Systematic Review
Long-Term Failure of Anterior Cruciate Ligament Reconstruction

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Purpose

The aim of this study was to review and describe the cumulative incidence of anterior cruciate ligament (ACL) graft rupture and/or clinical objective failures at greater than 10 years after ACL reconstruction.

Methods

A PubMed search was performed to identify and systematically evaluate all studies performed between 1980 and 2012 with clinical outcomes after intra-articular, non-artificial ACL reconstruction and minimum 10-year follow-up. Studies reporting standardized surgical technique, ACL graft rupture, and objective International Knee Documentation Committee (IKDC) grade or ligament stability examination were included for analysis. After we first identified patients with graft rupture, clinical failure was further identified as 1 or more of the following: overall IKDC objective score of C or D, IKDC grade C or D pivot shift (i.e., >2+ or pivot shift), IKDC grade C or D Lachman examination, and/or abnormal KT arthrometer (MEDmetric, San Diego, CA) measurement (i.e., >5 mm). For this study, cumulative ACL failure rates were defined as the sum of both clinical failures and ACL graft ruptures.

Results

After review and exclusion of 625 references, 14 studies were identified for subsequent review. At longer than 10 years' clinical follow-up, the reported ACL graft rupture rate was 6.2% (173 of 2,782) (range, 0% to 13.4%) and clinical failure occurred in approximately 10.3% (158 of 1,532) (range, 1.9% to 25.6%). The overall cumulative ACL failure rate was 11.9% (range, 3.2% to 27%).

Conclusions

At least 1 in 9 patients undergoing ACL reconstruction will have rerupture or clinical failure at long-term follow-up.

Level of Evidence

Level IV, systematic review of Level II and IV studies.

Section snippets

Methods

A PubMed/Medline database search was performed in September 2011 and updated in December 2012 by use of the terms “anterior cruciate year follow” to evaluate failure rates of ACL reconstruction at greater than 10 years' follow-up. All citations were then screened by 2 investigators. Inclusion criteria required English-language publication, intra-articular allograft or autograft ACL reconstruction, consistent surgical technique, minimum 10-year follow-up, reported rerupture rate, and objective

Results

After screening 625 results, we selected 26 studies for full review. Twelve of these were excluded because of surgical technique,4, 5, 6 insufficient clinical follow-up,7, 8 absent or inadequate stability testing,9, 10, 11, 12 no reported rerupture rate,13 non–English-language publication,14 and inconsistent surgical technique.15

Discussion

This cumulative failure rate of primary ACL reconstruction may be higher than previously documented. Previous studies have focused on a limited description of failure after primary ACL reconstruction, reporting only on rates of ipsilateral ACL rerupture.30 However, a more inclusive definition of ACL failure should encompass patients with poor clinical outcomes as indicated by established objective clinical measures. In this systematic review of 14 studies, ACL rerupture occurred in an average

Conclusions

At least 1 in 9 patients undergoing ACL reconstruction will have rerupture or clinical failure at long-term follow-up.

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    The authors report the following potential conflict of interest and sources of funding received in this article: J.H.L. is a consultant for Arthrex and Ivivi; paid speaker for DCI; receives royalties from Arthrex; holds stock in Ivivi; and has received research/institutional support from Arthrex, Breg, and Smith & Nephew.

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