Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport

Am J Sports Med. 2014 Jul;42(7):1567-73. doi: 10.1177/0363546514530088. Epub 2014 Apr 21.


Background: The incidence of second anterior cruciate ligament (ACL) injuries in the first 12 months after ACL reconstruction (ACLR) and return to sport (RTS) in a young, active population has been reported to be 15 times greater than that in a previously uninjured cohort. There are no reported estimates of whether this high relative rate of injury continues beyond the first year after RTS and ACLR.

Hypothesis: The incidence rate of a subsequent ACL injury in the 2 years after ACLR and RTS would be less than the incidence rate reported within the first 12 months after RTS but greater than the ACL injury incidence rate in an uninjured cohort of young athletes.

Study design: Cohort study; Level of evidence, 2.

Methods: Seventy-eight patients (mean age, 17.1 ± 3.1 years) who underwent ACLR and were ready to return to a pivoting/cutting sport and 47 controls (mean age, 17.2 ± 2.6 years) who also participated in pivoting/cutting sports were prospectively enrolled. Each participant was followed for injury and athlete exposure (AE) data for a 24-month period after RTS. Twenty-three ACLR and 4 control participants suffered an ACL injury during this time. Incidence rate ratios (IRRs) were calculated to compare the rates (per 1000 AEs) of ACL injury in athletes in the ACLR and control groups. For the ACLR group, similar comparisons were conducted for side of injury by sex.

Results: The overall incidence rate of a second ACL injury within 24 months after ACLR and RTS (1.39/1000 AEs) was nearly 6 times greater (IRR, 5.71; 95% CI, 2.0-22.7; P = .0003) than that in healthy control participants (0.24/1000 AEs). The rate of injury within 24 months of RTS for female athletes in the ACLR group was almost 5 times greater (IRR, 4.51; 95% CI, 1.5-18.2; P = .0004) than that for female controls. Although only a trend was observed, female patients within the ACLR group were twice as likely (IRR, 2.43; 95% CI, 0.8-8.6) to suffer a contralateral injury (1.13/1000 AEs) than an ipsilateral injury (0.47/1000 AEs). Overall, 29.5% of athletes suffered a second ACL injury within 24 months of RTS, with 20.5% sustaining a contralateral injury and 9.0% incurring a retear injury of the ipsilateral graft. There was a trend toward a higher proportion of female participants (23.7%) who suffered a contralateral injury compared with male participants (10.5%) (P = .18). Conversely, for ipsilateral injuries, the incidence proportion between female (8.5%) and male (10.5%) participants was similar.

Conclusion: These data support the hypothesis that in the 24 months after ACLR and RTS, patients are at a greater risk to suffer a subsequent ACL injury compared with young athletes without a history of ACL injuries. In addition, the contralateral limb of female patients appears at greatest risk.

Keywords: anterior cruciate ligament reconstruction; incidence rate; second injury; subsequent injury.

MeSH terms

  • Adolescent
  • Anterior Cruciate Ligament Injuries*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Athletes
  • Case-Control Studies
  • Cohort Studies
  • Female
  • Humans
  • Incidence
  • Knee Injuries / epidemiology*
  • Knee Injuries / surgery
  • Longitudinal Studies
  • Male
  • Prospective Studies
  • Return to Sport / statistics & numerical data*
  • Sports
  • Young Adult