knee injuries made up 15.2% of all high school sports-related injuries.9 Football, women’s soccer, and women’s gymnastics had the highest risk of knee injury in high school sports.24 In addition, Rechel et al20 reported that approximately half of all high school sports injuries that require orthopaedic surgery involved the knee. Most of these were complete ligament tears that medically disqualified athletes for the season. In recent years, an increasing number of collegiate athletes are entering college with a history of anterior cruciate ligament (ACL) tears, while more collegiate athletes are experiencing ACL tears.8,12 These athletes may have remaining functional deficits after surgery, which may predispose them to injuries when they enter college.10,11,16 Reinjury and contralateral injury after knee surgery are concerns for players and coaches alike. It has been demonstrated that patients with a history of ACL injury are at
z Address correspondence to Sharon L. Hame, MD, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, CHS 76-119, 10833 LeConte Avenue, Los Angeles, CA 90095-6902, USA (e-mail: [email protected]). *Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. y Athletic Department, University of California–Los Angeles, Los Angeles, California, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 42, No. 4 DOI: 10.1177/0363546513519951 Ó 2014 The Author(s)
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increased risk of subsequent ACL rupture on both the reconstructed and contralateral sides.2,7,17,21,23 Bourke et al2 reported a 14% and 23% risk of tearing either ACL after 5 and 15 years, respectively, after reconstruction with an autologous graft. Female sex and return to high activity may also predispose an athlete to rerupture.7,17,23 Similarly, an increasing number of collegiate athletes are entering college with a history of meniscal tears. While young athletes have improved outcomes in meniscal repairs compared with older patients, reoperation rates are still substantial.13,18,25 In a meta-analysis, 3.9% of partial meniscectomies and 20.7% of arthroscopic meniscal repairs required reoperation within 10 years of the index surgery.18 Currently, little is known about the effects of knee surgery in high school athletes and how it may affect their collegiate athletic careers. Thus, the goal of this study was to determine the athletic and medical outcomes in National Collegiate Athletic Association (NCAA) Division I athletes with a history of knee surgery at a single institution in the United States.
MATERIALS AND METHODS Institutional review board approval for this study was obtained. Athletes who underwent their initial preparticipation evaluation (PPE) and who began participation in 10 sports from fall 2003 to spring 2008 at our institution were eligible for the study. Five men’s teams (football, baseball, volleyball, basketball, and soccer) and 5 women’s teams (softball, gymnastics, volleyball, basketball, and soccer) were included in the study. Eligible athletes were identified using the institution sports archives and athletic training room records. All athletes underwent their first PPE before collegiate athletic participation by licensed physicians, and surgical histories, including any orthopaedic surgery, were identified. Returning athletes during the study period were not included in the study. Sport played, seasons played, and games played were elicited from the sports archives. Data on injury type and days missed due to injury were recorded from the Sports Injury Monitoring System (SIMS; FlanTech, Inc, Iowa City, Iowa, USA). In this system, athletic trainers recorded any medical concern as an injury if it was managed for more than 10 days and/or resulted in restriction in activity. Medical records and SIMS data were cross-referenced for diagnostic imaging and surgeries performed during college. Redshirt athletes, who are limited to less than 30% of competitions, were included for complete practice exposure data. Athletes were classified into different groups for comparison. The control group consisted of all athletes without a history of orthopaedic surgery before first collegiate PPE, whereas those athletes with an orthopaedic surgery before first collegiate PPE made up the orthopaedic surgery cohort (Ortho group). Within this group, subgroups of athletes with a history of any knee surgery (Knee group), ACL reconstruction (ACL group), and multiple orthopaedic surgeries (Multiple group) were identified. Athletes could be classified into 2 or more groups if they fulfilled the criteria. Statistical analyses were performed with GraphPad Prism 5 (GraphPad Software, La Jolla, California, USA). Two-
tailed t tests and Mann-Whitney U tests were used to compare injury groups to control for parametric and nonparametric distributions, respectively. Time-dependent analyses were completed using the Kaplan-Meier method, and curves were compared using the log-rank test. Dates of the entering PPE were used as the starting dates, and the last days of collegiate careers were censored if an athlete did not sustain a knee injury or undergo a knee surgery in college. Hazard ratios were calculated when comparing injury group survival curves to that of the Control. Significance was predefined at P \ .05.
RESULTS Demographic Data From fall 2003 to spring 2008, there were 456 athletes from 10 sports at our institution who underwent an initial PPE by a licensed physician (Table 1). Of these, 104 athletes (22.8%) had a history of orthopaedic surgery, which constituted 25.8% of female and 21.3% of male athletes. The sports with the highest percentage of incoming athletes with a history of orthopaedic surgery were women’s gymnastics (59.3%), women’s soccer (29.4%), men’s soccer (26.2%), and baseball (24.1%) (Figure 1). The sport with the smallest percentage of athletes with surgery history was softball (3.6%). Among the athletes with a history of orthopaedic surgery, 48 (10.5% of all athletes) had a history of knee surgery (Knee group). Sixteen (3.5%) had history of ACL reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Sports with the highest percentage of incoming athletes with a history of knee surgery were gymnastics (29.6%), women’s soccer (21.6%), and women’s volleyball (14.3%). Other previous surgeries involved the wrist and hand (16.3% of the Ortho group), foot and ankle (16.3%), elbow (12.5%), and shoulder (10.6%).
Participation Data: Seasons Played, Games Played, and Days Missed Average overall career length across all sports was 2.84 seasons. Average career length for controls was 2.86 seasons, compared with 2.50 seasons for the Knee cohort, 2.38 seasons for the ACL cohort, and 2.42 seasons for the Multiple cohort. Although there was a trend toward decreased career length in the surgery groups and specifically the Knee group (P = .059 vs controls), these were not statistically significant (Table 2). In addition, there were no differences in career length between men and women. Athletes in the control group played an average of 57.4% of games, while those in the Knee group played 54.4% of games (P = .385). Female athletes with a history of knee surgery played 53.2% of games compared with 59.8% for female athlete controls. However, this difference was not significant. Athletes in the control group missed an average of 34 days per season due to any injury. In contrast, those in the Knee and ACL groups missed 99 days (P \ .001) and
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TABLE 1 Demographics of NCAA Athletes With Prior Orthopaedic Surgery by Sporta Prior Surgery Type, No. (%) No. of Eligible Athletes Men’s sports Football Baseball Soccer Volleyball Basketball Women’s sports Soccer Softball Volleyball Gymnastics Basketball
Athletes With Prior Orthopaedic Surgery, No. (%)
301 142 58 42 34 25 155 51 28 28 27 21
64 27 14 11 8 4 40 15 1 6 16 2
(21.3) (19.0) (24.1) (26.2) (23.5) (16.0) (25.8) (29.4) (3.6) (21.4) (59.3) (9.5)
Knee Surgery 24 12 2 4 4 2 24 11 0 4 8 1
(8.0) (8.5) (3.4) (9.5) (11.8) (8.0) (15.5) (21.6) (0) (14.3) (29.6) (4.8)
ACL Reconstruction 6 (2.0) 2 (1.4) 0 (0) 2 (4.8) 2 (5.9) 0 (0) 10 (6.5) 4 (7.8) 0 (0) 2 (7.1) 3 (11.0) 1 (4.8)
Multiple Surgeries 16 7 4 1 3 1 12 3 0 3 6 0
(5.3) (4.9) (6.9) (2.4) (8.8) (4.0) (7.7) (5.9) (0) (10.7) (22.2) (0)
a
ACL, anterior cruciate ligament; NCAA, National Collegiate Athletics Association.
Figure 1. Percentage of incoming collegiate athletes with a history of single (black) or multiple (gray) orthopaedic surgeries, by sport. Number of athletes per sport is listed in parentheses. M, men’s; W, women’s.
Figure 2. Days missed per season due to any injury (black) or knee injury (gray). Error bars represent standard error of the mean. ACL, anterior cruciate ligament. *P \ .05 and # P \ .01 vs respective controls.
TABLE 2 Career Length of NCAA Athletes With a History of Orthopaedic Surgery vs Controlsa
average of 7 days due to a knee injury per season, whereas athletes in the Knee, ACL, and Multiple groups missed 45, 70, and 11 days, respectively, due to a knee injury (P \ .001 for all groups vs control). Figure 2 also shows days missed for athletes with a history of any orthopaedic surgery for comparison. Knee injuries made up nearly half of total days missed for the Knee and ACL groups. There were no differences in days missed due to any injury or knee injury between men and women.
Group Control Orthopaedic surgery Knee surgery ACL reconstruction Multiple surgeries
Career Length, Seasons, Mean 6 SD 2.86 2.79 2.50 2.38 2.42
6 6 6 6 6
1.20 1.20 1.22 1.36 1.26
P Value (vs Control)
.62 .06 .12 .13
a ACL, anterior cruciate ligament; NCAA, National Collegiate Athletics Association; SD, standard deviation.
Survival Analysis: Rate of Knee Injury and Knee Surgery
121 days (P = .016) per season, respectively, due to any injury (Figure 2). Athletes in the control group missed an
Athletes in the Knee group had a 6.8-fold increased rate of at least 1 knee injury compared with controls (95% confidence interval [CI], 3.73-12.43; P \ .001) (Figure 3A).
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Figure 3. Kaplan-Meier survival analysis of athletes who (A) sustained a knee injury or (B) underwent a knee surgery during their collegiate careers. ACL, anterior cruciate ligament. *P \ .01 vs control.
Figure 4. Average number of (A) knee surgeries and (B) magnetic resonance images (MRIs) per season. Error bars represent standard error of the mean. ACL, anterior cruciate ligament. *P \ .05 vs respective controls. Furthermore, athletes in the ACL and Multiple groups had a 19.6-fold (95% CI, 6.32-60.83) and 3.8-fold (95% CI, 1.847.66) increased rate of knee injury, respectively, compared with controls (P \ .001). The Knee group had a 14.4-fold (95% CI, 5.2-39.7) increased rate of knee surgery compared with the control group (P \ .001). Rate of knee surgery was also increased for ACL athletes (892.9-fold; 95% CI, 112.4-7097.2) and Multiple athletes (26.7-fold; 95% CI, 7.3-97.3) compared with control athletes (P \ .001). Knee surgeries made up 83.3% and 92.3% of all orthopaedic surgeries received by Knee and ACL athletes, respectively, compared with 34.4% in control athletes. Of note, there were no differences in the likelihood of knee injury or knee surgery between male and female athletes during college.
Surgeries and Diagnostic Imaging per Season Control athletes averaged 0.03 knee surgeries per athletic season (Figure 4A). In contrast, athletes in the Knee, ACL, and Multiple groups averaged 0.17, 0.24, and 0.21 knee surgeries per season, respectively (P \ .001 for all groups vs controls). Figure 4A also shows the number of knee surgeries for the Ortho group for comparison. Control athletes averaged 0.37 magnetic resonance images (MRIs) per season (Figure 4B). In contrast, athletes
in the Knee, ACL, and Multiple groups averaged 0.83, 1.29, and 0.97 MRIs per season, respectively (P \ .001, .009, and \.001 for Knee, ACL, and Multiple vs controls, respectively). Figure 4B also shows the MRIs performed for the Ortho group for comparison. Control athletes averaged 1.04 radiographs per season, while Multiple athletes required 1.51 radiographs per season (P = .044). There was no significant difference between the Knee or ACL groups versus controls for radiographs per season.
DISCUSSION While past studies have examined outcomes of athletes with a history of knee surgery entering high school and professional sports, no study to date has reported on similar outcomes in NCAA Division I collegiate athletes. These data are valuable to coaches, athletic trainers, physicians, athletes, and parents both at the high school and collegiate levels. Special challenges are present for Division I collegiate athletes. For many of the players, training intensity of collegiate athletics is greatly increased compared with high school athletics. Number and intensity of workouts increase, along with the introduction of added demands of college life. Given the paucity of literature regarding the outcomes of Division I athletes with a history of knee
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surgery, this study examined the epidemiology of incoming athletes at a single institution as well as their rate of injury, rate of surgery, and other related medical outcomes during their collegiate careers. Among matriculating athletes during the 5-year period, 23% entered college with a history of an orthopaedic surgery. A tenth of incoming athletes had a history of knee surgery, making the knee the most common previously operated joint. This is consistent with rates reported in studies of incoming professional athletes.3 Interestingly, only 3.5% of athletes had a history of an ACL tear (2.0% and 6.5% of male and female athletes, respectively). Many who sustain an ACL tear in high school may have been unable to pursue a Division I athletics career. This phenomenon was demonstrated in a study by the Multicenter Orthopaedic Outcomes Network (MOON) group,15 in which less than half of high school football athletes sustaining ACL reconstruction were able to return to their previous level of athletic participation. Other factors that may reduce the number of athletes with ACL injuries pursuing Division I athletics are the increased demand of collegiate athletics or less aggressive recruiting from college coaches because of an athlete’s injury history. Presently, the attitudes of college coaches with respect to injury history have not been studied. In the current study, women’s gymnastics and women’s soccer had the highest percentage of athletes with knee surgery before college. Knee injury rates in high school athletics have been found to be highest in football, women’s soccer, and women’s gymnastics.24 In this study, 8.5% of football athletes had a history of knee surgery, although surgery type was not available. Comparably, at the professional level, 10.3% of football athletes enter the National Football League (NFL) Combine with a history of meniscectomy, 8.2% have a history of knee arthroscopy, and 5.9% have a history of ACL reconstruction. While there was a trend toward decreased career length in the surgery groups, these trends were not significant. Previously injured collegiate football athletes who participated in the NFL Combine had a reduced likelihood of being drafted and a reduced longevity in the league.4 In particular, players with a history of meniscectomy had decreased longevity from 7.0 seasons to 5.6 seasons compared with matched controls. Furthermore, those who had combined ACL/meniscus surgery had decreased longevity from 6.1 seasons to 4.0 seasons compared with matched controls. Nevertheless, different positions in football have different physical stresses and requirements, and thus the risk of an injury and its subsequent effects may be position dependent.1,6,22 Of note, athlete attrition over 4 years was greater than 50% for all groups in this study, including controls. While the present study was unable to ascertain the cause of individual athlete attrition, medical disqualification, personal reasons, transition to a professional career, or transfer to another university are common reasons for discontinuing participation for athletes. Percentage of games played was not statistically significant between surgical groups (Knee, ACL, and Multiple) and controls, despite the substantial increase in injury and surgery rates for the former. One plausible
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explanation is the delay of surgeries until after the season, allowing athletes requiring surgeries during college to participate at a level comparable with healthy athletes. A 7% decrease in percentage games played for female athletes with a history of knee surgery compared with control athletes was observed; while this was not significant, future studies should investigate the role of sex in participation after a surgery. A study of NFL athletes demonstrated decreased games played for athletes who had had a meniscectomy or a combined meniscectomy/ACL reconstruction but not for those who had received isolated ACL reconstruction.5 In this study, athletes who had a prior meniscectomy before entering college could not be ascertained. The rate of knee injury during college was statistically increased for all surgery groups compared with controls, which is consistent with studies in high school athletes and athletes sustaining ACL tears.7,10,17 DuRant et al8 demonstrated that knee injuries were more likely to occur in athletes who had a history of knee injury or knee surgery. In this study, the Knee and ACL groups were 6.8fold and 19.6-fold more likely to sustain a knee injury than were controls. Fewer than 20% of the ACL group completed 4 years of participation without sustaining a knee injury. Serious injury is a predictor for worse quality of life in collegiate athletes,14 and while the present study looked at all minor and serious injuries, quality of life may be a consideration as previously injured athletes are looking forward to collegiate athletics. The risk of knee surgery was increased for all surgical groups compared with controls. However, analysis of athletes with a history of non–knee-related orthopaedic surgery showed no difference in the risk of surgery compared with controls. Thus, it appears that within the group of athletes with a history of surgery, those with a history of knee surgery (and especially ACL reconstruction) truly have an elevated risk of surgery. This is consistent with a study of high school athletes that showed joint-specific risks were related to prior injury on that joint.8 Athletes with a history of surgery required more MRIs and surgeries during college. The ACL group required 3 times as many MRIs per season compared with controls, the majority of which were for the knee. In addition, both ACL and Knee groups required more surgeries per season compared with controls. Within the Ortho group, the risk of surgery was not different from controls if the athlete had not had a prior knee surgery. This suggests that the Knee athletes within the Ortho group may have been contributing to the trends in increased medical intervention that were observed. Cost to the university is a significant concern for the athletic department and the university. The current study reveals significant increases in medical imaging and surgical intervention for athletes with a history of orthopaedic surgery. It is also likely that these athletes require more attention and therapy from the athletic trainers, physical therapists, and sports psychologists. Interestingly, most treatments received by collegiate athletes may be due to non–time loss injuries, which were not included in the current analysis.19 Therefore, this study may not have captured the full effect that athletes with a surgery history
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have on treatment cost. In addition, athletes on scholarship who become medically disqualified due to orthopaedic injury should be considered, since the university may be responsible for their scholarship and medical treatment throughout the athlete’s 4 years even if the athlete is not participating. There are a number of limitations to the current study. The research was performed at a single institution, reducing the generalizability to the entire NCAA population. In addition, this was a retrospective analysis of preexisting data, and thus no causality can be determined. Data for games played were available only for 86% of athletes. The Sports Injury Monitoring System may not capture every single event, but it is highly likely that major injuries to the knee and surgeries would be included. Of note, redshirt years for an athlete were included in the injury and surgery risk analysis; however, these athletes participated in fewer competitions and thus may have been at a decreased overall risk of injury. Research has shown that risk of injury is 3-fold higher during competition than during practices in collegiate athletics, and risk is even higher for contact sports such as football and soccer.9,20,22 Nevertheless, redshirt years were included for complete exposure (including practices) and injury data. Despite these limitations, this study demonstrated a significantly increased rate of knee injury and surgery during a collegiate athletic career given a prior history of knee surgery in a large cohort of Division I athletes. Moreover, these athletes tend to miss more days due to injury compared with other athletes, although differences in career length and games played were not significant. Future work will include a cost-benefit analysis and prospective data collection to more precisely examine any differences between sex, sport, and surgery type. REFERENCES 1. Badgeley MA, McIlvain NM, Yard E, Fields S, Comstock RD. Epidemiology of 10,000 high school football injuries: patterns of injury by position played. J Phys Act Health. 2013;10(2):160-169. 2. Bourke HE, Salmon LJ, Waller A, Patterson V, Pinczewski LA. Survival of the anterior cruciate ligament graft and the contralateral ACL at a minimum of 15 years. Am J Sports Med. 2012;40(9):1985-1992. 3. Brophy RH, Barnes R, Rodeo SA, Warren RF. Prevalence of musculoskeletal disorders at the NFL Combine—trends from 1987 to 2000. Med Sci Sports Exerc. 2007;39(1):22-27. 4. Brophy RH, Chehab EL, Barnes RP, Lyman S, Rodeo SA, Warren RF. Predictive value of orthopedic evaluation and injury history at the NFL Combine. Med Sci Sports Exerc. 2008;40(8):1368-1372. 5. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study. Am J Sports Med. 2009;37(11):2102-2107. 6. Brophy RH, Lyman S, Chehab EL, Barnes RP, Rodeo SA, Warren RF. Predictive value of prior injury on career in professional American football is affected by player position. Am J Sports Med. 2009;37(4):768-775.
7. Brophy RH, Schmitz L, Wright RW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med. 2012;40(11):2517-2522. 8. DuRant RH, Pendergrast RA, Seymore C, Gaillard G, Donner J. Findings from the preparticipation athletic examination and athletic injuries. Am J Dis Child. 1992;146(1):85-91. 9. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-319. 10. Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of knee injuries among boys and girls in US high school athletics. Am J Sports Med. 2008;36(6):1116-1122. 11. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan L. Preseason strength and flexibility imbalances associated with athletic injuries in female collegiate athletes. Am J Sports Med. 1991;19(1):76-81. 12. Lively MW, Feathers CC. Increasing prevalence of anterior cruciate ligament injuries in a collegiate population. W V Med J. 2012;108(4):8-11. 13. Logan M, Watts M, Owen J, Myers P. Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up. Am J Sports Med. 2009;37(6):1131-1134. 14. McAllister DR, Motamedi AR, Hame SL, Shapiro MS, Dorey FJ. Quality of life assessment in elite collegiate athletes. Am J Sports Med. 2001;29(6):806-810. 15. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40(11):2523-2529. 16. Nadler SF, Malanga GA, Feinberg JH, Rubanni M, Moley P, Foye P. Functional performance deficits in athletes with previous lower extremity injury. Clin J Sport Med. 2002;12(2):73-78. 17. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med. 2012;22(2):116-121. 18. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27(9):1275-1288. 19. Powell JW, Dompier TP. Analysis of injury rates and treatment patterns for time-loss and non-time-loss injuries among collegiate student-athletes. J Athl Train. 2004;39(1):56-70. 20. Rechel JA, Collins CL, Comstock RD. Epidemiology of injuries requiring surgery among high school athletes in the United States, 2005 to 2010. J Trauma. 2011;71(4):982-989. 21. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005; 21(8):948-957. 22. Shankar PR, Fields SK, Collins CL, Dick RW, Comstock RD. Epidemiology of high school and collegiate football injuries in the United States, 2005-2006. Am J Sports Med. 2007;35(8):1295-1303. 23. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246251. 24. Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among US high school athletes, 2005/06-2010/11. Med Sci Sports Exerc. 2013;45(3):462-469. 25. Vanderhave KL, Moravek JE, Sekiya JK, Wojtys EM. Meniscus tears in the young athlete: results of arthroscopic repair. J Pediatr Orthop. 2011;31(5):496-500.
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Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes Caitlin M. Rugg, Dean Wang, Pamela Sulzicki and Sharon L. Hame Am J Sports Med 2014 42: 959 originally published online February 11, 2014 DOI: 10.1177/0363546513519951 The online version of this article can be found at: http://ajs.sagepub.com/content/42/4/959
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
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Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes Caitlin M. Rugg,* MS, Dean Wang,* MD, Pamela Sulzicki,y MS, ATC, and Sharon L. Hame,*z MD Investigation performed at the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Background: High school and professional athletes with a history of orthopaedic surgery have decreased career lengths and are at a greater risk for reinjury compared with their peers. It is unknown whether the same risk applies to intercollegiate athletes. Purpose: To determine the effect of prior knee surgery in National Collegiate Athletic Association (NCAA) Division I athletes in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: Division I athletes who began participation in collegiate athletics at a single institution from fall 2003 to spring 2008 were identified. Athletes with a history of orthopaedic surgery were identified through preparticipation evaluation forms. Data on the number of seasons and games played, number of days missed, diagnostic imaging, athletic injuries sustained, and surgical operations during college were collected through medical records and the Sports Injury Monitoring System (SIMS). Results: During the 5-year study period, 456 athletes completed preparticipation evaluation forms. Of these, 104 athletes (22.8%) had a history of orthopaedic surgery (Ortho group). Forty-eight (10.5% of all athletes) had a history of knee surgery (Knee group), 16 (3.5%) had a history of anterior cruciate ligament reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Days missed per season due to any injury and due to knee injury were increased for all surgical groups compared with controls (P \ .016). The rate of knee injury and knee surgery while in college was significantly increased for all surgery groups. Athletes in the Knee and ACL groups were 6.8- and 19.6-fold more likely to sustain a knee injury and 14.4- and 892.9-fold more likely to undergo a knee surgery during their collegiate careers compared with controls (P \ .001). The number of MRIs per season were 0.83 for the Knee group (P \ .001), 1.29 for the ACL (P = .009), and 0.97 for the Multiple group (P \ .001), compared with 0.37 for controls. Average career length and percentage of games played were not significantly different between any of the surgery groups compared with controls. Conclusion: Athletes who had a history of knee surgery before participation in collegiate athletics miss more days due to injury, have increased rates of knee injury and knee surgery, and require more MRIs during their collegiate careers than their peers. Keywords: knee; surgery; collegiate; anterior cruciate ligament; athlete; imaging; prior injury; sports; return
Knee injuries are among the most common injuries sustained by high school and collegiate athletes and can have devastating results for individual athletes and the team.8-10,12,22,24 In the 2005-2006 and 2006-2007 school
years, knee injuries made up 15.2% of all high school sports-related injuries.9 Football, women’s soccer, and women’s gymnastics had the highest risk of knee injury in high school sports.24 In addition, Rechel et al20 reported that approximately half of all high school sports injuries that require orthopaedic surgery involved the knee. Most of these were complete ligament tears that medically disqualified athletes for the season. In recent years, an increasing number of collegiate athletes are entering college with a history of anterior cruciate ligament (ACL) tears, while more collegiate athletes are experiencing ACL tears.8,12 These athletes may have remaining functional deficits after surgery, which may predispose them to injuries when they enter college.10,11,16 Reinjury and contralateral injury after knee surgery are concerns for players and coaches alike. It has been demonstrated that patients with a history of ACL injury are at
z Address correspondence to Sharon L. Hame, MD, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, CHS 76-119, 10833 LeConte Avenue, Los Angeles, CA 90095-6902, USA (e-mail: [email protected]). *Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. y Athletic Department, University of California–Los Angeles, Los Angeles, California, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 42, No. 4 DOI: 10.1177/0363546513519951 Ó 2014 The Author(s)
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increased risk of subsequent ACL rupture on both the reconstructed and contralateral sides.2,7,17,21,23 Bourke et al2 reported a 14% and 23% risk of tearing either ACL after 5 and 15 years, respectively, after reconstruction with an autologous graft. Female sex and return to high activity may also predispose an athlete to rerupture.7,17,23 Similarly, an increasing number of collegiate athletes are entering college with a history of meniscal tears. While young athletes have improved outcomes in meniscal repairs compared with older patients, reoperation rates are still substantial.13,18,25 In a meta-analysis, 3.9% of partial meniscectomies and 20.7% of arthroscopic meniscal repairs required reoperation within 10 years of the index surgery.18 Currently, little is known about the effects of knee surgery in high school athletes and how it may affect their collegiate athletic careers. Thus, the goal of this study was to determine the athletic and medical outcomes in National Collegiate Athletic Association (NCAA) Division I athletes with a history of knee surgery at a single institution in the United States.
MATERIALS AND METHODS Institutional review board approval for this study was obtained. Athletes who underwent their initial preparticipation evaluation (PPE) and who began participation in 10 sports from fall 2003 to spring 2008 at our institution were eligible for the study. Five men’s teams (football, baseball, volleyball, basketball, and soccer) and 5 women’s teams (softball, gymnastics, volleyball, basketball, and soccer) were included in the study. Eligible athletes were identified using the institution sports archives and athletic training room records. All athletes underwent their first PPE before collegiate athletic participation by licensed physicians, and surgical histories, including any orthopaedic surgery, were identified. Returning athletes during the study period were not included in the study. Sport played, seasons played, and games played were elicited from the sports archives. Data on injury type and days missed due to injury were recorded from the Sports Injury Monitoring System (SIMS; FlanTech, Inc, Iowa City, Iowa, USA). In this system, athletic trainers recorded any medical concern as an injury if it was managed for more than 10 days and/or resulted in restriction in activity. Medical records and SIMS data were cross-referenced for diagnostic imaging and surgeries performed during college. Redshirt athletes, who are limited to less than 30% of competitions, were included for complete practice exposure data. Athletes were classified into different groups for comparison. The control group consisted of all athletes without a history of orthopaedic surgery before first collegiate PPE, whereas those athletes with an orthopaedic surgery before first collegiate PPE made up the orthopaedic surgery cohort (Ortho group). Within this group, subgroups of athletes with a history of any knee surgery (Knee group), ACL reconstruction (ACL group), and multiple orthopaedic surgeries (Multiple group) were identified. Athletes could be classified into 2 or more groups if they fulfilled the criteria. Statistical analyses were performed with GraphPad Prism 5 (GraphPad Software, La Jolla, California, USA). Two-
tailed t tests and Mann-Whitney U tests were used to compare injury groups to control for parametric and nonparametric distributions, respectively. Time-dependent analyses were completed using the Kaplan-Meier method, and curves were compared using the log-rank test. Dates of the entering PPE were used as the starting dates, and the last days of collegiate careers were censored if an athlete did not sustain a knee injury or undergo a knee surgery in college. Hazard ratios were calculated when comparing injury group survival curves to that of the Control. Significance was predefined at P \ .05.
RESULTS Demographic Data From fall 2003 to spring 2008, there were 456 athletes from 10 sports at our institution who underwent an initial PPE by a licensed physician (Table 1). Of these, 104 athletes (22.8%) had a history of orthopaedic surgery, which constituted 25.8% of female and 21.3% of male athletes. The sports with the highest percentage of incoming athletes with a history of orthopaedic surgery were women’s gymnastics (59.3%), women’s soccer (29.4%), men’s soccer (26.2%), and baseball (24.1%) (Figure 1). The sport with the smallest percentage of athletes with surgery history was softball (3.6%). Among the athletes with a history of orthopaedic surgery, 48 (10.5% of all athletes) had a history of knee surgery (Knee group). Sixteen (3.5%) had history of ACL reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Sports with the highest percentage of incoming athletes with a history of knee surgery were gymnastics (29.6%), women’s soccer (21.6%), and women’s volleyball (14.3%). Other previous surgeries involved the wrist and hand (16.3% of the Ortho group), foot and ankle (16.3%), elbow (12.5%), and shoulder (10.6%).
Participation Data: Seasons Played, Games Played, and Days Missed Average overall career length across all sports was 2.84 seasons. Average career length for controls was 2.86 seasons, compared with 2.50 seasons for the Knee cohort, 2.38 seasons for the ACL cohort, and 2.42 seasons for the Multiple cohort. Although there was a trend toward decreased career length in the surgery groups and specifically the Knee group (P = .059 vs controls), these were not statistically significant (Table 2). In addition, there were no differences in career length between men and women. Athletes in the control group played an average of 57.4% of games, while those in the Knee group played 54.4% of games (P = .385). Female athletes with a history of knee surgery played 53.2% of games compared with 59.8% for female athlete controls. However, this difference was not significant. Athletes in the control group missed an average of 34 days per season due to any injury. In contrast, those in the Knee and ACL groups missed 99 days (P \ .001) and
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TABLE 1 Demographics of NCAA Athletes With Prior Orthopaedic Surgery by Sporta Prior Surgery Type, No. (%) No. of Eligible Athletes Men’s sports Football Baseball Soccer Volleyball Basketball Women’s sports Soccer Softball Volleyball Gymnastics Basketball
Athletes With Prior Orthopaedic Surgery, No. (%)
301 142 58 42 34 25 155 51 28 28 27 21
64 27 14 11 8 4 40 15 1 6 16 2
(21.3) (19.0) (24.1) (26.2) (23.5) (16.0) (25.8) (29.4) (3.6) (21.4) (59.3) (9.5)
Knee Surgery 24 12 2 4 4 2 24 11 0 4 8 1
(8.0) (8.5) (3.4) (9.5) (11.8) (8.0) (15.5) (21.6) (0) (14.3) (29.6) (4.8)
ACL Reconstruction 6 (2.0) 2 (1.4) 0 (0) 2 (4.8) 2 (5.9) 0 (0) 10 (6.5) 4 (7.8) 0 (0) 2 (7.1) 3 (11.0) 1 (4.8)
Multiple Surgeries 16 7 4 1 3 1 12 3 0 3 6 0
(5.3) (4.9) (6.9) (2.4) (8.8) (4.0) (7.7) (5.9) (0) (10.7) (22.2) (0)
a
ACL, anterior cruciate ligament; NCAA, National Collegiate Athletics Association.
Figure 1. Percentage of incoming collegiate athletes with a history of single (black) or multiple (gray) orthopaedic surgeries, by sport. Number of athletes per sport is listed in parentheses. M, men’s; W, women’s.
Figure 2. Days missed per season due to any injury (black) or knee injury (gray). Error bars represent standard error of the mean. ACL, anterior cruciate ligament. *P \ .05 and # P \ .01 vs respective controls.
TABLE 2 Career Length of NCAA Athletes With a History of Orthopaedic Surgery vs Controlsa
average of 7 days due to a knee injury per season, whereas athletes in the Knee, ACL, and Multiple groups missed 45, 70, and 11 days, respectively, due to a knee injury (P \ .001 for all groups vs control). Figure 2 also shows days missed for athletes with a history of any orthopaedic surgery for comparison. Knee injuries made up nearly half of total days missed for the Knee and ACL groups. There were no differences in days missed due to any injury or knee injury between men and women.
Group Control Orthopaedic surgery Knee surgery ACL reconstruction Multiple surgeries
Career Length, Seasons, Mean 6 SD 2.86 2.79 2.50 2.38 2.42
6 6 6 6 6
1.20 1.20 1.22 1.36 1.26
P Value (vs Control)
.62 .06 .12 .13
a ACL, anterior cruciate ligament; NCAA, National Collegiate Athletics Association; SD, standard deviation.
Survival Analysis: Rate of Knee Injury and Knee Surgery
121 days (P = .016) per season, respectively, due to any injury (Figure 2). Athletes in the control group missed an
Athletes in the Knee group had a 6.8-fold increased rate of at least 1 knee injury compared with controls (95% confidence interval [CI], 3.73-12.43; P \ .001) (Figure 3A).
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Figure 3. Kaplan-Meier survival analysis of athletes who (A) sustained a knee injury or (B) underwent a knee surgery during their collegiate careers. ACL, anterior cruciate ligament. *P \ .01 vs control.
Figure 4. Average number of (A) knee surgeries and (B) magnetic resonance images (MRIs) per season. Error bars represent standard error of the mean. ACL, anterior cruciate ligament. *P \ .05 vs respective controls. Furthermore, athletes in the ACL and Multiple groups had a 19.6-fold (95% CI, 6.32-60.83) and 3.8-fold (95% CI, 1.847.66) increased rate of knee injury, respectively, compared with controls (P \ .001). The Knee group had a 14.4-fold (95% CI, 5.2-39.7) increased rate of knee surgery compared with the control group (P \ .001). Rate of knee surgery was also increased for ACL athletes (892.9-fold; 95% CI, 112.4-7097.2) and Multiple athletes (26.7-fold; 95% CI, 7.3-97.3) compared with control athletes (P \ .001). Knee surgeries made up 83.3% and 92.3% of all orthopaedic surgeries received by Knee and ACL athletes, respectively, compared with 34.4% in control athletes. Of note, there were no differences in the likelihood of knee injury or knee surgery between male and female athletes during college.
Surgeries and Diagnostic Imaging per Season Control athletes averaged 0.03 knee surgeries per athletic season (Figure 4A). In contrast, athletes in the Knee, ACL, and Multiple groups averaged 0.17, 0.24, and 0.21 knee surgeries per season, respectively (P \ .001 for all groups vs controls). Figure 4A also shows the number of knee surgeries for the Ortho group for comparison. Control athletes averaged 0.37 magnetic resonance images (MRIs) per season (Figure 4B). In contrast, athletes
in the Knee, ACL, and Multiple groups averaged 0.83, 1.29, and 0.97 MRIs per season, respectively (P \ .001, .009, and \.001 for Knee, ACL, and Multiple vs controls, respectively). Figure 4B also shows the MRIs performed for the Ortho group for comparison. Control athletes averaged 1.04 radiographs per season, while Multiple athletes required 1.51 radiographs per season (P = .044). There was no significant difference between the Knee or ACL groups versus controls for radiographs per season.
DISCUSSION While past studies have examined outcomes of athletes with a history of knee surgery entering high school and professional sports, no study to date has reported on similar outcomes in NCAA Division I collegiate athletes. These data are valuable to coaches, athletic trainers, physicians, athletes, and parents both at the high school and collegiate levels. Special challenges are present for Division I collegiate athletes. For many of the players, training intensity of collegiate athletics is greatly increased compared with high school athletics. Number and intensity of workouts increase, along with the introduction of added demands of college life. Given the paucity of literature regarding the outcomes of Division I athletes with a history of knee
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surgery, this study examined the epidemiology of incoming athletes at a single institution as well as their rate of injury, rate of surgery, and other related medical outcomes during their collegiate careers. Among matriculating athletes during the 5-year period, 23% entered college with a history of an orthopaedic surgery. A tenth of incoming athletes had a history of knee surgery, making the knee the most common previously operated joint. This is consistent with rates reported in studies of incoming professional athletes.3 Interestingly, only 3.5% of athletes had a history of an ACL tear (2.0% and 6.5% of male and female athletes, respectively). Many who sustain an ACL tear in high school may have been unable to pursue a Division I athletics career. This phenomenon was demonstrated in a study by the Multicenter Orthopaedic Outcomes Network (MOON) group,15 in which less than half of high school football athletes sustaining ACL reconstruction were able to return to their previous level of athletic participation. Other factors that may reduce the number of athletes with ACL injuries pursuing Division I athletics are the increased demand of collegiate athletics or less aggressive recruiting from college coaches because of an athlete’s injury history. Presently, the attitudes of college coaches with respect to injury history have not been studied. In the current study, women’s gymnastics and women’s soccer had the highest percentage of athletes with knee surgery before college. Knee injury rates in high school athletics have been found to be highest in football, women’s soccer, and women’s gymnastics.24 In this study, 8.5% of football athletes had a history of knee surgery, although surgery type was not available. Comparably, at the professional level, 10.3% of football athletes enter the National Football League (NFL) Combine with a history of meniscectomy, 8.2% have a history of knee arthroscopy, and 5.9% have a history of ACL reconstruction. While there was a trend toward decreased career length in the surgery groups, these trends were not significant. Previously injured collegiate football athletes who participated in the NFL Combine had a reduced likelihood of being drafted and a reduced longevity in the league.4 In particular, players with a history of meniscectomy had decreased longevity from 7.0 seasons to 5.6 seasons compared with matched controls. Furthermore, those who had combined ACL/meniscus surgery had decreased longevity from 6.1 seasons to 4.0 seasons compared with matched controls. Nevertheless, different positions in football have different physical stresses and requirements, and thus the risk of an injury and its subsequent effects may be position dependent.1,6,22 Of note, athlete attrition over 4 years was greater than 50% for all groups in this study, including controls. While the present study was unable to ascertain the cause of individual athlete attrition, medical disqualification, personal reasons, transition to a professional career, or transfer to another university are common reasons for discontinuing participation for athletes. Percentage of games played was not statistically significant between surgical groups (Knee, ACL, and Multiple) and controls, despite the substantial increase in injury and surgery rates for the former. One plausible
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explanation is the delay of surgeries until after the season, allowing athletes requiring surgeries during college to participate at a level comparable with healthy athletes. A 7% decrease in percentage games played for female athletes with a history of knee surgery compared with control athletes was observed; while this was not significant, future studies should investigate the role of sex in participation after a surgery. A study of NFL athletes demonstrated decreased games played for athletes who had had a meniscectomy or a combined meniscectomy/ACL reconstruction but not for those who had received isolated ACL reconstruction.5 In this study, athletes who had a prior meniscectomy before entering college could not be ascertained. The rate of knee injury during college was statistically increased for all surgery groups compared with controls, which is consistent with studies in high school athletes and athletes sustaining ACL tears.7,10,17 DuRant et al8 demonstrated that knee injuries were more likely to occur in athletes who had a history of knee injury or knee surgery. In this study, the Knee and ACL groups were 6.8fold and 19.6-fold more likely to sustain a knee injury than were controls. Fewer than 20% of the ACL group completed 4 years of participation without sustaining a knee injury. Serious injury is a predictor for worse quality of life in collegiate athletes,14 and while the present study looked at all minor and serious injuries, quality of life may be a consideration as previously injured athletes are looking forward to collegiate athletics. The risk of knee surgery was increased for all surgical groups compared with controls. However, analysis of athletes with a history of non–knee-related orthopaedic surgery showed no difference in the risk of surgery compared with controls. Thus, it appears that within the group of athletes with a history of surgery, those with a history of knee surgery (and especially ACL reconstruction) truly have an elevated risk of surgery. This is consistent with a study of high school athletes that showed joint-specific risks were related to prior injury on that joint.8 Athletes with a history of surgery required more MRIs and surgeries during college. The ACL group required 3 times as many MRIs per season compared with controls, the majority of which were for the knee. In addition, both ACL and Knee groups required more surgeries per season compared with controls. Within the Ortho group, the risk of surgery was not different from controls if the athlete had not had a prior knee surgery. This suggests that the Knee athletes within the Ortho group may have been contributing to the trends in increased medical intervention that were observed. Cost to the university is a significant concern for the athletic department and the university. The current study reveals significant increases in medical imaging and surgical intervention for athletes with a history of orthopaedic surgery. It is also likely that these athletes require more attention and therapy from the athletic trainers, physical therapists, and sports psychologists. Interestingly, most treatments received by collegiate athletes may be due to non–time loss injuries, which were not included in the current analysis.19 Therefore, this study may not have captured the full effect that athletes with a surgery history
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have on treatment cost. In addition, athletes on scholarship who become medically disqualified due to orthopaedic injury should be considered, since the university may be responsible for their scholarship and medical treatment throughout the athlete’s 4 years even if the athlete is not participating. There are a number of limitations to the current study. The research was performed at a single institution, reducing the generalizability to the entire NCAA population. In addition, this was a retrospective analysis of preexisting data, and thus no causality can be determined. Data for games played were available only for 86% of athletes. The Sports Injury Monitoring System may not capture every single event, but it is highly likely that major injuries to the knee and surgeries would be included. Of note, redshirt years for an athlete were included in the injury and surgery risk analysis; however, these athletes participated in fewer competitions and thus may have been at a decreased overall risk of injury. Research has shown that risk of injury is 3-fold higher during competition than during practices in collegiate athletics, and risk is even higher for contact sports such as football and soccer.9,20,22 Nevertheless, redshirt years were included for complete exposure (including practices) and injury data. Despite these limitations, this study demonstrated a significantly increased rate of knee injury and surgery during a collegiate athletic career given a prior history of knee surgery in a large cohort of Division I athletes. Moreover, these athletes tend to miss more days due to injury compared with other athletes, although differences in career length and games played were not significant. Future work will include a cost-benefit analysis and prospective data collection to more precisely examine any differences between sex, sport, and surgery type. REFERENCES 1. Badgeley MA, McIlvain NM, Yard E, Fields S, Comstock RD. Epidemiology of 10,000 high school football injuries: patterns of injury by position played. J Phys Act Health. 2013;10(2):160-169. 2. Bourke HE, Salmon LJ, Waller A, Patterson V, Pinczewski LA. Survival of the anterior cruciate ligament graft and the contralateral ACL at a minimum of 15 years. Am J Sports Med. 2012;40(9):1985-1992. 3. Brophy RH, Barnes R, Rodeo SA, Warren RF. Prevalence of musculoskeletal disorders at the NFL Combine—trends from 1987 to 2000. Med Sci Sports Exerc. 2007;39(1):22-27. 4. Brophy RH, Chehab EL, Barnes RP, Lyman S, Rodeo SA, Warren RF. Predictive value of orthopedic evaluation and injury history at the NFL Combine. Med Sci Sports Exerc. 2008;40(8):1368-1372. 5. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study. Am J Sports Med. 2009;37(11):2102-2107. 6. Brophy RH, Lyman S, Chehab EL, Barnes RP, Rodeo SA, Warren RF. Predictive value of prior injury on career in professional American football is affected by player position. Am J Sports Med. 2009;37(4):768-775.
7. Brophy RH, Schmitz L, Wright RW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med. 2012;40(11):2517-2522. 8. DuRant RH, Pendergrast RA, Seymore C, Gaillard G, Donner J. Findings from the preparticipation athletic examination and athletic injuries. Am J Dis Child. 1992;146(1):85-91. 9. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-319. 10. Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of knee injuries among boys and girls in US high school athletics. Am J Sports Med. 2008;36(6):1116-1122. 11. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan L. Preseason strength and flexibility imbalances associated with athletic injuries in female collegiate athletes. Am J Sports Med. 1991;19(1):76-81. 12. Lively MW, Feathers CC. Increasing prevalence of anterior cruciate ligament injuries in a collegiate population. W V Med J. 2012;108(4):8-11. 13. Logan M, Watts M, Owen J, Myers P. Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up. Am J Sports Med. 2009;37(6):1131-1134. 14. McAllister DR, Motamedi AR, Hame SL, Shapiro MS, Dorey FJ. Quality of life assessment in elite collegiate athletes. Am J Sports Med. 2001;29(6):806-810. 15. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40(11):2523-2529. 16. Nadler SF, Malanga GA, Feinberg JH, Rubanni M, Moley P, Foye P. Functional performance deficits in athletes with previous lower extremity injury. Clin J Sport Med. 2002;12(2):73-78. 17. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med. 2012;22(2):116-121. 18. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27(9):1275-1288. 19. Powell JW, Dompier TP. Analysis of injury rates and treatment patterns for time-loss and non-time-loss injuries among collegiate student-athletes. J Athl Train. 2004;39(1):56-70. 20. Rechel JA, Collins CL, Comstock RD. Epidemiology of injuries requiring surgery among high school athletes in the United States, 2005 to 2010. J Trauma. 2011;71(4):982-989. 21. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005; 21(8):948-957. 22. Shankar PR, Fields SK, Collins CL, Dick RW, Comstock RD. Epidemiology of high school and collegiate football injuries in the United States, 2005-2006. Am J Sports Med. 2007;35(8):1295-1303. 23. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246251. 24. Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among US high school athletes, 2005/06-2010/11. Med Sci Sports Exerc. 2013;45(3):462-469. 25. Vanderhave KL, Moravek JE, Sekiya JK, Wojtys EM. Meniscus tears in the young athlete: results of arthroscopic repair. J Pediatr Orthop. 2011;31(5):496-500.
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