Risk factors for contralateral anterior cruciate ligament injury after primary anterior cruciate ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Yong , YU Zeping ,  LI Jian , LI Qi

Department of Orthopedics, Institute of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

LI Jian, Email: hxlijian@163.com

Keywords：

Anterior cruciate ligament; posterior tibial slope; ligament reconstruction; non-contact contralateral anterior cruciate ligament injury; risk factor

DOI：

10.7507/1002-1892.202301045

Video：

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Objective To investigate the risk factors of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Methods A retrospective review was conducted on the 716 patients with ACL injury who received primary ACL reconstruction surgery and met the selection criteria between January 2012 and September 2018. After a mean follow-up period of 7.6 years (range, 4-10 years), 65 patients (9.1%) experienced contralateral ACL injury (injured group) and 651 patients (90.9%) did not (uninjured group). There was no significant difference in age, body mass index, and preoperative Lachman test degree between groups (P>0.05). However, the proportion of female in the injured group was significantly higher than that of male (P<0.05), and the preoperative posterior tibial slope (PTS) was significantly higher than that of the uninjured group (P<0.05). Using the outcome of contralateral ACL injury as the dependent variable, the clinical data of the patient was first used as the independent variable, and univariate COX regression was used to analyze the prognostic influencing factors. Then, the indicators with differences in univariate COX regression were used as the independent variable, and multivariate COX regression was used to analyze the independent risk factors affecting prognosis. Log-Rank (Mantel-Cox) test was used to test and analyze the occurrence time of contralateral ACL injury in patients of different genders; X-tile software was used to analyze the occurrence time of contralateral ACL injury in patients with different PTS using Log-Rank (Mantel-Cox) test and PTS cut-off values. Results Univariate COX regression analysis showed that gender and PTS were influence factors for contralateral ACL injury (P<0.05); further multivariate COX regression analysis showed that female and increased PTS were independent risk factors for contralateral ACL injury (P<0.05). The Log-Rank (Mantel-Cox) test results showed that the contralateral ACL injury occurred in female at 8.853 (8.600, 9.106) years, which was significantly shorter than that in male [9.661 (9.503, 9.819) years] (χ²=20.323, P<0.001). Using X-tile software to analyze the cut-off value of PTS, it was found that the cut-off value of PTS for contralateral ACL injury was 10.92°. According to the Log-Rank (Mantel-Cox) test, it was found that the contralateral ACL injury occurred in 5.762 (4.981, 6.543) years in patients with PTS≥10.92°, which was significantly shorter than patients with PTS<10.92° [9.751 (9.650, 9.853) years](χ²=302.479, P<0.001). Conclusion Female and PTS≥10.92° after primary ACL reconstruction are independent risk factors for contralateral ACL injury.

Citation： WANG Yong, YU Zeping, LI Jian, LI Qi. Risk factors for contralateral anterior cruciate ligament injury after primary anterior cruciate ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(5): 578-583. doi: 10.7507/1002-1892.202301045 Copy

1.	Kaeding CC, Léger-St-Jean B, Magnussen RA. Epidemiology and diagnosis of anterior cruciate ligament injuries. Clin Sports Med, 2017, 36(1): 1-8.
2.	Boden BP, Dean GS, Feagin JA, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics, 2000, 23(6): 573-578.
3.	Andernord D, Desai N, Björnsson H, et al. Predictors of contralateral anterior cruciate ligament reconstruction: a cohort study of 9061 patients with 5-year follow-up. Am J Sports Med, 2015, 43(2): 295-302.
4.	Louboutin H, Debarge R, Richou J, et al. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee, 2009, 16(4): 239-244.
5.	Dragoo JL, Braun HJ, Durham JL, et al. Incidence and risk factors for injuries to the anterior cruciate ligament in National Collegiate Athletic Association football: data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System. Am J Sports Med, 2012, 40(5): 990-995.
6.	Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc, 2009, 17(7): 705-729.
7.	Cronström A, Tengman E, Häger CK. Return to sports: A risky business? A systematic review with meta-analysis of risk factors for graft rupture following ACL reconstruction. Sports Med, 2023, 53(1): 91-110.
8.	De Sousa Filho PGT, Marques AC, Pereira LS, et al. Analysis of posterior tibial slope as risk factor to anterior cruciate ligament tear. Rev Bras Ortop (Sao Paulo), 2021, 56(1): 47-52.
9.	Colyer S, Miles JJ, Crump FJ, et al. Association between biological maturation and anterior cruciate ligament injury risk factors during cutting. J Sports Med Phys Fitness, 2022, 62(8): 1078-1087.
10.	Bisciotti GN, Chamari K, Cena E, et al. Anterior cruciate ligament injury risk factors in football. J Sports Med Phys Fitness, 2019, 59(10): 1724-1738.
11.	Webb JM, Salmon LJ, Leclerc E, et al. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med, 2013, 41(12): 2800-2804.
12.	Lipps DB, Wilson AM, Ashton-Miller JA, et al. Evaluation of different methods for measuring lateral tibial slope using magnetic resonance imaging. Am J Sports Med, 2012, 40(12): 2731-2736.
13.	Hashemi J, Chandrashekar N, Mansouri H, et al. Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries. Am J Sports Med, 2010, 38(1): 54-62.
14.	Nazzal EM, Zsidai B, Pujol O, et al. Considerations of the posterior tibial slope in anterior cruciate ligament reconstruction: A scoping review. Curr Rev Musculoskelet Med, 2022, 15(4): 291-299.
15.	Hiranaka Y, Muratsu H, Tsubosaka M, et al. Influence of posterior tibial slope on sagittal knee alignment with comparing contralateral knees of anterior cruciate ligament injured patients to healthy knees. Sci Rep, 2022, 12(1): 14071. doi: 10.1038/s41598-022-18442-y.
16.	Alaia MJ, Kaplan DJ, Mannino BJ, et al. Tibial sagittal slope in anterior cruciate ligament injury and treatment. J Am Acad Orthop Surg, 2021, 29(21): e1045-e1056.
17.	Hendrix ST, Barrett AM, Chrea B, et al. Relationship between posterior-inferior tibial slope and bilateral noncontact ACL injury. Orthopedics, 2017, 40(1): e136-e140.
18.	Grassi A, Pizza N, Zambon Bertoja J, et al. Higher risk of contralateral anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under-18-year-old patients with steep tibial plateau slope. Knee Surg Sports Traumatol Arthrosc, 2021, 29(6): 1690-1700.
19.	Salmon LJ, Heath E, Akrawi H, et al. 20-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft: the catastrophic effect of age and posterior tibial slope. Am J Sports Med, 2018, 46(3): 531-543.
20.	Cristiani R, Forssblad M, Edman G, et al. Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR. Knee Surg Sports Traumatol Arthrosc, 2022, 30(5): 1828-1835.
21.	Di Benedetto P, Buttironi MM, Mancuso F, et al. Anterior cruciate ligament reconstruction: the role of lateral posterior tibial slope as a potential risk factor for failure. Acta Biomed, 2020, 91(14-S): e2020024. doi: 10.23750/abm.v91i14-S.10996.
22.	Hewett TE, Zazulak BT, Myer GD. Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review. Am J Sports Med, 2007, 35(4): 659-668.
23.	Motohashi M. Profile of bilateral anterior cruciate ligament injuries: a retrospective follow-up study. J Orthop Surg (Hong Kong), 2004, 12(2): 210-215.
24.	Beynnon BD, Hall JS, Sturnick DR, et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med, 2014, 42(5): 1039-1048.
25.	Bernhardson AS, Aman ZS, Dornan GJ, et al. Tibial slope and its effect on force in anterior cruciate ligament grafts: anterior cruciate ligament force increases linearly as posterior tibial slope increases. Am J Sports Med, 2019, 47(2): 296-302.
26.	Lee JA, Koh YG, Kim PS, et al. Biomechanical effect of tibial slope on the stability of medial unicompartmental knee arthroplasty in posterior cruciate ligament-deficient knees. Bone Joint Res, 2020, 9(9): 593-600.
27.	Shelburne KB, Kim HJ, Sterett WI, et al. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res, 2011, 29(2): 223-231.

1. Kaeding CC, Léger-St-Jean B, Magnussen RA. Epidemiology and diagnosis of anterior cruciate ligament injuries. Clin Sports Med, 2017, 36(1): 1-8.
2. Boden BP, Dean GS, Feagin JA, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics, 2000, 23(6): 573-578.
3. Andernord D, Desai N, Björnsson H, et al. Predictors of contralateral anterior cruciate ligament reconstruction: a cohort study of 9061 patients with 5-year follow-up. Am J Sports Med, 2015, 43(2): 295-302.
4. Louboutin H, Debarge R, Richou J, et al. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee, 2009, 16(4): 239-244.
5. Dragoo JL, Braun HJ, Durham JL, et al. Incidence and risk factors for injuries to the anterior cruciate ligament in National Collegiate Athletic Association football: data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System. Am J Sports Med, 2012, 40(5): 990-995.
6. Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc, 2009, 17(7): 705-729.
7. Cronström A, Tengman E, Häger CK. Return to sports: A risky business? A systematic review with meta-analysis of risk factors for graft rupture following ACL reconstruction. Sports Med, 2023, 53(1): 91-110.
8. De Sousa Filho PGT, Marques AC, Pereira LS, et al. Analysis of posterior tibial slope as risk factor to anterior cruciate ligament tear. Rev Bras Ortop (Sao Paulo), 2021, 56(1): 47-52.
9. Colyer S, Miles JJ, Crump FJ, et al. Association between biological maturation and anterior cruciate ligament injury risk factors during cutting. J Sports Med Phys Fitness, 2022, 62(8): 1078-1087.
10. Bisciotti GN, Chamari K, Cena E, et al. Anterior cruciate ligament injury risk factors in football. J Sports Med Phys Fitness, 2019, 59(10): 1724-1738.
11. Webb JM, Salmon LJ, Leclerc E, et al. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med, 2013, 41(12): 2800-2804.
12. Lipps DB, Wilson AM, Ashton-Miller JA, et al. Evaluation of different methods for measuring lateral tibial slope using magnetic resonance imaging. Am J Sports Med, 2012, 40(12): 2731-2736.
13. Hashemi J, Chandrashekar N, Mansouri H, et al. Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries. Am J Sports Med, 2010, 38(1): 54-62.
14. Nazzal EM, Zsidai B, Pujol O, et al. Considerations of the posterior tibial slope in anterior cruciate ligament reconstruction: A scoping review. Curr Rev Musculoskelet Med, 2022, 15(4): 291-299.
15. Hiranaka Y, Muratsu H, Tsubosaka M, et al. Influence of posterior tibial slope on sagittal knee alignment with comparing contralateral knees of anterior cruciate ligament injured patients to healthy knees. Sci Rep, 2022, 12(1): 14071. doi: 10.1038/s41598-022-18442-y.
16. Alaia MJ, Kaplan DJ, Mannino BJ, et al. Tibial sagittal slope in anterior cruciate ligament injury and treatment. J Am Acad Orthop Surg, 2021, 29(21): e1045-e1056.
17. Hendrix ST, Barrett AM, Chrea B, et al. Relationship between posterior-inferior tibial slope and bilateral noncontact ACL injury. Orthopedics, 2017, 40(1): e136-e140.
18. Grassi A, Pizza N, Zambon Bertoja J, et al. Higher risk of contralateral anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under-18-year-old patients with steep tibial plateau slope. Knee Surg Sports Traumatol Arthrosc, 2021, 29(6): 1690-1700.
19. Salmon LJ, Heath E, Akrawi H, et al. 20-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft: the catastrophic effect of age and posterior tibial slope. Am J Sports Med, 2018, 46(3): 531-543.
20. Cristiani R, Forssblad M, Edman G, et al. Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR. Knee Surg Sports Traumatol Arthrosc, 2022, 30(5): 1828-1835.
21. Di Benedetto P, Buttironi MM, Mancuso F, et al. Anterior cruciate ligament reconstruction: the role of lateral posterior tibial slope as a potential risk factor for failure. Acta Biomed, 2020, 91(14-S): e2020024. doi: 10.23750/abm.v91i14-S.10996.
22. Hewett TE, Zazulak BT, Myer GD. Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review. Am J Sports Med, 2007, 35(4): 659-668.
23. Motohashi M. Profile of bilateral anterior cruciate ligament injuries: a retrospective follow-up study. J Orthop Surg (Hong Kong), 2004, 12(2): 210-215.
24. Beynnon BD, Hall JS, Sturnick DR, et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med, 2014, 42(5): 1039-1048.
25. Bernhardson AS, Aman ZS, Dornan GJ, et al. Tibial slope and its effect on force in anterior cruciate ligament grafts: anterior cruciate ligament force increases linearly as posterior tibial slope increases. Am J Sports Med, 2019, 47(2): 296-302.
26. Lee JA, Koh YG, Kim PS, et al. Biomechanical effect of tibial slope on the stability of medial unicompartmental knee arthroplasty in posterior cruciate ligament-deficient knees. Bone Joint Res, 2020, 9(9): 593-600.
27. Shelburne KB, Kim HJ, Sterett WI, et al. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res, 2011, 29(2): 223-231.

Chinese Journal of Reparative and Reconstructive Surgery

Risk factors for contralateral anterior cruciate ligament injury after primary anterior cruciate ligament reconstruction

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