DETERMINANTS OF RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

To systematically review and meta-analyze the performance of return to play (RTP) and non-RTP patients in different assessment tools after anterior cruciate ligament reconstructions (ACLR).

Methods:

Out of 182 studies searched on PubMed, 11 presented RTP and non-RTP groups assessing the performance of young individuals, practitioners of different sports, with different tools.

Results:

There was higher limb symmetry (7.13% [95%CI 4.55; 9.70], p < 0.001), Tegner activity scale (2.41 [95%CI 0.18; 4.64], p = 0.03), functional scores such as International Knee Documentation Committee (x7.44 [95%CI 4.69; 10.19], p < 0.001), Knee Osteoarthritis Outcome score for quality of life (14.75 [95%CI 10.96; 18.54], p < 0.001) and for sports/recreation (11.86 [95%CI 8.87; 14.86], p < 0.001); and lower knee laxity (-0.25 mm [95%CI -0.36; -0.14], p < 0.001) in RTP compared to non-RTP patients following ACLR.

Conclusion:

We confirmed that these different tools can differentiate RTP for non-RTP patients, which may contribute to the physician’s decision about the ideal time for RTP. Level of Evidence III, Systematic review of Level III studies.

Keywords:
Anterior Cruciate Ligament Reconstruction; Sports; Arthroplasty; Knee

First author, year (subgroup)	Gender. Group age (y). Level of play before injury. Time to RTP	Graft type	Exclusion criteria	RTP criteria
Burland et al. ¹⁷17. Burland JP, Kostyun RO, Kostyun KJ, Solomito M, Nissen C, Milewski MD. Clinical outcome measures and return-to-sport timing in adolescent athletes after anterior cruciate ligament reconstruction. J Athl Train. 2018;53(5):442-51.	Both. 15.9 ± 1.8 (non-RTP 15.6 ± 1.9). NR. Time to RTP: 7.4 ± 1.9 mo.	Hamstrings autograft.	≥19y of age. Failed to follow up. Had a previous surgery on the contralateral knee. Had reconstructive surgery with a bonepatellar tendon-bone graft. Underwent a revision surgery. Sustained a multiligamentous injury.	Full pain-free range of motion; resolution of joint effusion; an LSI of 80% for quadriceps isometric and isokinetic testing at 180°/s; and a satisfactory score on the Noyes hop test.
Fältström et al. ¹⁸18. Fältström A, Hägglund M, Kvist J. Factors associated with playing football after anterior cruciate ligament reconstruction in female football players. Scand J Med Sci Sport. 2016;26(11):1343-52.	Women. 20.1 ± 2.3 (non-RTP 20.8 ± 3.0). Elite; Sub-elite; Recreational level. Time to RTP: 6 to 36 mo.	Hamstrings; pattelar tendon; others.	Had returned to football but were not currently playing. Just played football at the injury occasion. Have never played football. Bilateral ACL injury. Re-rupture or revision ACLR. Still under rehabilitation.	Currently playing football after ACLR (training with the team) and currently playing at any level at the time of follow-up (current players).
Takazawa et al. ¹⁹19. Takazawa Y, Ikeda H, Saita Y, Ishijima M, Nagayama M, Kaneko H, et al. Case series: revision anterior cruciate ligament reconstructions using patellar tendon autografts. Knee. 2015;22(6):569-73.	Both. 24.0 ± 4.0 (non-RTP 27.1 ± 6.7). NR. Time to RTP: 38.2 ± 10.2 mo.	Primary ACLR: Hamstring-single bundle; Hamstring-double bundle; Iliotibial tract; and Artificial. Revision ACLR: BPTB patellar tendon autografts.	History of previous revision reconstruction. Reason not otherwise described, including not using BTPB gratfs. High tibial osteotomy was needed after surgery. Tegner activity scale was less than 4.	Full postoperative rehabilitation program had been completed, and the patients had achieved a full range of knee motion and adequate knee stability.
Hamrin Senorski et al. ¹⁶16. Hamrin Senorski E, Samuelsson K, Thomeé C, Beischer S, Karlsson J, Thomeé R. Return to knee-strenuous sport after anterior cruciate ligament reconstruction: a report from a rehabilitation outcome registry of patient characteristics. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1364-74. (Men)	Men. 23.7 ± 4.5 (non-RTP 23.3 ± 4.2). Knee-strenuous sports. Time to RTP: 10.2 ± 3.1 mo (non-RTP 9.8 ± 3.4 mo).	NR	Follow up other than 6-18 months. Tegner Activity Scale < 6. Still in rehabilitation.	Patients who had returned to their pre-injury level Tegner ± 1 but a minimum of Tegner 6, and two, patients who had returned to a Tegner of 6 or higher.
Hamrin Senorski et al. ¹⁶16. Hamrin Senorski E, Samuelsson K, Thomeé C, Beischer S, Karlsson J, Thomeé R. Return to knee-strenuous sport after anterior cruciate ligament reconstruction: a report from a rehabilitation outcome registry of patient characteristics. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1364-74. (Women)	Women. 20.8 ± 3.0 (non-RTP 21.4 ± 3.8). Knee-strenuous sports. Time to RTP: 10.1 ± 3.1 mo (*non-RTP 10.8 ± 3.7 mo).	NR	Follow up other than 6-18 months. Tegner Activity Scale < 6. Still in rehabilitation.	Patients who had returned to their pre-injury level Tegner ± 1 but a minimum of Tegner 6, and two, patients who had returned to a Tegner of 6 or higher.
McCullough et al. ²⁰20. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, et al. 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):2523-9. (High School)	NR	Autograft, allograft.	Multi-ligament injuries.	NR
McCullough et al. ²⁰20. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, et al. 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):2523-9. (College)	NR	Autograft, allograft.	Multi-ligament injuries.	NR
Müller et al. ²¹21. Müller U, Krüger-Franke M, Schmidt M, Rosemeyer B. Predictive parameters for return to pre-injury level of sport 6 months following anterior cruciate ligament reconstruction surgery. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3623-31.	Both. 31.4 ± 10.3 (non-RTP 33.0 ± 10.5). Level I or level II recreational sports. Time to RTP: 9.2 ± 3.1 wk (*non-RTP: 10.8 ± 4.1 wk)	Hamstring graft.	Concomitant injuries, such as injuries involving lateral ligaments or menisci, adjacent joints (hip or foot) or the contralateral leg. Patients with other orthopaedic, internal, neurological or psychiatric diseases, as well as pregnant women.	At the 6-month surgeon's examination, the operated knee joint had to be free of pain, without irritation, and it had passively full range of motion. The Lachman and Pivot Shift Test had to be positive. The patients had to be able to stand and hop on the operated leg and did not report a subjective feeling of instability. They had to be able to perform level III activities without symptoms.
Rodríguez-Roiz, 2015 ²²22. Rodríguez-Roiz JM, Caballero M, Ares O, Sastre S, Lozano L, Popescu D. Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study. Arch Orthop Trauma Surg. 2015;135(8):1117-22. (RTP-SL)	Both. 30 (14 to 52). Recreational sports. Time to RTP: until 36 mo.	Hamstring graft.	Multiple ligament injury. Chondral lesions above 1 square cm. History of previous surgery on the same knee. ACL revision surgery. Bilateral ACL injury.	NR
Rodríguez-Roiz et al. ²²22. Rodríguez-Roiz JM, Caballero M, Ares O, Sastre S, Lozano L, Popescu D. Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study. Arch Orthop Trauma Surg. 2015;135(8):1117-22. (RTP-LL)	Both. 30 (14 to 52). Recreational sports. Time to RTP: until 36 mo.	Hamstring graft.	Multiple ligament injury. Chondral lesions above 1 square cm. History of previous surgery on the same knee. ACL revision surgery. Bilateral ACL injury.	NR
Sandon et al. ⁶6. Sandon A, Werner S, Forssblad M. Factors associated with returning to football after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2514-21.	Both. 23.9 ± 8.3 (non-RTP 25.5 ± 9). Time to RTP: 6 mo.	Hamstrings, pattelar tendon.		NR
Sonesson et al. ²³23. Sonesson S, Kvist J, Ardern C, Österberg A, Silbernagel KG. Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1375-84. (4mo)	NR. 22: 15 to 41 (non-RTP 23: 16 to 44). Elite; competitive, recreation; and none. Time to RTP: 4 mo.	Hamstring graft.	Previous ACL reconstruction (to either knee). Other major injuries to either knee (i.e. grade III collateral ligament injury, PCL injury, or grade III articular cartilage injury).	NR
Sonesson et al. ²³23. Sonesson S, Kvist J, Ardern C, Österberg A, Silbernagel KG. Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1375-84. (13mo)	NR. 22: 15 to 41 (non-RTP 23: 16 to 44). Elite; competitive, recreation; and none. Time to RTP: 13 mo.	Hamstring graft.	Previous ACL reconstruction (to either knee). Other major injuries to either knee (i.e. grade III collateral ligament injury, PCL injury, or grade III articular cartilage injury).	NR
Webster et al. ⁵5. Webster KE, Feller JA. Younger patients and men achieve higher outcome scores than older patients and women after anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2017;475(10):2472-80.	Both. 26 ± 9 (non-RTP 28 ± 10). NR. Time to RTP: 14 (12 to 20) mo.	Autograft, allograft.	Bilateral ACL injuries, who received a double-bundle reconstruction between 2007 and 2010. Does not practice any sport. Underwent further surgery within the first 12 months after their ACL reconstruction.	NR
Werner et al. ¹⁴14. Werner JL, Burland JP, Mattacola CG, Toonstra J, English RA, Howard JS. Decision to return to sport participation after Anterior Cruciate Ligament Reconstruction, Part II: self-reported and functional performance outcomes. J Athl Train. 2018;53(5):464-74.	Both. 23 ± 11 (non-RTP 23 ± 11). NR. Time to RTP: 04.02 ± 3.20y (*non-RTP 3.68 ± 2.71y).	Hamstrings, Quadriceps tendon and Ipsilateral patelar tendon autograft and allograft.	Posterior cruciate ligament tear. Any history of previous surgery to or injury of the contralateral lower extremity in the 6 months before the study. ACLR revision, fracture, or knee dislocation.	RTP individuals were required to have returned to at least 1 of the cutting or landing sports in which they were participating before ACL injury. Individuals who changed to a non-cutting sport, such as running, were not considered RTP.

Test	K	References	RMD (95%CI)	P value	P difference
Dynamometer	6	17,21	13.37 (7.01; 19.73)	< 0.001	< 0.001
Hop tests	9	5,14,21	4.21 (3.11; 7.46)	< 0.001
Age	K		RMD (95%CI)	P value	P difference
Adolescents	5	17	14.45 (6.77; 22.12)	< 0.001	0.014
Young	10	5,14,21	4.44 (2.18; 6.694)	< 0.001

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[1] Correspondence: André Luís Lugnani de Andrade. School of Medical Sciences, Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz, Campinas, SP, Brazil, 13083887. drandre@unicamp.br