C L I N I C A L F E AT U R E S

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Factors Affecting Return to Play After Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature

DOI: 10.3810/psm.2014.11.2093

Matthew Bauer, BS 1 Brian T. Feeley, MD 2 John R. Wawrzyniak, MS, PT, ATC, CSCS 1 Gregory Pinkowsky, MD 1 Robert A. Gallo, MD 1 1 Department of Orthopaedic Surgery, Pennsylvania State University College of Medicine, Hershey, PA; 2Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, CA

Abstract: Anterior cruciate ligament reconstruction has been reported to produce normal or near-normal knee results in . 90% of patients. A recent meta-analysis suggested that, despite normal or near-normal knees, many athletes do not return to sports. Rates and timing of return to competitive athletics are quite variable depending on the graft type, the age of the patient, the sport, and the level of play. Even when athletes do return to play, often they do not return to their previous level. Graft failure, subjective physical factors, and psychological factors, including fear of reinjury and lack of motivation, appear to play a large role in patients’ ability to return to sporting activities. Keywords: anterior cruciate ligament; knee injury; sports performance; athletic performance

Introduction

Anterior cruciate ligament (ACL) reconstruction has been reported to produce normal or near-normal knee results in over 90% of patients.1 A recent meta-analysis suggested that, despite normal or near-normal knees, many athletes do not return to sports.1 This article reviews (1) the biology of graft healing, (2) the criteria used to determine return to play, (3) return to play rates based on personal characteristics, (4) the reasons athletes do not return to play, and (5) graft re-tears.

Materials and Methods

The literature from 1970 through March 2014 was searched using the terms anterior cruciate ligament reconstruction and outcomes, ligamentization, biology, graft healing, return to play, and return to sports. Sources included Medline, Google Scholar, and Ovid. Sources that were original prospective, randomized studies or reviews that were meta-analyses or systematic reviews were preferred and emphasized.

Biology of ACL and Graft Healing Correspondence: Robert A. Gallo, MD, Assistant Professor, Sports Medicine, Penn State Hershey Bone and Joint Institute, 30 Hope Drive, Building B, Suite 2400, Hershey, PA 17033-0850. Tel: 717-531-5638 Fax: 717-531-0498 E-mail: [email protected]

The ACL is an intra-articular, extrasynovial ligament. Unlike extra-articular ligaments such as the medial collateral ligament, the ACL has limited ability to heal spontaneously if torn. The differences in healing potential between intra-articular and extra-articular ligaments are not completely understood but may be related to differences in ligament structure, local environment, and cellular properties. When most ligaments tear, a local hematoma forms, prompts an inflammatory response, and gradually is replaced by granulation or fibrous tissue to form a scar. When the ACL is torn, the bleeding

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generated from the torn surfaces of the ligament does not congeal into a hematoma; rather, blood dissipates through the knee joint and creates a diffuse hemarthrosis. Therefore, no bridging of torn ends of the ACL occurs and no scaffold is available for repair and remodeling. These factors contribute to the unlikely healing of ACL tears if left untreated. Over 3 decades ago, attempts were made to repair the ACL. However, overall repair yielded unpredictable outcomes, and failure was reported in 50% to 90% of patients.2,3 Unpredictable results combined with reported 90% normal or near-normal knees following ACL reconstruction have prompted surgeons to favor ACL reconstructions over repair.1 All currently available tissue used for ACL reconstruction is tendinous and, therefore, once implanted, must undergo a series of changes, termed “ligamentization,” that transform its physical properties to those more similar to ligaments.4 During this process, the graft heals via creeping substitution, in which the graft undergoes necrosis, is repopulated by fibroblasts, and eventually remodels over time.5 The period of necrosis ensues over the first 3 weeks and leaves the graft most vulnerable to injury.6 Next, an inflammatory response occurs with the presence of macrophages and neutrophils, which release cytokines into the local environment.7 During this stage of healing, roughly 4 to 6 weeks postoperatively, these inflammatory cells prompt the repopulation of the graft with fibroblasts.8 Shortly thereafter, the graft undergoes revascularization through angiogenesis, as vascular synovial tissue initially penetrates the periphery and moves toward the center of the graft between 6 and 8 weeks postoperatively.9 The last stage of ACL graft incorporation is the process of remodeling, during which the graft metamorphoses and alters its collagen and proteoglycan components over a period of up to 9 years postoperatively in allograft tissues.10 At 9 months, tendon autografts are usually “mature” and share properties similar to a native ligament.10 Although advantageous because of the lack of donor-site morbidity and less painful postoperative rehabilitation,11 allografts may have biological disadvantages and have shown slower incorporation rates compared with autografts.12 In addition to the process of ligamentization, graft adherence to the walls of the bone tunnel is required for successful ACL reconstruction. The type of bond formed depends on graft type, that is, graft using a bony plug (eg, patellar tendon) or soft tissue exclusively (eg, hamstrings). Patellar tendon auto- or allograft heals with direct bone-to-bone healing. Histological studies have demonstrated that the bone plug is subjected to initial osteonecrosis and hypocellularity, 72

followed by revascularization, fibroblast invasion, and collagen synthesis, with subsequent rapid incorporation with the surrounding bone within 6 to 12 weeks.13 Soft tissue grafts heal differently from those of the tunnel walls. The normal direct insertion site of the native ACL consists of 4 layers: ligament, nonmineralized cartilage, mineralized cartilage, and bone. This arrangement distributes the stress in the ligament to the subchondral bone. Conversely, ACL soft tissue tendon graft heals with an indirect insertion site; that is, the fibers run obliquely from the tendon to the bone. Following graft insertion, a fibrovascular scar is formed between the graft and the bone tunnel. Bone progressively ingrows into this scar tissue and eventually strengthens over time.

Criteria for Return to Play

Return to play following ACL reconstruction is often based on temporal or functional objective parameters. Based on the biology of healing of ACL graft and ligamentization that occurs during graft maturation, many surgeons delay the patient’s return to play based solely on the factor of time,14 generally delaying the return for 6 to 12 months postoperatively. Surprisingly, 40% of surgeons queried did not use any structured criteria to determine unrestricted return to play.14 There is increasing evidence that return to play is not as automatic as many assume.1 Indeed, compliance with rehabilitation and the requisite time delay does not guarantee the return to sports. Furthermore, reinjury and the need for additional surgery are not uncommon. Hettrich et al15 reported that at a 6-year follow-up on 980 athletes who underwent ACL reconstruction, 18.9% had additional procedures on the same reconstructed knee. Of these patients, 7.7% had a revision ACL reconstruction and 6.4% underwent an ACL reconstruction on the contralateral knee. Objective criteria have been suggested as an alternative to temporal factors. Quadriceps and hamstring strength, instrumented knee stability, functional tests, and attainment of proprioceptive skills are all commonly used parameters to assist in decision to return to unrestricted activity. Table 1 lists commonly used criteria guiding the return to play. However, only 35% to 40% of surgeons rely solely on objective parameters to guide their decision on when to permit return to play.14,16 Traditionally, instrumented knee laxity has been used to assess the amount of objective stability following ACL reconstruction. However, instruments used to determine stability (eg, the xxxKT-1000 arthrometer) generally only

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Factors Affecting Return to Play After ACL Reconstruction

Table 1.  Commonly Used Criteria for Return to Play Parameter

Threshold Value for Return to Play

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Stability (Davies et al75)

KT-2000 , 3 mm of excursion compared with the uninjured knee Isokinetic testing (Wilk et al76) Quadriceps bilateral comparison . 80% at 180° per second Hamstring bilateral comparison . 110% at 180° per second Quadriceps peak torque-to-body weight ratio . 55% at 180° per second Hamstring to quadriceps ratio . 70% at 180° per second Functional testing (Myer et al24) Single-leg single hop . 90% contralateral limb Single-leg triple hop . 90% contralateral limb

test anterior-posterior laxity and largely ignore rotational instability, which some cite as a key determinant of subjective stability.17 Furthermore, several studies have questioned the accuracy of instrumented tests in detecting instability.18–20 Isokinetic testing has fallen out of favor in recent years but has been shown to be an objective, valid, and reliable tool in assessing an athlete’s quadriceps and hamstring strength prior to return to play.21 Studies have demonstrated that postoperative isokinetic quadriceps strength of the operative knee have a positive association with patient-reported functional outcome after ACL reconstruction.22,23 Functional tests, such as single-leg single and triple hop tests, are widely used due to their simplicity and lack of requirement for additional equipment. The single-leg single hop and triple hop tests for distance, the X hop test, and timed hop tests have all been clinically validated and correlated with self-reported measures.24,25 Jarvela et al26 demonstrated that the 1-legged single hop test for distance correlated well with more sophisticated isokinetic testing, especially when performed in full extension. Similarly, Schmitt et al27 reported that individuals who performed superiorly on hop testing demonstrated greater levels of quadriceps femoris strength and performed at the same level as uninjured control subjects. Disruption of the ACL has been associated with impaired joint position sense.28 Joint position sense may remain altered despite return to normal functional tests and isokinetic strength.29 Recently, an 8-week course of whole-body vibration therapy, initiated for 1 month and geared to improve proprioception, was shown to improve postural control, isokinetic performance, single-legged hop, and shuttle run but had no significant effect in knee joint position sense and stability.30

Return to Play After ACL Reconstruction

For athletes, both competitive and recreational, the goal of ACL reconstruction is to return to play as soon as possible. Many studies show rates of athletes returning to preinjury sport activities at , 50%, even after lengthy follow-up. In a study of bilateral ACL injuries using unilateral ACL reconstruction as a control, 43% of control patients returned to play, with only 28% returning to the same preinjury activity level.31 Ardern et al32 found that 46% of 196 athletes involved in competitive sports returned to play 39 months after surgery. Of all 314 study participants involved from competitive sport to just practice, only 140 (45%) athletes had returned to the preinjury level participation.32 In a meta-analysis from 2011, return to competitive sport rate was 44% (from 17 studies). The mean return to play times varied widely from 4.1 months when measured as resuming sport training, to 7.3 months when measured as return to any sport, and to 36.7 months after surgery for return to competitive sport. The range stems from the differences in each study’s definition of return to play.1 By 12 months postoperation, 1 study reported that 67% of patients had attempted some level of sports training, with only 33.4% of all patients returning to full preinjury level of competition.33 Return to play rates among different grafts used in reconstruction are variable but can be determined, whereas age and sex differences in return to play are harder to determine. Studies focused on athletes in particular sports show much higher return to play percentages.

Graft Type

Many studies have compared patellar tendon autografts with other graft types, including a meta-analysis that showed no significant differences in return to play between patellar and hamstring tendon autograft cohorts. However, this study did not exclusively include athletes, for whom the return to play is most important.34 Individual studies comparing time and rates of return to play between patellar tendon and hamstring autografts are conflicting. Zaffagnini et  al35 found that patients who underwent reconstruction using patellar tendon autograft had a mean return to play of 6.6 months, which was statistically slower than those receiving hamstring tendon autografts who returned at a mean 3.8 months.35 Conversely, in 2 small cohort studies, no significant difference was found in return to play times of patellar and hamstring autografts.36,37 In a study of 60 sports-playing males, rates of return to play between patellar and hamstring tendon autograft patients were not significantly different,38 whereas in a study of females with

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hamstring or patellar tendon autografts, a significantly higher number of hamstring autograft patients returned to preinjury sport activity scores.39 Studies regarding return to play after autograft versus allograft reconstruction are likewise varied. In 3 studies pooled in a meta-analysis, no difference in return to play existed among 349 patients who received either a patellar tendon autograft or a patellar tendon allograft.40 In another meta-analysis of patellar tendon autografts and allografts, pooled data from 17 studies showed that after 71.3 months for autograft patients and 68.1 months for allograft patients, 57.1% and 68.3%, respectively, had returned to preinjury activity level. The odds ratio significantly favored the allograft patients.41 In a quadriceps tendon autograft study of 34 patients with a wide range of preinjury athletic activity, 18 participated in preinjury strenuous activities and 17 of them returned to strenuous activities within a 7-year follow-up.42 There are no significant data that show the superiority of a single graft type in regard to return to play (Table 2).

Age

Changes including less motivation; decreased mobility, flexibility, and strength; and less opportunity for competitive sports play in older patients make it difficult to isolate the differences in return to play among different age cohorts. In a small study of patients aged . 55 years, only 28.6% had the same Tegner score postoperatively as they had preinjury.43 In a meta-analysis of patients aged . 40 years who underwent ACL reconstruction, the majority of patients returned to preinjury activity levels; these patients were not involved in competitive level sports, however, and none had a reported preinjury Tegner score level . 6.44 When analyzing a small group of 55 adolescent and young adult patients (aged 13−20 years), 59% of athletes returned to sport by 6 months, with some returning as early as 3 months.45 In a small study among patients with preactivity Tegner scores . 5, age was not significantly different in those returning to play compared with those not returning

to the same level of sports activity.46 However, in a larger cohort study involving only athletes, the return to play rate was significantly affected by age: the highest rate was found in the 18- to 25-year age group (57%). The , 18-year age group also had a significantly higher return to play rate of 49% than the older 2 cohorts of 25 to 32 years (44%) and  . 32 years (33%).32 The data suggest that younger patients have higher return to play rates, but there are many confounding factors.

Sex

Sex differences in rates of return to play are not evident. In separate studies comparing graft types, an average of 54.8% of 60 male athletes returned to playing sports,38 whereas 46.5% of highly active, though not necessarily sportsplaying, females returned to preinjury activity.39 There was a wide range in return to play rates between graft type for the female study and a narrow range of return to play in the study of male athletes in regard to the different graft types. Of significance, at 12 months’ follow-up, 37% of men had attempted to return to play compared with only 26% of women.33 However, there was no sex difference in return to play at 2- to 7-year follow-up.1 These findings are consistent with Thing’s47 qualitative conclusion that female athletes take longer to return to play than male athletes after ACL injury. Another study of exclusively soccer players reached a similar conclusion regarding sex and return to play.48

Sport

Return to play rates are available for most popular contact and pivot sports but are lacking for other, less popular contact sports. The data are difficult to pool for meta-analysis because of varied reporting techniques and outcomes. In a study of 100 soccer players, 72% returned to play at an average of 12.2 to 14.3 months after ACL reconstruction.48 Another study of 50 male and female soccer players who all returned to play showed a faster time to return of 185 days.49 For 18 female WNBA players, the return to play rate following ACL reconstruction was 78%50 compared with 78% to 98%

Table 2.  Return to Play Rates Based on Graft Type Graft Type

Return to Play Rate

Patellar tendon autograft Hamstring autograft Patellar tendon allograft

33%-57.1% (Mascarenhas et al, Dauty et al, Siebold et al,39 Krych et al,40 Krauetler et al41) 43%-60% (Mascarenhas et al,37 Dauty et al,38 Siebold et al39) 68.3% (Krauetler et al41)

Quadriceps tendon autograft

94.4% (Chen et al42)

74

Return to Play Time 37

38

6.6-71.3 months (Zaffagnini et al,35 Krauetler et al41) 3.8 months (Zaffagnini et al35) 8.9-68.1 months (Krauetler et al,41 Chen et al,42 van Eck et al72) Within 7 years (Chen et al42)

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Factors Affecting Return to Play After ACL Reconstruction

of NBA players.51,52 Although most NBA players return to play within a year of surgery, performance (games per season, points and rebounds per game, and field goal percentage) significantly declined after the injury, although not significantly different from that of controls.51 Male rugby players had the highest return to play rate of all sports: all 18 professional and nonprofessional players studied returned to the sport within 2 years of ACL reconstruction.53 Table 3 shows higher return to play rates in studies involving specific athletes than in studies with a broader patient population. Football has been the most thoroughly studied sport with regard to return to play, and, not surprisingly, the findings parallel those of other sports. The return to play rate of mixed high school/collegiate football athletes was 66%,54 whereas for 49 NFL players the return to play rate was 63%, with an average time of 10.8 months.55 A lower number in the initial draft round and less experience have been suggested as predictors for the inability to return to play among NFL players undergoing an ACL reconstruction.55 Even among those returning to football following ACL reconstruction, many players demonstrate a decrease in performance. In a study by McCullough et al,54 only 45% and 38% of high school and college players, respectively, returned to play at their preinjury level after surgery. Professional football players, especially skill-position players, are not exempt from a decline in performance; 80% of NFL running backs and wide receivers return to play by an average of 55 weeks, but their performance was reduced by 30%.56

Factors Limiting Return to Play

Objective clinical markers, such as laxity and strength, generally indicate that ACL reconstructions yield normal or near-normal knee function in 90% of patients.1 Despite the apparent success of ACL reconstruction, only 82% of patients resume some kind of sports participation, and a paltry 63% return to preinjury sporting levels according to a large meta-analysis.1 Furthermore, associated factors such as the condition of the articular cartilage and menisci and the normalcy of the contralateral knee, have been shown not

to be predictive of activity level at 2 years.57 These findings suggest that factors other than objective physical parameters contribute to a patient’s ability to return to play after ACL reconstruction. Subjective physical parameters, such as persistent knee symptoms and fear of reinjury, have been cited as the most common cause limiting return to play.58 In a cohort of those who did not return to previous sports levels, 68% reported persistent knee symptoms and 52% admitted fear of reinjury as reasons contributing to their decision. Among physical parameters, the presence of postoperative knee effusion, subjective instability, pain, decreased tibial rotation, and decreased quadriceps strength have all been associated with a lower likelihood to return to sports.46,59 In addition to fear of reinjury, limited ability/talent, advice from physician, and lack of motivation have all been postulated to contribute to the inability to return to the previous sports level.1,55 Although most studies cite fear of reinjury as the primary reason among those not returning to sport,59,60 many of the factors cited above may overlap. For instance, many patients who underwent an ACL reconstruction not only fear re-tearing it, but, more importantly, fear the consequences, such as lost income or the inability to perform at the desired level.61 Personality traits have been shown to affect the likelihood to return to play; the traits associated with not returning to play are cautiousness, having a relaxed outlook, pessimism, and a lack of self-confidence and selfmotivation.60,62 The common perception after ACL reconstruction is that athletes, especially high-level athletes, are able to return to their previous level of play. As discussed earlier, in elite professional athletes, the return to play rates are actually lower than commonly perceived. Thus, it may be beneficial to proactively discuss with the patient the goals of the ACL reconstruction before surgery, and to develop a return to play plan that includes psychological evaluation and counseling in those who wish to return to play. Tools such as the Tampa Scale of Kinesiophobia,63,64 which has been used in some studies to assess return to play capabilities,60 may be

Table 3.  Return to Play Rates and Times for Different Sports Sport

Return to Play Rate

Return to Play Time

Men’s soccer (Brophy et al48) Women’s soccer (Brophy et al48) Football Women’s basketball (Namdari et al50) Men’s basketball Men’s rugby (Fabbriciani et al53)

76% 67%

7.3-10.2 months 15.0-20.3 months 10.8 months (McCullough et al54) Not reported 325 days (Busfield et al52) Not reported

63%-66% (McCullough et al,54 Shah et al55) 78% 78%-98% (Harris et al,51 Busfield et al52) 100%

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beneficial to utilize during the recovery period to help guide motivated patients back to sports.

Figure 1.  Tunnel malposition is a common technical cause of ACL graft failure. (A) An anteriorly placed femoral tunnel may cause graft impingement on the roof of the intercondylar notch. (B) A vertical femoral tunnel may correct anterior translation of the tibia but may lead to residual rotational instability.

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Re-Tears: How and When Do They Occur?

Despite the overall success rate of ACL reconstruction, a significant percentage of patients have a reinjury. In most studies, the re-tear rate after ACL reconstruction is between 7% and 15%,65 and as high as 30% in studies evaluating the use of allograft tissue in young athletes. Two distinct categories of re-tears are (1) those reconstructions that fail immediately before a true return to sports, and (2) those that fail after an established period of time. In those suffering an early re-tear, the common causes are technical error, failure of graft incorporation (especially in allografts), and premature return to sports. The most common cause of ACL failure is technical error at the time of surgery, with the femoral tunnel placed either too far anterior or vertical in the tunnel as the primary cause of failure (Figure 1).66–68 In many of these patients, failure occurs within the first 2 months following return to sports activities, either with an acute reinjury or with a feeling of subjective instability. Young patients who undergo allograft reconstruction are at an increased risk of failure, often due to a failure of incorporation of the graft. Although large meta-analyses have shown similar failure rates across broad populations,69,70 when young populations are studied, allografts have a significantly higher failure rate (10%) than autografts (5%).71 One important factor to consider in patients who do elect to have an allograft reconstruction is the timing of return to play. Van Eck et al72 recently reviewed predictors of failure after allograft reconstruction. In this study, 27 of 206 (13%) had a failure at an average of 303 days after surgery. Half of these patients failed before 9 months, before they had been formally cleared to play, and 6 more failed in the first 3 months after returning to play. It may be prudent to consider a slower rehabilitation program for patients who undergo allograft reconstruction to decrease the risk of early re-rupture. Several recent studies have used population-based ACL registries to address the survival of primary ACL reconstructions. Wasserstein et al73 evaluated risk factors for recurrent ACL reconstruction using a large population database with 12 967 procedures. Over a 5-year period, the failure rate was low, 2.6%, and the authors found that grafts ruptured at a linear rate of approximately 0.5% per year. A similar study using the Norwegian Cruciate Ligament Registry compared the risk of revision in patients who had hamstring or patella tendon reconstruction.74 The overall revision rate was higher 76

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Factors Affecting Return to Play After ACL Reconstruction

in patients who had a hamstring reconstruction.74 Almost 50% of these patients had suffered a re-tear within the first year after returning to sports.74 The rate of re-tear after the second year was linear at approximately 1% per year.74

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Conclusion

Following reconstruction, the graft undergoes ligamentization, a process that takes about 9 months until the tendon graft assumes properties resembling native ligament.10 For some surgeons, the return to play is time-dependent, based on this biology of healing, whereas others rely on the athlete achieving functional goals prior to clearance.16 Half of re-tears occur within the first year following reconstruction.74 Rates and timing of return to competitive athletics are quite variable, depending on the graft type, the age of the patient, the sport, and the level of play.1,31–33,35–55,59 Even when athletes do return to play, often they do not return to their previous level.32,51,54,55,59 Graft failure, physical factors, and psychological factors, including fear of reinjury and lack of motivation, can all play a role in the patient’s ability to return to sports activities.

Conflict of Interest Statement

Matthew Bauer, BS, Brian T. Feeley, MD, Gregory Pinkowsky, MD, and Robert A. Gallo, MD, have no conflict of interest to declare. John R. Wawrzyniak, MS, PT, ATC, CSCS, is a shareholder in Ridonk, LLC.

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Factors affecting return to play after anterior cruciate ligament reconstruction: a review of the current literature.

Anterior cruciate ligament reconstruction has been reported to produce normal or near-normal knee results in > 90% of patients. A recent meta-analysis...
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