Scand J Med Sci Sports 2001: 11: 342–346 COPYRIGHT C MUNKSGAARD 2001 ¡ ISSN 0905-7188

Printed in Denmark ¡ All rights reserved

Functional outcome of anterior cruciate ligament reconstruction inrecreational and competitive athletes

R. Jerre, L. Ejerhed1, A. Wallmon, J. Kartus1, S. Brandsson, J. Karlsson

Department of Orthopaedics, Sahlgrenska University Hospital/Östra, Göteborg, and 1Department of Orthopaedics, NAL-Hospital,Trollhaltan, SwedenCorresponding author: Jon Karlsson, Department of Orthopaedics, Sahlgrenska University Hospital/Östra, SE-416 85 Göteborg,Sweden

Accepted for publication 26 February 2001

The aim of this study was to compare the outcome after an-terior cruciate ligament reconstruction in recreational andcompetitive athletes, with a minimum follow-up of twoyears. Forty-nine patients (24 males and 25 females) who, atthe time of the index injury, were classified as recreationalathletes (Tegner level 2–5) were compared with 226 patients(61 females and 165 males) who, at the time of the index in-jury, were classified as competitive athletes (Tegner level 9–10). At the follow-up, no significant differences were foundbetween the study groups in terms of the Lysholm score,

There appears to be agreement in the literature thatthe treatment of anterior cruciate ligament (ACL)ruptures in a young population participating in pivot-ing sports should be surgical reconstruction (Frank &Jackson, 1997; Roos & Karlsson, 1998). The optimaltreatment for recreational athletes is, however, con-troversial (Järvinen, Natri, Lehto, Kannus, 1995). Itis well known that not all patients who have sustainedan ACL rupture require a surgical reconstruction ofthe ligament (Noyes, McGinnis, Grood, 1985;Casteleyn & Handelberg, 1996). Some studies haveshown that surgically treated patients do not have ahigher activity level compared with non-surgicallytreated patients, when reviewed after two to sevenyears (Sandberg, Balkfors, Nilsson, 1987; Roos, Or-nell, Gardsell, Lohmander, 1995a).

The patient selection for ACL reconstruction hasnot been clearly defined and there are no scientificallyproven absolute indications or contraindications. It isassumed that participation in pivoting and contactsports and frequent giving-way episodes are indi-cations for ACL reconstruction in young and phys-ically active patients who have sustained an ACL rup-ture, either alone or in combination with other liga-ment injuries (Andersson, Odensten, Good, Gillqvist,1989; Engebretsen, Benum, Fasting, Molster, Strand,1990; Daniel, Malcom, Losse, Stone, Sachs, Burks,1994; Järvinen, Natri, Lehto, Kannus, 1995). Brands-

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IKDC evaluation system, one-leg-hop test, KT-1000 laxitymeasurements, anterior knee pain and the patients’ subjec-tive evaluation of the results. However, the competitive ath-letes displayed a significantly higher reduction in Tegner ac-tivity level than the recreational athletes. The functional andobjective results after anterior cruciate ligament recon-struction were comparable for the recreational and competi-tive athletes. We, therefore, conclude that anterior cruciateligament reconstruction could be recommended for rec-reational athletes as well as competitive athletes.

son et al. (2000) have shown that patients over theage of 40 are equally satisfied with their knee after anACL reconstruction compared with patients between21 and 24 years of age. Age is, therefore, probablyonly a relative contraindication, if the patient suffersfrom recurrent giving-way in activities in daily living.

Non-surgical treatment has been reported to pro-duce mixed results. This is probably caused by differ-ent patient populations in the studies (Frank & Jack-son 1997; Roos & Karlsson, 1998). It may be thatyoung high-level athletes were offered reconstructionof the ruptured ACL, while recreational athletes weremost often recommended non-surgical treatment(Friden, Zatterstrom, Lindstrand, Mortiz, 1991).Comparisons of these groups are therefore not suit-able due to different selection criteria.

The aim of this study was to compare the subjec-tive and objective results after ACL reconstruction inrecreational and competitive athletes in a large cohortwith a medium-term follow-up. Our hypothesis wasthat the final outcome in terms of subjective and ob-jective parameters would be similar in recreationaland competitive athletes.

Patients and methodsBetween 1991 and 1997, 1089 patients underwent an ACL re-construction at three hospitals in Sweden. Of those, 991 (91%)

Functional outcome of ACL reconstruction

were re-examined two to five years after the index procedure.From this cohort, we selected two subgroups of patients for thepurpose of this study.

The inclusion criteria for both groups were:1. The patient had a normal contralateral ACL.2. The reconstruction was performed using the arthroscopic

one-incision technique (Rosenberg, 1991) and interferencescrew fixation (Kurosaka, Yoshiya, Andrish, 1987) a mini-mum of two months after the index injury.

3. A central-third patellar tendon autograft harvested througha vertical 7–8 cm incision was used.

4. The rehabilitation was performed according to an acceler-ated protocol (Shelbourne & Nitz, 1990).

Group A comprised 49 patients (24 females and 25 males) who,at the time of the index injury, were classified as recreationalathletes (Tegner level 2–5). Group B comprised 226 patients (61females and 165 males) who, at the time of the index injury,were classified as competitive athletes (Tegner level 9–10). Thedemographics of the study groups are presented in Table 1.

Independent observers not involved in the surgical treatmentor the rehabilitation of the patients performed the follow-up.The follow-up was based on the Lysholm (Tegner & Lysholm,1985), Tegner (Tegner & Lysholm, 1985), and IKDC (Hefti,Muller, Jakob, Staubli, 1993) evaluation systems. The func-tional performance was evaluated using the one-leg-hop testquotient (Tegner, Lysholm, Lysholm, Gillquist, 1986).

The knee-walking test was classified as normal, unpleasant,

Table 1. Demographics of the study groups

Recreational athletes Competitive athletes Significance(Group A) (Group B)

Age (years) 35 (15–53) 24 (15–33) P,0.0001Gender (female/male) 24/25 61/165 P,0.01Time period between index injury and 24 (3–360) 12 (2–168) P,0.0001

reconstruction (months)

The competitive athletes were significantly younger and comprised significantly more males. The time period between the index injury and thereconstruction was significantly longer in the recreational athlete group.

Table 2. Functional and objective results at the follow-up

Recreational athletes Competitive athletes Significance(Group A) (Group B)

Follow-up (months) 31 (23–52) 32 (21–68) n.s.Lysholm score (points) 85 (37–100) 89 (34–100) n.s. (PΩ0.07)KT-1000 anterior side-to-side laxity (mm) 2.0 (ª2.5 to 8) 1.5 (7–11) n.s.KT-1000 total side-to-side laxity (mm) 2.0 (ª3 to 8.5) 1.5 (ª5 to 13) n.s.Tegner activity level preinjury 5 (2–5) 9 (9–10) P,0.0001Tegner activity level at follow-up 4 (1–6) 7 (2–10) P,0.0001Desired Tegner activity level at follow-up 5 (2–6) 9 (3–10) P,0.0001Change of Tegner activity level 0 (ª3 to π3) 2 (ª7 to π1) P,0.0001Patello-femoral pain 20/49 (41%) 72/226 (32%) n.s.

Knee-walking test normal 7/49 (14%) 36/226 (16%) n.s.*Knee-walking test unpleasant 19/49 (39%) 104/226 (46%)Knee-walking test difficult 11/49 (22%) 52/226 (23%)Knee-walking test impossible 12/49 (25%) 34/226 (15%)

IKDC A 10/49 (20%) 56/226 (25%) n.s.*IKDC B 22/49 (45%) 113/226 (50%)IKDC C 15/49 (31%) 43/226 (19%)IKDC D 2/49 (4%) 14/226 (6%)

At the final follow-up, there were no significant differences in terms of the Lysholm score, KT-1000 measurements and the IKDC evaluation systembetween recreational and competitive athletes. *chi-square test (four categories)

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difficult or impossible to perform (Kartus, Stener, Lindahl,Engstrom, Eriksson, Karlsson, 1997). The patients were classi-fied as having subjective anterior knee pain if they registeredpain during stair walking, sitting with the knee in 90æ of flexionand during or after activity.

The anterior and total side-to-side laxities were measuredusing the KT-1000 laxity meter (Daniel et al., 1985).

The patients were asked to classify the result of the recon-struction as excellent, good, fair or poor and correspondinglyto classify the extent to which the reconstruction had met theirexpectations (Sernert et al., 1999).

Statistical analyses

The Mann-Whitney U test was used for the comparison of bothcontinuous and non-continuous data. The chi-square test wasused to compare categorical data. Median (range) values arepresented. A P-value of ,0.05 was considered statistically sig-nificant.

Results

In Group A the cause of injury was contact sport in16/49 (32%) of the patients, non-contact sport in 15/49 (31%) and other activities in 18/49 (37%). The cor-

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Table 3. Functional and objective results at the follow-up

Recreational athletes Competitive athletes Significance(Group A) (Group B)

One-leg-hop test (%) 92 (49–167)% 96 (0–130)% n.s. (PΩ0.11)

Patient evaluation excellent 16/49 (33%) 90/226 (40%) n.s.*Patient evaluation good 23/49 (47%) 100/226 (44%)Patient evaluation fair 6/49 (12%) 28/226 (12%)Patient evaluation poor 4/49 (8%) 8/226 (4%)

Patient expectation excellent 18/49 (37%) 107/226 (47%) n.s.*Patient expectation good 28/49 (57%) 112/226 (50%)Patient expectation fair 3/49 (6%) 4/226 (2%)Patient expectation poor 0/49 (0%) 3/226 (1%)

At the final follow-up, there were no significant differences in terms of the one-leg-hop test, subjective evaluation and subjective expectations betweenthe recreational and competitive athletes. *chi-square test (four categories)

responding values in Group B were: contact sport in210/226 (93%) of the patients, non-contact sport in10/226 (4%) and other activities in 6/226 (3%). Afterthe reconstruction 29/49 (59%) in Group A and 86/226 (38%) in Group B returned to the preinjury levelof activity or higher (P,0.01).

The follow-up was performed after 31 (23–52)months in Group A and after 32 (21–68) months inGroup B (n.s.).

The recreational athletes (Group A) were signifi-cantly older at the index injury (P,0.0001) and hadwaited significantly longer for their operation(P,0.0001) than the competitive athletes (Group B).Furthermore, there were significantly more femalepatients among the recreational athletes (P,0.01)(Table 1).

At the follow-up, the patients in Group A had asignificantly lower activity level than the patients inGroup B (P,0.0001) (Table 2). However, the activitylevel had decreased significantly less in Group A thanin Group B (P,0.0001) (Table 2).

At the follow-up, no significant differences werefound between the groups in terms of anterior kneepain, the knee-walking test, KT-1000 anterior andtotal laxity measurements, Lysholm score, IKDCevaluation system and the one-leg-hop test (Table 2).Furthermore, the patients’ subjective evaluation andexpectation of the results did not reveal any signifi-cant differences between the study groups (Table 3).

Meniscal injuries found and treated between theindex injury and the follow-up were registered in 34/49 (69%) patients in Group A and 144/226 (64%) inGroup B (n.s.).

Discussion

The principal finding in the present study was thatthere were no significant differences in terms of thesubjective and objective outcome between the rec-reational and competitive athletes. The competitive

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athletes had reduced their activity level significantlymore than the recreational athletes from the preinjurylevel to the level at follow-up.

The strengths of the study were the high numberof patients that were included and that the follow-ups were uniform and made by independent ob-servers not involved in the surgical treatment or re-habilitation of the patients. Potential weaknesseswere the retrospective nature of the study and thatthe groups were not matched. During the set up ofthe study matching was discussed; however, it wasconsidered impossible due to the limited number ofcompetitive female athletes, who fulfilled the in-clusion criteria.

Despite numerous studies of ACL injuries and re-constructions, it is still not known which reconstruc-tive method should be preferred, whether an ACL re-construction will change the natural course in termsof meniscal injuries and the development of osteo-arthrosis, or even whether the torn ACL should bereconstructed at all.

In the present study we found no significant differ-ences between the study groups in terms of the num-ber of meniscal injuries treated after the index injury.It is our opinion that meniscal damage found afteran ACL rupture is related to the index injury, ir-respective of whether the meniscal damage is foundand treated before, at or after the ACL reconstruc-tion. It is, however, possible that the meniscal damageamong the recreational athletes was caused by minorreinjury episodes that occurred between the index in-jury and the reconstruction, while the competitiveathletes sustained their meniscal damage by a moreviolent mechanism of injury.

In recent decades, new surgical techniques fortreating ACL ruptures have evolved (Frank & Jack-son, 1997; Roos & Karlsson, 1998). Arthroscopic re-construction using autografts, preferably from thecentral part of the patellar tendon, followed by anaggressive post-operative rehabilitation protocol, are

Functional outcome of ACL reconstruction

probably the two main reasons for less post-operativemorbidity and increased long-term patient satisfac-tion (Johnson, Beynnon, Nichols, Renstrom, 1991;Dahlstedt & Dahlen, 1993; Frank & Jackson, 1997).Furthermore, it is well known that frequent giving-way episodes increase the risk of cartilage and menis-cal injuries and might therefore lead to osteoarthrosisin the long term (Roos, Adalberth, Dahlberg,Lohmander, 1995b). Even so, the majority of patientsundergoing ACL reconstruction are competitive ath-letes (Eriksson, 1976; Franke, 1985; Roos et al.,1995a; Roos & Karlsson, 1998). We are not aware ofany other studies which compare the outcome afteran ACL reconstruction in recreational and competi-tive athletes.

In the present study, the final results after an ACLreconstruction were satisfactory in the majority ofpatients, irrespective of their previous activity level.This is in line with the results of Novak et al. (1996),who studied the outcome after ACL reconstructionin recreational athletes over the age of 35 years. Theyfound that the majority of their patients had satisfac-tory results after a minimum follow-up of two years.However, their study only comprised 19 patients.Järvinen et al. (1995) studied the results after ACLreconstruction using bone-patellar tendon-bone auto-grafts in 30 athletes, followed for an average periodof 2.2 years. In line with the results of the presentstudy, a reduction in activity level was registered. Intheir study, eight of 15 competitive athletes were ableto return to their preinjury level of activity. In thepresent study, a reduction in activity level was regis-tered in both the recreational group (Group A) andthe competitive group (Group B). At the final follow-up, the patients in Group A had a significantly loweractivity level than the patients in Group B. The de-crease in activity level between the index injury andthe follow-up was, however, significantly higher inGroup B. Furthermore, significantly more of the pa-tients in Group A had returned to their preinjury ac-tivity level or higher.

When selecting patients for an ACL reconstruc-tion, several variables, including the activity level, thefunctional expectations of the patient, the degree ofgiving-way during activities, the presence of osteo-arthrosis and concomitant injuries, have to be con-

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Andersson C, Odensten M, Good L, Brandsson S, Kartus J, Larsson J, operative management of anteriorGillqvist J. Surgical or non-surgical Lundin O, Eriksson B, Karlsson J. A cruciate ligament injuries in the generaltreatment of acute rupture of the comparison of results in middle-aged population. J Bone Joint Surg 1996:anterior cruciate ligament. A and young patients after anterior 78-B: 446–451.randomised study with long-term cruciate ligament reconstruction. Dahlstedt L, Dahlen N. Anterior cruciatefollow-up. J Bone Joint Surg 1989: Arthroscopy 2000: 16: 178–182. injured knees: Review of evaluation71-A: 965–974. Casteleyn PP, Handelberg F. Non- methods and treatment regimens.

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sidered. In most previous studies, ACL reconstruc-tion has been performed in high-activity athletes andrelatively little is known about the functional out-come in recreational athletes. The increased risk ofosteoarthrosis in patients with meniscal injuries andthe increased risk of meniscal injuries in patients withACL ruptures, who have had multiple giving-way epi-sodes, has made several authors advocate ACL recon-struction to protect the menisci and, at least theoret-ically, reduce the risk of future osteoarthrosis (Sand-berg et al., 1987; Sommerlath & Hamberg, 1989;Keene, Bickerstaff, Rae, Paterson, 1993; Daniel et al.,1994; Roos et al., 1995b).

In the present study, we found that the results aftera minimum follow-up of two years were equally goodin recreational athletes, compared with competitiveathletes. In previous studies, we have shown that in-creased age (Brandsson et al., 2000), as well as gender(Wiger, Brandsson, Kartus, Eriksson, Karlsson,1999), did not appear to affect the outcome afterACL reconstruction. In the present study, this opin-ion is further supported by the fact that the rec-reational athletes were significantly older, had waitedsignificantly longer for their ACL reconstruction andcomprised significantly more female patients than thecompetitive athletes. In spite of this, the results werestill comparable.

Perspectives

Following the findings in the present study, we nowoffer ACL reconstruction to recreational athleteswith subjective knee instability more frequently thanbefore. It is our opinion that low activity level, ageand gender should not disqualify patients from ACLreconstruction.

Key words: anterior cruciate ligament; reconstruc-tion; athletes; competitive; recreational.

AcknowledgementsFinancial support was provided by the Swedish NationalCentre for Research in Sports (CIF), Göteborg Medical Societyand the Västra Götaland (Norra Alusborg and Bohus CountyCouncil) research and development fund.

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