Return to Sport After Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Revision anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established procedure to restore knee stability and improve function after a failed primary ACLR. In active individuals, patient, injury, and operative variables influencing successful return to sport (RTS) after revision ACLR remain poorly understood.

To evaluate RTS outcomes in patients undergoing revision ACLR.

Meta-analysis, Level of evidence, 4Methods:A systematic review was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was conducted by querying 5 databases from inception through January 2025 to identify studies reporting on RTS outcomes in athletes undergoing revision ACLR. Meta-analysis was performed using random-effects models at 95% confidence intervals, with odds ratios used for comparative studies.

A total of 52 studies, consisting of 3814 patients, met inclusion criteria. The mean patient age was 27.6 ± 8.4 years, with 66.3% (2340/3532) of the patients being male. Soccer was the most commonly reported sport (24.6%; 390/1584), followed by basketball (17.6%; 278/1584) and football (7.8%; 124/1584). The overall pooled RTS rate was 77.8% (95% CI, 0.732-0.824), with the RTS rate to the previous level of competition being 48.2% (95% CI, 0.410-0.553). The weighted mean time to RTS was 9.3 ± 2.7 months. Patients undergoing revision ACLR with the addition of a lateral extra-articular procedure (LEAP) had a significantly higher RTS rate (90.6% vs 74.9%; P < .00001), while greater articular cartilage damage was associated with less successful RTS (OR, 0.214; 95% CI, 0.078-0.584). The mean postoperative Anterior Cruciate Ligament Return to Sport after Injury score was 61.2 ± 24.1 (n = 535). The most commonly reported reason for failure to RTS or RTS at a lower competition level was fear of reinjury (28.0%; 142/508), followed by knee pain (12.0%; 61/508) and persistent instability (7.3%; 37/508).

The overall RTS rate after revision ACLR was 77.8%, with 48.2% returning to the previous level of competition. The addition of a LEAP led to improved RTS rates. Fear of reinjury was reported as the most commonly reported barrier to successful RTS.