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Comparison of Return-to-Sport and Patient-Reported Outcomes Between Primary and Revision ACL Reconstruction: An
Min-Hao Sun1, Ying-Chen Kuo2,3,4, Chih-Hao Chiu5,6,7
1Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Background:
Anterior cruciate ligament (ACL) injuries are among the most common sports-related injuries worldwide. Primary ACL reconstruction (PACLR) is the standard treatment, but graft failure may necessitate revision ACLR (RACLR). Even though RACLR restores knee stability, outcomes such as return to sport (RTS) and patient-reported measures are thought to be inferior compared with PACLR. While RACLR is widely recognized as resulting in inferior clinical outcomes compared with PACLR, there remains a need for an updated, head-to-head meta-analysis to precisely quantify the magnitude of these disparities in terms of RTS and specific patient-reported outcomes (PROs) across larger patient populations.
Purpose/Hypothesis:
This study aimed to compare RTS and PROs between PACLR and RACLR. It was hypothesized that RACLR would result in significantly lower RTS rates and inferior PROs compared with PACLR.
Study Design:
Systematic review; Level of evidence, 3.
Methods:
A systematic search was conducted in PubMed and Cochrane Library (August 26, 2025) using terms related to "primary,""revision,""anterior cruciate ligament,""reconstruction," and "outcome." Inclusion criteria included (1) comparative studies between PACLR and RACLR, (2) reporting of RTS or PROs through outcome measures (subjective International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Lysholm, and Tegner), and (3) randomized controlled trials, cohort, cross-sectional, or case-control studies. Exclusion criteria comprised duplicates, reviews, case reports, abstracts, or letters. Two independent reviewers performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale and Joanna Briggs Institute checklist. Data on RTS (categorical) were analyzed using risk difference (RD) and PROs (continuous) using mean difference (MD). Random- or fixed-effects models were applied based on heterogeneity. Analyses were conducted with RevMan Web.
Results:
A total of 22 studies were included, comprising a total of 24,773 patients (22,767 PACLR and 2006 RACLR). While no significant difference was observed between groups in overall RTS rates (RD, 0.09; 95% CI, -0.02 to 0.19; P = .11), the PACLR group demonstrated significantly higher rates of returning to the same level of sports (RTS-S) compared with the RACLR group (RD, 0.17; 95% CI, 0.08 to 0.27; P = .0002). Regarding PROs, PACLR was found to be superior in all assessed metrics, including the IKDC (MD, 5.21; 95% CI, 2.41 to 8.00; P = .0003), Lysholm (MD, 4.62; 95% CI, 3.58 to 5.66; P < .00001), and Tegner activity scores (MD, 0.30; 95% CI, 0.13 to 0.48; P = .0005). Furthermore, PACLR showed significantly better results across all 5 domains of the KOOS, with the most pronounced disparities observed in the Sport and Recreation and Quality of Life subscales.
Conclusion:
Compared with PACLR, RACLR demonstrated similar overall RTS rates but significantly lower RTS-S and consistently worse PROs. While revision surgery can restore function for daily living, substantial limitations remain in sports performance and quality of life.
