The occurrence time of an ipsilateral graft injury has been report- ed to be earlier than the contralateral ACL injury postoperatively (Borchers, Pedroza, & Kaeding, 2009; Bourke, Salmon, Waller, Patterson, & Pinczewski, 2012; Kyritsis et al., 2016; Webster & Feller, 2016). Paterno et al. (2012) reported that half of the pa- tients incurred second ACL injury during the first 72 sport expo- sure including participation in sport games and practice sessions. The exact reason as to why the second ACL injury occurred is not yet clear. However, it could result from early high-frequency expo- sure of the harvested graft tissue to excessive loads, particularly during participation in high-demand physical activities. Risk fac- tors that may have contributed to injuring the contralateral ACL might be the continued presence of the risk factors that caused the initial ACL injury (Hewett et al., 2005), unresolved abnormal joint biomechanics, and functional limitation before returning to sport activities (Di Stasi, Hartigan, & Snyder-Mackler, 2015; Har- tigan et al., 2010; Nawasreh et al., 2016; Paterno et al., 2010; Paterno, Ford, Myer, Heyl, & Hewett, 2007; Roewer et al., 2011; Schmitt et al., 2012). Multiple risk factors have been proposed as contributing factors to ipsilateral graft injury, some of which are patient-specific factors including being a youth athlete (Lind, Menhert, & Pedersen, 2012; Magnussen et al., 2012; Shelbourne et al., 2009) and a family history of ACL injury (Bourke, Gordon, et al., 2012; Webster et al., 2014). Sustaining a contact mechanism of injury at the time of initial ACL injury also has been reported to associate with second ACL injury (Salmon et al., 2005). Surgical-specific risk factors included a verti- cal graft orientation (Bourke, Salmon, et al., 2012; Hui et al., 2011; Leys et al., 2012), small graft size and laxity (Bourke, Salmon et al., 2012; Magnussen et al., 2012; Park et al., 2013; Pinczewski et al., 2007), and using a hamstrings graft (Maletis et al., 2013). Physi- cal activities status postoperatively has been also attributed to second ACL injury. This can include return to highly physical and pivoting sport activities (Salmon et al., 2005; Bourke, Salmon, et al., 2012; Paterno et al., 2012), with an early return to competitive sport activities increasing the rate of second ACL injury (Borchers et al., 2009; Laboute et al., 2010; Paterno et al., 2012; Webster & Feller, 2016). et al., 2014). Restoring passive knee stability by the reconstructive surgery did not prevent the development of knee osteoarthritis; instead, patients who were managed operatively were 3-times more likely to develop knee osteoarthritis in the reconstructed knee compared to the contralateral knee, with no difference in the knee osteoarthritis prevalence between the bone-patellar tendon-bone and hamstrings tendon autografts (Barenius et al., 2014). A systemic study indicated that the prevalence of radiolog- ical knee osteoarthritis was not different between operative and nonoperative ACL management (Chalmers et al., 2014) although another systematic review published in the same year found lower prevalence of osteoarthritis following nonoperative versus opera- tive management (Luc et al., 2014). Feller, Whitehead, & Webster, 2013). In those who returned, those with more positive perception of their return had greater intrinsic motivation, a greater sense of autonomy, competence, and re- latedness needs satisfaction (Ardern et al., 2013). Evidence also suggests that positive emotions increase and negative emotions decrease as rehabilitation progresses and upon return to sport (Everhart et al., 2013; Hartigan, Lynch, Logerstedt, Chmielewski, & Snyder-Mackler, 2013; Wu, Liu, Dines, Kelly, & Garcia, 2016). Fear of movement and reinjury decreases as rehabilitation pro- gresses after surgery but can continue to impact function during return-to-activity time frames (Chmielewski et al., 2008). Although patient activity levels may decrease for non-knee related life events that include decreased organized sports opportunities, oc- cupation, education, or child care (Everhart et al., 2013), patients who have not returned to preinjury activity levels several years
Female athletes who returned to soccer after reconstructive sur - gery had a rate of second ACL injury of 20%, whereas men soccer players had a rate of 5.5% (Brophy et al., 2012). Women incurred greater injuries in the intact contralateral ACL compared to the ipsilateral graft (Ahldén et al., 2012; Maletis, Inacio, & Funahashi, 2015; Paterno et al., 2014, 2012; Shelbourne, Gray, & Haro, 2009), whereas men demonstrated an equal or higher ipsilateral graft injury compared to contralateral ACL injuries (Maletis et al., 2015; Shelbourne et al., 2009; Webster & Feller, 2016). A recent systemic review demonstrates that incurring an ipsilateral graft in- jury was not different between men and women (Ryan et al., 2014; Tan, Lau, Khin, & Lingaraj, 2016). Paterno and colleagues (2012) found that women who underwent a reconstructive surgery had 15 times higher risk of incurring a second ACL injury compared to heathy uninjured women. Compared to men, women are four times more likely to incur a graft injury and six times more likely to incur a contralateral ACL injury (Paterno et al., 2012). Despite the allograft having an advantage of requiring a shorter surgical procedure time and no donor site morbidity, this ap- proach has consistently been reported to have a higher failure rate compared to the autograft (Engelman, Carry, Hitt, Polousky, & Vidal, 2014; Maletis, Inacio, Desmond, & Funahashi, 2013; Mas- carenhas et al., 2015). Patients with an allograft demonstrated a higher rate of graft injury (retear) than that of the intact contra- lateral ACL (Aglietti, Buzzi, Zaccherotti, & De Biase, 1994; Corry et al., 1999; Marder, Raskind, & Carroll, 1991). Reasons for the high prevalence of second ACL injuries and poor postoperative outcomes in patients with allograft, and the advancement in the reconstructive surgery procedures in using autografts, may have influenced the decision-making of surgeons to veer toward har- vesting autografts. Harvesting autografts demonstrated equal second ACL injury rates between patellar tendon and hamstrings tendon autografts (Mohtadi, Chan, Dainty, & Whelan, 2011; Tay- lor et al., 2009) to a higher rate of ipsilateral graft rupture in the hamstrings tendon compared to the patellar tendon (Freedman, D’Amato, Nedeff, Kaz, & Bach, 2003; Persson et al., 2013; Rein- hardt et al., 2010). Long-term knee joint health In addition to the second ACL injury, injuries to the intra-articular knee structures and long-term knee health also have been stud- ied after ACL injury and surgery. Patients who fail to demonstrate knee stability after ACL injury are 12-times more likely to incur a meniscus injury that requires them to seek operative manage- ment (K. L. Dunn et al., 2016; Logerstedt, et al., 2010b), whereas patients who are managed operatively demonstrate lower risk for meniscus tear and require less subsequent knee surgery (Chalm- ers et al., 2014). Chondral lesions are reported as an adverse ef- fect of knee instability after ACL injury, with the severity of the lesion increasing with longer time from injury (Logerstedt et al., 2010a). Unfortunately, meniscus and chondral lesions may con- tinue to deteriorate, which in turn may impact knee joint health and place the knee at even higher risk of osteoarthritis (Barenius Psychosocial factors Following ACL injury, 60% of athletes who have been cleared for return to sport have not returned to full competition at 1 year from surgery, and half of patients are not participating in prein- jury activity levels 3 to 4 years after ACL reconstruction (Kvist et al., 2005; Lentz et al., 2012; Webster et al., 2008). Despite these poor results, 90% of patients demonstrate normal or near-normal knee function when assessed using impairment- based outcomes within this same time frame (Ardern et al., 2011a). This apparent disparity may result from the influence of psychosocial factors – including fear of reinjury, decreased self-efficacy, and emotional factors – on the ability to return to preinjury activity levels. Psycho- logical distress is frequently encountered after ACL reconstruc- tion and typically improves over time. A study demonstrates that athletes who did not return to sport after ACL reconstruction had significantly lower preoperative motivation and less positive psy- chological response than those who did return (Ardern, Taylor,
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