Evidence-Based Orthopaedics   |    
Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL ReconstructionA Systematic Review
Rick W. Wright, MD1; Robert A. Magnussen, MD2; Warren R. Dunn, MD3; Kurt P. Spindler, MD3
1 Department of Orthopaedic Surgery, Washington University, 1 Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address: wright@wudosis.wustl.edu
2 Department of Orthopaedic Surgery, Duke University, DUMC, Box 3639, Durham, NC 27710
3 Department of Orthopaedic Surgery, Vanderbilt Orthopaedic Institute, 1215 21st Avenue, South, Suite 4200, Nashville, TN 37232
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Kenneth D. Schermerhorn Endowment, the Vanderbilt Sports Medicine Research Fund, an NIH grant (#5 K23 AR052392-04), and an AOSSM-MTF Career Development Award Supplement. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, and the Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, Missouri

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jun 15;93(12):1159-1165. doi: 10.2106/JBJS.J.00898
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Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL is a devastating outcome following successful ACL reconstruction, rehabilitation, and return to sport. Little evidence exists regarding the intermediate to long-term risk of these events.


The present study is a systematic review of Level-I and II prospective studies that evaluated the rate of rupture of the ACL graft and the ACL in the contralateral knee following a primary ACL reconstruction with use of a mini-open or arthroscopic bone-tendon-bone or hamstring autograft after a minimum duration of follow-up of five years.


Six studies met the inclusion and exclusion criteria. The ipsilateral ACL graft rupture rate ranged from 1.8% to 10.4%, with a pooled percentage of 5.8%. The contralateral injury rate ranged from 8.2% to 16.0%, with a pooled percentage of 11.8%.


This systematic review demonstrates that the risk of ACL tear in the contralateral knee (11.8%) is double the risk of ACL graft rupture in the ipsilateral knee (5.8%). Additional studies must be performed to determine predictors for these injuries and to improve our ability to avoid this devastating outcome.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Kellie K. Middleton, MPH; James J. Irrgang, PT PhD ATC FAPTA; Freddie H. Fu, MD, DSc (Hon), DPs (Hon)
    Posted on October 31, 2011
    Comment on, 'Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction: A SystematicReview.'
    University of Pittsburgh Medical Center (UPMC) Department of Orthopaedic Surgery Pittsburgh, Pennsylvania

    We read the article “Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction” by Dr. Rick W. Wright et al. with great interest.(1) It is a very well done systematic review of Level-I and Level-II prospective studies evaluating the long-term rate of ACL graft rupture and ACL rupture in the contralateral knee following primary reconstruction. The major issue addressed in the review is the rate of ipsilateral ACL re-rupture and contralateral ACL rupture after long term follow-up. Past studies have shown that the risk is low (3%) for both ipsilateral graft rupture and contralateral ACL rupture after two-years of follow-up.(1, 2) However, Wright et al. found that after five years of follow-up, the risk of ACL tear in the contralateral knee (11.8/%) is nearly double the risk of ACL graft rupture in the ipsilateral knee (5.8%). This is an interesting finding that has important implications when counseling patients with an ACL injury. We agree with the authors that there is difficulty in “ensuring that all ipsilateral and contralateral injuries [are] identified.” Knowing that the risk of contralateral ACL tears increase substantially over time, it is highly likely that the current methods used to assess post-operative outcomes in the ipsilateral and contralateral knee – patient report of re-injury, Lachman and KT-1000 test for anterior translation, and knee and ACL specific patient-reported outcome scores – may lead to an underestimation of re-tear and contralateral ACL ruptures. At our institution, we carefully follow our patients and evaluate the status of the graft and knee stability bilaterally. Because of our careful attention to long-term patient follow-up, our rate of graft rupture was found to be generally higher than other institutions.(3) Better quantitative measures of graft structure and function, such as MRI are needed to determine the true rate of graft failure and contralateral ACL rupture rates. As the authors identified, the etiology of contralateral knee rupture following ACL reconstruction has yet to be elucidated. Some have speculated that the contralateral knee “protects” the ipsilateral reconstructed knee, thus exposing the contralateral ACL to potentially injurious loads. Furthermore, Roberts et al. found decreased proprioceptive ability in patients after ACL reconstruction in both the injured and uninjured knees compared to an age-matched control group.(4) In both cases, decreased proprioception and increased load could increase the risk of ACL injury in the contralateral knee. To help offset such risks, the authors suggest strategies including activity modification, modification of the rehabilitation protocol and modification of return to sports training programs. We agree that given the findings of increased long-term risk of ACL injury in the contralateral knee has important implications for rehabilitation and return to sports; however, it is unlikely that changing the immediate post-operative rehabilitation protocol would have any bearing on contralateral ACL injury risk five years after ACL reconstruction if it did not also have an effect 2 years after injury. Post-op rehabilitation involves improving muscle strength and neuromuscular control bilaterally. Because the 2 year rates of ipsilateral graft re-rupture and rupture of the contralateral ACL have been found to be similar, it suggests that factors related to incomplete rehabilitation and lack of neuromuscular control may not contribute to the long-term increased rate of contralateral ACL rupture. An alternate hypothesis that we propose for the greater risk of contralateral ACL rupture is that traditional methods of ACL reconstruction do not restore normal anatomy and function of the knee. In vitro cadaveric research has demonstrated that in situ graft forces following anatomic ACL reconstruction are more similar to the in situ forces on the native ACL than those on the graft following non-anatomic ACL reconstruction.(5,6) It is unclear whether or not the studies included in this systematic review reconstructed the ACL anatomically. If the ACL was reconstructed non-anatomically, the graft would be more vertically oriented and would experience fewer forces than the native ACL which would, to some extent, protect the graft from re-rupture. The force that would normally be shared with the ACL would likely be transferred to surrounding joint structures and possibly to the contralateral knee. This increase in force on the contralateral native ACL could thus predispose it to rupture during high-demand activity, especially if any biomechanical or neuromuscular abnormalities that contributed to the initial ACL injury persist after ipsilateral ACL reconstruction and rehabilitation. Though this has never been evaluated, we hypothesize that following anatomic ACL reconstruction, the incidence of ipsilateral graft rupture and contralateral ACL rupture would be similar even after five years follow-up. Overall, this is a well-done, systematic review with very sound conclusions. The authors should be applauded for their rigorous work. Their contributions to the literature related to ACL reconstruction highlight the importance of individualized surgery and restoring a patient’s native anatomy. REFERENCES: (1) Wright RW, Magnussen RA, Dunn WR, and Spindler KP. Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: A systematic review. J Bone Joint Surg Am. 2011;93:1159-65. (2) Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and fourstrand hamstring tendon autograft. Am J Sports Med. 1999;27: 444-54. (3) van Eck C, et al. Prospective analysis of failure rate and predictors of failure after anatomic ACL reconstruction with allograft. Accepted for publication in the Am J Sports Med. October 2011. Not yet published. (4) Roberts D, Friden T, Stomberg A, Lindstrand A, and Moritz U. Bilateral proprioceptive defects in patients with a unilateral anterior cruciate ligament reconstruction: A comparison between patients and health individuals. J Orthop Res. 2000; 18(4): 565-571. (5) Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH. Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc. 2010;18(1):2-10. (6) Wu JL, Seon JK, Gadikota HR, Hosseini Al, Sutton KM, Gill TJ, and Li G. In situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions. Am J Sports Med.2010. Published online before print. **NOTE: One or more of the authors has declared the following potential conflict of interest or source of funding: Our institution receives funding from Smith & Nephew for research on ACL reconstruction; it is not related to the research presented in this contribution. **

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