Summary

This study aims to address this gap in literature and provide the specific reasons for why an athlete fails to return to sport after ACL reconstruction; we estimated the rate of failure to return to sports after ACL reconstruction to be 25.5%, with one-third of athletes citing fear of reinjury as the major deterrent for returning to sports.

Abstract

Purpose

Anterior cruciate ligament (ACL) injuries are a relatively common orthopedic injury with an estimated incidence rate of 1 in 3000, however this number is believed to be much higher in the young athletic population. While existing literature has investigated outcomes of patient with successful return to sport, the outcomes of those who fail to return to sport have not been characterized. The purpose of this systematic review is to determine the rate of athletes who did not return to sport (RTS) after primary ACL reconstruction. We aimed to identify the specific reasons for failure to RTS by non-returning athletes.

Methods

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included those explicitly reporting the rate of failure for RTS following ACL reconstruction as well as providing details on reasons for why athletes were unable to return. Data was collected on the number of athletes, average age, average follow up time, type of sport played, failure to RTS rate, and specific reasons for failure to return. A random effects model was employed to conduct the meta-analysis.

Results

Thirty-one studies met the inclusion criteria and reported on a collective total of 4762 athletes. Among the athletes included, 2929/4762 (61.4%) were males, and 1839/4762 (38.6%) were females. The weighted rate of failure to return to sport after ACL reconstruction was 25.5% (95% CI, 19.88 - 31.66%). The estimated proportion of non-knee related reasons cited for failure to RTS was significantly greater than knee related reasons for failure RTS (55.4 % vs. 44.6 %, p-value < 0.0001). The most commonly cited reasons for failure to return was fear of injury (33.0%) followed by other reasons unrelated to the knee (11.0%) and unspecified or otherwise poor knee function (10.2%). Among knee related reasons for failure to return, the most frequently cited included unspecified knee problems/poor function (28.4%), pain (24.3%), and weakness (11.9%). Evidence for potential publication bias and study heterogeneity was present.

Conclusion

Multiple systematic reviews and meta-analyses have reported in detail the rate of return to sport after ACL reconstruction. However, the data reported in these studies often fails to provide insight as to the specific reasons for why an athlete fails to return to sport after this procedure. This study aims to address this gap in literature and provide the specific reasons for why an athlete fails to return to sport after ACL reconstruction. This study estimates the rate of failure to return to sports after ACL reconstruction to be 25.5%, with one-third of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of direct surgical outcomes may impact an athlete’s ability to return to play given that the predominant reason for not returning to sport after ACL reconstruction was unrelated to the knee.