The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis

BACKGROUND: There is no consensus on the components of return-to-sport (RTS) testing following anterior cruciate ligament (ACL) reconstruction or whether passing RTS criteria can reduce a patient's risk of reinjury. OBJECTIVES: To determine whether impartial, criteria-based RTS decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury). METHODS: In this systematic review with meta-analysis, the authors conducted an electronic literature search in PubMed/MEDLINE, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses Global using database-specific vocabulary related to ACL reconstruction and return to sport. Individual study quality was assessed using the modified Downs and Black checklist, and overall quality of evidence was determined with the Grading of Recommendations Assessment, Development and Evaluation scale. Pooled risk difference (passed versus failed RTS criteria), injury incidence proportion, and the diagnostic accuracy of each RTS criterion were calculated. RESULTS: Four studies met the selection criteria. Overall, 42.7% (95% confidence interval [CI]: 18%, 69%) of patients passed RTS criteria, and 14.4% (95% CI: 8%, 21%) of those who passed experienced a second ACL injury (graft rupture or contralateral ACL injury). There was a nonsignificant 3% reduced risk of a second ACL injury after passing RTS criteria (risk difference, -3%; 95% CI: -16%, 10%; I-2 = 74%, P = .610). The evidence rating of the Grading of Recommendations Assessment, Development and Evaluation scale was "very low quality," due to imprecision and heterogeneity of the pooled risk difference estimate. CONCLUSION: Passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. The quality-of-evidence rating prevents a definitive conclusion on this question and indicates an opportunity for future research.