while return to lower activity level was associated with being a woman, smoking within 6 months of the surgery, 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, & Rosemeyer, 2015; van Melick et al., 2016) and confidence postoperatively, and higher patients’ perception of knee function preoperatively. 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 symmetry (Ardern, Österberg et al., 2014). In elite athletes, factors related 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 Second ACL injury Returning to preinjury level of sport without incurring further injuries is one of the desired outcomes after ACL injury and reconstruction 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 limited 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). However, the prevalence of second ACL injury after reconstructive surgery between limbs is controversial. A systemic review reported that the rate of incurring an ipsilateral graft injury in young athletes 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 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 patients’ age, sex, graft types, sport activities, and competition levels. Webster and Feller (2016) reported that 29% of the patients 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
and colleagues (2013) reported that return to sport after reconstruction surgery was associated with greater postoperative quadriceps 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% (Shelbourne 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 effusion, 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), frequency 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). years and having returned to sports) were combined, the rate increased to 23% (Wiggins et al., 2016). Female athletes who returned to soccer after reconstructive surgery 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 injury 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 approach 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; Mascarenhas et al., 2015). Patients with an allograft demonstrated a higher rate of graft injury (retear) than that of the intact contralateral 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 harvesting autografts. Harvesting autografts demonstrated equal second ACL injury rates between patellar tendon and hamstrings tendon autografts (Mohtadi, Chan, Dainty, & Whelan, 2011; Taylor 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; Reinhardt et al., 2010). The occurrence time of an ipsilateral graft injury has been reported 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 patients incurred second ACL injury during the
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