Return to Sport After Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background:

Revision anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established procedure to restore knee stability and improve function after a failed primary ACLR. In active individuals, patient, injury, and operative variables influencing successful return to sport (RTS) after revision ACLR remain poorly understood.

Purpose:

To evaluate RTS outcomes in patients undergoing revision ACLR.

Study Design:

Meta-analysis, Level of evidence, 4

Methods:

A systematic review was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was conducted by querying 5 databases from inception through January 2025 to identify studies reporting on RTS outcomes in athletes undergoing revision ACLR. Meta-analysis was performed using random-effects models at 95% confidence intervals, with odds ratios used for comparative studies.

Results:

A total of 52 studies, consisting of 3814 patients, met inclusion criteria. The mean patient age was 27.6 ± 8.4 years, with 66.3% (2340/3532) of the patients being male. Soccer was the most commonly reported sport (24.6%; 390/1584), followed by basketball (17.6%; 278/1584) and football (7.8%; 124/1584). The overall pooled RTS rate was 77.8% (95% CI, 0.732-0.824), with the RTS rate to the previous level of competition being 48.2% (95% CI, 0.410-0.553). The weighted mean time to RTS was 9.3 ± 2.7 months. Patients undergoing revision ACLR with the addition of a lateral extra-articular procedure (LEAP) had a significantly higher RTS rate (90.6% vs 74.9%; P < .00001), while greater articular cartilage damage was associated with less successful RTS (OR, 0.214; 95% CI, 0.078-0.584). The mean postoperative Anterior Cruciate Ligament Return to Sport after Injury score was 61.2 ± 24.1 (n = 535). The most commonly reported reason for failure to RTS or RTS at a lower competition level was fear of reinjury (28.0%; 142/508), followed by knee pain (12.0%; 61/508) and persistent instability (7.3%; 37/508).

Conclusion:

The overall RTS rate after revision ACLR was 77.8%, with 48.2% returning to the previous level of competition. The addition of a LEAP led to improved RTS rates. Fear of reinjury was reported as the most commonly reported barrier to successful RTS.