to high activity level at 2 years after surgery was associated with participating in high-level activity and lower body mass index at the time of injury, while return to lower activity level was associ- ated with being a woman, smoking within 6 months of the sur- gery, and having a revision reconstruction surgery (W. R. Dunn, Spindler, & MOON Consortium, 2010). Ardern and colleagues (2014) reported returning to preinjury activity level was favored in athletes who participate in running, cutting, decelerating, and pivoting activities. Factors that were associated with higher rate of return to preinjury sport activities after surgery may include lower knee joint pain and effusion, lower kinesiophopia, higher quadriceps muscle strength, higher self-motivation preoperatively (Czuppon, Racette, Klein, & Harris-Hayes, 2013; U. Müller, Krüger-Franke, Schmidt, & Rose- meyer, 2015; van Melick et al., 2016) and confidence postopera- tively, and higher patients’ perception of knee function preop- eratively. In a systemic review study, returning to preinjury level of sport was favored in young men who play elite sports, being psychologically ready, and demonstrating limb-to-limb hop sym- metry (Ardern, Österberg et al., 2014). In elite athletes, factors re- lated to patients having high physical and athletic skills, knee joint proprioception, psychological status, and receiving high-quality health care and financial compensation to play accounted for the high rate of return-to-sport activities (Lai et al., 2017). Czuppon and colleagues (2013) reported that return to sport after recon- struction surgery was associated with greater postoperative quad- riceps strength and tibia rotational ROM and no knee effusion, pain, and instability. Return to sport was also associated with higher confidence, lower kinesiophobia, and preoperative self-motivation and knee self- efficacy. Return- to-sport rate after revision ACL reconstruction using BPTB autograft was examined by Shelbourne, Benner, & Gray (2014). Shelbourne and colleagues’ study indicated that the rate of return to same preinjury level in school- and colleague-age athletes was 74% and in recreational athletes it was 62% (Shel- bourne et al., 2014). In a study of return-to-sport outcomes at 1 year following ACL reconstruction, patients reporting return to preinjury levels of sports participation had less knee joint effu- sion, fewer episodes of knee instability, lower knee pain intensity, higher quadriceps peak torque/body weight, higher IKDC score, and lower TSK-11 score. The strongest contributors to return-to- sport status were self- reported knee function (IKDC score), fre- quency of knee instability, and knee joint effusion, indicating that these factors may have the strongest influence on return-to-sport outcomes at 1 year post-surgery (Lentz et al., 2012). ACL. Reid and colleagues (2007) found a higher ipsilateral graft injury (9%) compared to the contralateral ACL (2%). The second ACL injury rate is multifactorial, including the pa- tients’ age, sex, graft types, sport activities, and competition levels. Webster and Feller (2016) reported that 29% of the pa- tients who were 20 years or younger at the time of the initial injury experienced a second injury. Patients who are younger than 20 years also were six-times more likely to incur an ipsilateral graft injury and 3-times more likely to incur a contralateral ACL injury (Webster & Feller, 2016). Athletes who returned to cutting and pivoting sport activities were 3.9-times more likely to sustain a reinjury to the ipsilateral graft and were 5-times more likely to sustain an injury to the contralateral ACL (Webster & Feller, 2016). A systemic review of second injury in young athletes reported the rate of second ACL injury to be 15%, the rate of ipsilateral graft injury was 7%, and the rate of contralateral ACL was 8% (Wiggins et al., 2016). In the same systemic review, the rate of second ACL injury for patients younger than 25 years was 21% and for those returning to sports was 21%; when these two factors (age younger than 25 years and having returned to sports) were combined, the rate increased to 23% (Wiggins et al., 2016).
77% to 88%); the time of returning to sports ranged from 6 to 13 months after surgery (Lai et al., 2017). Between sport activities, the highest rate of return to sport among elite athletes was for those who played soccer (85%), followed by basketball (82%) and American football (75%; Lai et al., 2017). A high rate of return to preinjury activity was 71% for professional soccer athletes, return- ing within 4 years following surgery (Lai et al., 2017). The rate of return to preinjury sport activities was reported to be higher in men compared to women, with men 1.4-times more likely to return to preinjury level of sport compared to women (Ar- dern, Taylor, et al., 2014; Ardern et al., 2011a; Brophy et al., 2012; Webster, Feller, Whitehead, Myer, & Merory, 2017). However, Shelbourne, Sullivan, Bohard, Gray, & Urch (2009) reported more high school women returning to play soccer (93%) compared to men (80%) after surgery. With regard to the graft types, patients with bone-patella tendon- bone autograft are 1.2-times more likely return to preinjury level of sport compared to those who had hamstrings tendon autograft (Ardern, Taylor, et al., 2014; Ardern et al., 2011a; Brophy et al., 2012; Webster et al., 2017). Ardern and colleagues (2014) indi- cated that patients with patellar tendon autograft are more likely to return to preinjury sport level, whereas those with hamstrings tendon are more likely to return to competitive sport. Returning to preinjury level of sport is multifactorial, as it can be attributed to different contextual, physical, functional, and psy- chological factors (Ardern, Österberg, et al., 2014). Age, sex, and psychological status play a role in return to preinjury level of sport after reconstruction surgery, with young men, elite ath- letes, and patient psychological readiness all factors contributing to likelihood of return to sport (Ardern, Österberg, et al., 2014). Elite athletes who play at high competitive levels and those who are confident and have less fear due to the injury or surgery are more likely to return to their sports. Men are about 1.5-times more likely to return to preinjury level of sport or competitive sports compared to women (Ardern, Taylor et al., 2014).Although there is no clear evidence to explain why more men return to sport than women, it could be because men are less affected by the ACL injury and demonstrate better functional recovery at the time they are cleared to return to activities postoperatively (Hewett, Ford, & Myer, 2006; Nawasreh et al., 2016; Paterno et al., 2012; Wright et al., 2011). The high rate of return to sport in young athletes might have resulted because they need to maintain their aca- demic scholarship and have a better opportunity to participate in sports. In comparison, the older athlete may have changed their priority with more family, work, and socioeconomic concerns (Ar- dern, Taylor et al., 2014). A previous study revealed that return Second ACL injury Returning to preinjury level of sport without incurring further in- juries is one of the desired outcomes after ACL injury and recon- struction surgery. Incurring a second ACL injury is devastating for patients because it extends the time of the rehabilitation training and the time off working or playing sports, increases the medical heath cost, and results in poor outcomes and frustration. After ACL reconstruction, up to 30% of the patients may incur a second ACL injury (Ardern, Taylor, et al., 2014; Hui et al., 2011; Kamath et al., 2014; Leys et al., 2012; Paterno et al., 2010; Salmon et al., 2005; Shelbourne & Muthukaruppan, 2005; Wright et al., 2011). Unfortunately, second injury after reconstructive surgery is not lim- ited to the harvested graft. The rupture rate of injury to the intact contralateral ACL may be comparable to that of the ipsilateral graft injury (Webster & Feller, 2016; Wiggins et al., 2016). How- ever, the prevalence of second ACL injury after reconstructive sur- gery between limbs is controversial. A systemic review reported that the rate of incurring an ipsilateral graft injury in young ath- letes was 7%, whereas in contralateral ACL it was 8% (Wiggins et al., 2016). Wright and colleagues (2011) also found, in a systemic review, that 5.8% of patients injured their graft and 11.8% injured their contralateral ACL. In comparison, Bourke and colleagues (Bourke, Salmon, et al., 2012) indicated a greater rate of 17% in ipsilateral graft injury, compared to only 9.7% in the contralateral
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