Summary

Elite athletes achieved high initial RTP rates after revision ACL-R with the majority returning to pre-operative levels of competition; however, significant decreases in RTP level were noted at 2 and 5 years post-operatively.

Abstract

Introduction

The aim of this study was to determine the rate of return to play ( RTP) and competition levels at 2 and 5 years post revision ACL-R in elite / professional athletes. The secondary objectives were to assess the association between meniscus and chondral pathologies at the time of revision surgery on RTP and competition level.

Methodology

A retrospective review of a consecutive series of all revision ACL-R undertaken by the senior author between 2009 and 2019 was carried out. Patients were included if they were elite athletes aged 17 years or older who underwent revision ACL-R a minimum of 2 years previously. Cases of combined-ligament injury and cases which required high tibial osteotomy (HTO), either concurrently or previously were excluded.

Outcome measures used were RTP rates, time to return to play and competition level.

Statistical Analysis

Chi square or Fisher’s exact tests were used to determine whether RTP rates and competition level differed or not with age, sport, having a medial or lateral meniscus lesion and the presence and extent of chondral damage at revision ACL surgery. Kaplan–Meier curves were generated to illustrate RTP rates and maintenance of pre-injury competition level´s survival at 2 and 5 years after revision ACL-R.

Results

Forty-nine knees in 48 elite athletes met the inclusion criteria. After revision ACL-R 43 (87.8%) elite athletes achieved RTP, of which 75.5% were at the same level. At 2 years post-surgery, 39 (79.6%) were still playing, 25 (51%) at the same level; and at 5 years post-surgery 20 (44.4%) were still playing, 9 (20%) at the same level. Elite athletes with < 50% thickness or no articular cartilage lesions were more likely to RTP (94.6% versus 66.7%, p = 0.026), as well as maintain the same competition level (83.8% versus 50%, p = 0.047) compared to those with >50% thickness chondral lesions. Those without medial meniscus pathology were more likely to RTP at the same level after revision surgery (94.4% versus 64.5%, p = 0.036). The median time elite athletes continued to play after revision ACL-R was 73 months(6y1m) (95% CI, 43.4 to 102.6), 23 months at the same level (95% CI, 13.6 to 32.4). The probability of still playing at 5 years post-surgery was 55.9% with 22.5% chance of maintaining pre-injury competition level.

Conclusion

In elite athletes, RTP rates and competition level decreased over time after revision ACL-R. The presence of > 50% thickness chondral pathology was associated with lower RTP rates and competition level at RTP time, while medial meniscus pathology was associated with lower competition level at RTP.