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Contralateral ACL tears strongly contribute to high rates of secondary ACL injuries in professional ski racers

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To analyse the effects of graft selection, sex, injury complexity and time to return to competition on the odds to suffer secondary ACL injury (either re-rupture or contralateral ACL tear) in professional alpine skiers.

Methods

The database of a specialised joint surgery clinic was screened for professional alpine skiers who had participated in competitions at the FIS race, European Cup and World Cup level prior to having to undergo a primary ACL reconstruction, and who had returned to the same competitional level at least one year prior to the end of the observation period. The rates of secondary ACL injuries were statistically compared between athletes with hamstring and quadriceps tendon autografts, men and women, simple and complex (involvement of menisci or cartilage) primary ACL injuries, and between early (≤ 300 days after primary reconstruction) and late (> 300 days) returners to competition.

Results

Fourteen out of the 30 athletes included (46.7%) suffered secondary ACL injuries on average 29.4 ± 22.5 months after primary reconstruction. The secondary injuries comprised five re-ruptures (16.7%) and nine contralateral ACL tears (30.0%). The odds to suffer contralateral ACL tears were non-significantly higher in patients with hamstring tendon autografts (OR 5.69, n.s.) and in those whose primary injuries were classified as simple ACL tears (OR 5.31, n.s.). None of the factors assessed was associated with the odds of graft failure.

Conclusion

The odds of ACL-injured professional alpine ski racers to suffer secondary ACL tears are nearly 50%, with subsequent contralateral ACL injuries being more common than graft failures. While statistical significance could not be established due to a lack of power, greater odds of contralateral ACL tears were observed in athletes with hamstring tendon grafts as well as those with simple primary ACL injuries. No factors potentially predisposing athletes for graft failure could be identified.

Level of evidence

III.

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Abbreviations

ACL:

Anterior cruciate ligament

BPTB:

Bone patellar tendon bone (autograft)

HT:

Hamstring tendon (autograft)

QT:

Quadriceps tendon (autograft

References

  1. Ajrawat P, Dwyer T, Whelan D, Theodoropoulos J, Murnaghan L, Bhargava M et al (2019) A comparison of quadriceps tendon autograft with bone-patellar tendon-bone autograft and hamstring tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review and quantitative synthesis. Clin J Sport Med. https://doi.org/10.1097/JSM.0000000000000765

    Article  PubMed  Google Scholar 

  2. Barber-Westin S, Noyes FR (2020) One in 5 athletes sustain reinjury upon return to high-risk sports after ACL reconstruction: a systematic review in 1239 athletes younger than 20 years. Sports Health. https://doi.org/10.1177/1941738120912846

    Article  PubMed  PubMed Central  Google Scholar 

  3. Belk JW, Kraeutler MJ, Marshall HA, Goodrich JA, McCarty EC (2018) Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review of comparative studies with minimum 2-year follow-up. Arthroscopy 34(5):1699–1707

    Article  Google Scholar 

  4. Bere T, Flørenes TW, Nordsletten L, Bahr R (2014) Sex differences in the risk of injury in World Cup alpine skiers: a 6-year cohort study. Br J Sports Med 48(1):36–40

    Article  Google Scholar 

  5. Cavaignac E, Coulin B, Tscholl P, Nik Mohd Fatmy N, Duthon V, Menetrey J (2017) Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years. Am J Sports Med. 45(6):1326–1332

    Article  Google Scholar 

  6. Chen Y, Buggy C, Kelly S (2019) Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective. Sports Med Open 5(1):15

    Article  Google Scholar 

  7. Claes S, Verdonk P, Forsyth R, Bellemans J (2011) The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med 39(11):2476–2483

    Article  Google Scholar 

  8. Csapo R, Hoser C, Gföller P, Raschner C, Fink C (2018) Fitness, knee function and competition performance in professional alpine skiers after ACL injury. J Sci Med Sport Suppl 1:39–43

    Google Scholar 

  9. Csapo R, Pointner H, Hoser C, Gföller P, Raschner C, Fink C (2020) Physical fitness after anterior cruciate ligament reconstruction: influence of graft, age, and sex. Sports (Basel) 8(3):30

    Article  Google Scholar 

  10. Ekeland A, Engebretsen L, Fenstad AM, Heir S (2020) Similar risk of ACL graft revision for alpine skiers, football and handball players: the graft revision rate is influenced by age and graft choice. Br J Sports Med 54(1):33–37

    Article  Google Scholar 

  11. Fischer F, Fink C, Herbst E, Hoser C, Hepperger C, Blank C et al (2018) Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26(2):418–425

    Article  Google Scholar 

  12. Geib TM, Shelton WR, Phelps RA, Clark L (2009) Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy 25(12):1408–1414

    Article  Google Scholar 

  13. Gorschewsky O, Klakow A, Pütz A, Mahn H, Neumann W (2007) Clinical comparison of the autologous quadriceps tendon (BQT) and the autologous patella tendon (BPTB) for the reconstruction of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 15(11):1284–1292

    Article  CAS  Google Scholar 

  14. Haida A, Coulmy N, Dor F, Antero-Jacquemin J, Marc A, Ledanois T et al (2016) Return to sport among french alpine skiers after an anterior cruciate ligament rupture: results from 1980 to 2013. Am J Sports Med 44(2):324–330

    Article  Google Scholar 

  15. Han HS, Seong SC, Lee S, Lee MC (2008) Anterior cruciate ligament reconstruction: quadriceps versus patellar autograft. Clin Orthop Relat Res 466(1):198–204

    Article  Google Scholar 

  16. Horvath A, Senorski EH, Westin O, Karlsson J, Samuelsson K, Svantesson E (2019) Outcome after anterior cruciate ligament revision. Curr Rev Musculoskelet Med 12(3):397–405

    Article  Google Scholar 

  17. Hsu C-J, Meierbachtol A, George SZ, Chmielewski TL (2017) Fear of reinjury in athletes. Sports Health 9(2):162–167

    Article  Google Scholar 

  18. Jordan M, Aagaard P, Herzog W (2017) Anterior cruciate ligament injury/reinjury in alpine ski racing: a narrative review. Open Access J Sports Med 8:71–83

    Article  Google Scholar 

  19. Jordan MJ, Doyle-Baker P, Heard M, Aagaard P, Herzog W (2017) A retrospective analysis of concurrent pathology in ACL-reconstructed knees of elite alpine ski racers. Orthop J Sports Med 5(7):2325967117714756

    Article  Google Scholar 

  20. King E, Richter C, Jackson M, Franklyn-Miller A, Falvey E, Myer GD et al (2020) Factors influencing return to play and second anterior cruciate ligament injury rates in level 1 athletes after primary anterior cruciate ligament reconstruction: 2-year follow-up on 1432 reconstructions at a single center. Am J Sports Med 48(4):812–824

    Article  Google Scholar 

  21. Lind M, Nielsen TG, Soerensen OG, Mygind-Klavsen B, Faunø P (2020) Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial. Br J Sports Med 54(3):183–187

    Article  Google Scholar 

  22. Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M (2014) Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Arthroscopy 30(5):593–598

    Article  Google Scholar 

  23. McPherson AL, Feller JA, Hewett TE, Webster KE (2019) Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries. Am J Sports Med 47:857–862

    Article  Google Scholar 

  24. Nagelli CV, Hewett TE (2017) Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and Functional Considerations. Sports Med 47(5):221–232

    Article  Google Scholar 

  25. Oates KM, Van Eenenaam DP, Briggs K, Homa K, Sterett WI (1999) Comparative injury rates of uninjured, anterior cruciate ligament-deficient, and reconstructed knees in a skiing population. Am J Sports Med 27(5):606–610

    Article  CAS  Google Scholar 

  26. Pandya NK, Feeley B, Lansdown D, Rubenstein W, Allahabadi S (2019) ACL graft failure in professional athletes compared to the pediatric population. Orthop J Sports Med 7(3 Suppl):2325967119S00102

    PubMed Central  Google Scholar 

  27. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE (2014) Incidence of second ACL injuries 2 years after primary acl reconstruction and return to sport. Am J Sports Med 42(7):1567–1573

    Article  Google Scholar 

  28. Pujol N, Rousseaux Blanchi MP, Chambat P (2007) The incidence of anterior cruciate ligament injuries among competitive alpine skiers: a 25-year investigation. Am J Sports Med 35:1070–1074

    Article  Google Scholar 

  29. Ristolainen L, Kettunen JA, Kujala UM, Heinonen A (2012) Sport injuries as the main cause of sport career termination among Finnish top-level athletes. Eur J Sport Sci 12:274–282

    Article  Google Scholar 

  30. Runer A, Csapo R, Hepperger C, Herbort M, Hoser C, Fink C (2020) Anterior cruciate ligament reconstructions using quadriceps tendon autograft carries a lower risk of graft failure but similar functional outcomes compared to hamstring tendon autograft. Am J Sports Med 48:2195–2204

    Article  Google Scholar 

  31. Runer A, Wierer G, Herbst E, Hepperger C, Herbort M, Gföller P, Hoser C, Fink C (2018) There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc 26:605–614

    Article  Google Scholar 

  32. Sandon A, Engström B, Forssblad M (2020) High risk of further anterior cruciate ligament injury in a 10-year follow-up study of anterior cruciate ligament-reconstructed soccer players in the swedish national knee ligament registry. Arthroscopy 36:189–195

    Article  Google Scholar 

  33. Stevenson H, Webster J, Johnson R, Beynnon B (1998) Gender differences in knee injury epidemiology among competitive alpine ski racers. Iowa Orthop J 18:64–66

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Stuhlman CR, Owens CJ, Samuelson EM, Vermillion RP, Shermansky MD, King KB, Connor PM (2019) Recurrent anterior cruciate ligament tears in the national football league: a case-control study. Orthop J Sports Med 7:2325967119891413

    Article  Google Scholar 

  35. Swärd P, Kostogiannis I, Roos H (2010) Risk factors for a contralateral anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 18:277–291

    Article  Google Scholar 

  36. Tarka MC, Davey A, Lonza GC, O’Brien CM, Delaney JP, Endres NK (2019) Alpine ski racing injuries. Sports Health 11:265–271

    Article  Google Scholar 

  37. Valenzuela C (1993) 2 solutions for estimating odds ratios with zeros. Rev Med Chil 121:1441–1444

    CAS  PubMed  Google Scholar 

  38. Wright RW, Magnussen RA, Dunn WR, Spindler KP (2011) Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: a systematic review. J Bone Joint Surg Am 93:1159–1165

    Article  Google Scholar 

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Funding

No external funding was received in support of this study.

Author information

Authors and Affiliations

  1. Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG, UMIT Tirol, Eduard-Wallnöfer-Zentrum 1, 6060, Hall in Tirol, Austria

    Robert Csapo, Christian Hoser & Christian Fink

  2. Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria

    Armin Runer

  3. Gelenkpunkt Sports and Joint Surgery, Innsbruck, Austria

    Christian Hoser & Christian Fink

Authors
  1. Robert Csapo
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  2. Armin Runer
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  3. Christian Hoser
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  4. Christian Fink
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Contributions

RC analysed the data and drafted the manuscript. AR, CH and CF revised the manuscript. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Robert Csapo.

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Conflict of interest

All authors have no conflicts of interest to disclose.

Ethical approval

The study was approved by the ethical committee of the Medical University of Innsbruck (AN2015-0050346/4.28).

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Written informed consent was obtained from all participants.

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Csapo, R., Runer, A., Hoser, C. et al. Contralateral ACL tears strongly contribute to high rates of secondary ACL injuries in professional ski racers. Knee Surg Sports Traumatol Arthrosc 29, 1805–1812 (2021). https://doi.org/10.1007/s00167-020-06234-8

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  • DOI: https://doi.org/10.1007/s00167-020-06234-8

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