Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture

Kyritsis P, Bahr R, Landreau P, Miladi R, & Witvrouw E. Br J Sp Med. Published Online First: May 23, 2016. doi: 10.1136/bjsports-2015-095908

http://bjsm.bmj.com/content/early/2016/05/23/bjsports-2015-095908.short?rss=1

Clinicians are often faced with the question of how quickly we can return a patient to sport after anterior cruciate ligament (ACL) rupture. The decision as to whether or not an athlete is ready to return to sport (RTS) after ACL reconstruction is difficult as the commonly used RTS criteria have not been validated. In many cases there are no set return to play parameters that need to be met. The purpose of this study was to evaluate whether a set of objective discharge criteria, including muscle strength and functional tests, are associated with risk of ACL graft rupture after RTS. The authors conducted a prospective cohort study to evaluate whether certain return-to-play criteria (e.g., functional assessments) were associated with risk of an ACL graft rupture after return to sport. The authors followed 158 male professional athletes after ACL reconstruction, who returned to sport on average 229 days after injury (range 116-513 days). Before players returned to sport they underwent a battery of discharge tests (isokinetic strength testing at 60°, 180° and 300°/s, a running t test, single hop, triple hop and triple crossover hop tests). Athletes were monitored for ACL re-ruptures once they returned to sport (median follow-up 646 days, range 1–2060).

Of the 158 athletes, twenty-six (16.5%) suffered graft ruptures an average of 105 days after RTS. (11 suffered contralateral ACL ruptures). An increased graft rupture risk was identified in athletes who did not attain all 6 discharge criteria or who had decreased hamstring-to-quadriceps ratios. Two factors were associated with increased risk of ACL graft rupture: (1) not meeting all six of the discharge criteria before returning to team training (HR 4.1, 95% CI 1.9 to 9.2, p≤0.001); and (2) decreased hamstring to quadriceps ratio of the involved leg at 60°/s (HR 10.6 per 10% difference, 95% CI 10.2 to 11, p=0.005).

CONCLUSION: Athletes who did not meet the discharge criteria before returning to professional sport had a four times greater risk of sustaining an ACL graft rupture compared with those who met all six RTS criteria. In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of an ACL graft rupture.

The findings from this study are of value to clinician’s because these authors showed that an objective set of return-to-sport criteria may be associated with ACL injury risk after an ACL reconstruction. In addition to meeting set criteria, early return to sport may also be linked to an increased risk of ACL graft rupture because the 60% of the graft ruptures tended to occur relatively early after injury in relationship to return to sport. The bottom line to clinicians is that we should utilize or obtain objective criteria rather than getting patients to “as good as we can get,” because we may be setting the patient up for failure.

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