25-year results after anterior cruciate ligament reconstruction with the use of a patellar tendon autograft

Abstract

Background: Only a few studies of ACL reconstruction with >20 years of follow-up exists. It is still a pause in the literature concerning the patient’s further sports participation and long-term subjective and objective outcome after surgery.

Purpose: To report return to sports rate, the length of the sports career and the risk of reinjury after ACL reconstruction in pivoting sports athletes. Furthermore, to evaluate subjective and objective outcome and assess risk factors of knee OA at median 25 years after ACL reconstruction with a bone-patellar tendon-bone autograft.

Methods: Unilateral ACL reconstructions performed at “Kysthospitalet i Hagevik” from 1987 to 1994 were included. A prospective evaluation with clinical testing and questionnaires (PROMSs) were included at the 3, 6, 12 and 24-month follow-up. The median 25-year follow-up also included an evaluation of radiographs.

Results: Paper I: Although 83% of patients returned to pivoting sports after early ACLR, only 53% returned to preinjury level. The pooled reinjury rate after return to preinjury level of sports was 41% (30% contralateral injuries and 11%, revision surgery). Paper II: Five slightly loose grafts (28%) and 6 tight grafts (5%) were classified as failures after 2 years (P = .002). Thirty percent of patients with slightly loose grafts and 6% with tight grafts had undergone revision (P = .004) by follow-up (25 years, range, 22-30 years). Paper III: Sixty percent (141/235) of patients had radiographic osteoarthritis (OA) in the involved knee and 18% (40/227) in the contralateral knee at the long-term follow-up (P<0.001). Medial (OR 1.88 (95% CI, 1.03-3.43)) and lateral (OR 1.96 (95% CI 1.05-3.67)) meniscus surgery were independently associated with OA development.

Conclusions: The subjective and objective outcomes after ACL reconstruction are generally good 25 years after surgery. However, an ACL reconstruction does not necessarily enable a return to preinjury sports participation. Return to sports also come with a prize as athletes returning to pivoting sports are facing a worryingly high risk of contralateral ACL injuries. Moreover, despite undergoing ACL surgery, a high incidence of OA development was seen 25 years after surgery in the current thesis.

Implications: Rupture of the ACL is a severe injury, and an ACL reconstruction does not necessarily reestablish the patients prior knee function and long-term knee health. Therefore, it is important to focus on preventive strategies to reduce ACL injuries. When an ACL injury has happened, patients should be informed about the surgical aspects, the return to sport rates, the risk of reinjuries and long-term outcome so as to be able to make informed decisions about their ACL treatment and further sports participation.