Background: Long-term prospective follow-up studies of single-incision endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors.

Purpose: This longitudinal prospective study reports the outcomes of isolated ACL reconstruction using middle-third patellar tendon autografts in 90 patients over 20 years.

Study Design: Case series; Level of evidence, 4.

Methods: Between January 1993 and April 1994, a total of 90 patients met study inclusion criteria: evaluation at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. Exclusion criteria were associated ligamentous injuries requiring surgery, previous meniscectomy or meniscal injuries requiring more than one-third meniscectomy, chondral injuries, and an abnormal contralateral knee.

Results: At 20 years, 32 (36%) patients had sustained another ACL injury: 8 (9%) to the index limb and 27 (30%) to the contralateral limb (3 injuring both knees). The mean International Knee Documentation Committee (IKDC) score was 86. Of the patients, 50% participated in strenuous/very strenuous activities, and kneeling pain was present in 63%. Radiographic degenerative change was found in 61%; 20% had IKDC grade C, and 0% had grade D. The IKDC clinical examination revealed that 95% had a normal/nearly normal knee. Significant sex differences existed: when compared with male patients, female patients were less likely to reinjure the reconstructed ACL (18% vs 2%, respectively; P = .01), reported poorer IKDC subjective scores (90 vs 83, respectively; P = .03), had more activity-related pain (20% vs 57%, respectively; P = .02), and were less likely to participate in strenuous activities (66% vs 35%, respectively; P = .009). ACL graft survival was not related to age. Patients <18 years old had an increased odds ratio (3.2) for rupturing the contralateral ACL. A coronal graft angle <17° increased the risk of failure compared with an angle >17° (77% vs 96% survival, respectively) by a factor of 8.5.

Conclusion: Injuries more commonly occurred in the contralateral ACL than in the reconstructed ACL graft, and the most significant predictor of a contralateral ACL injury was age <18 years. The most significant predictor of an ACL graft rupture was a coronal graft angle <17°. Female patients had lower rerupture rates, poorer subjective scores, and decreased participation in strenuous activities, putting the graft at a lower risk of failure. Kneeling pain remained persistent over 20 years. Radiographic osteoarthritis was evident in 61% of patients, but symptomatic osteoarthritic symptoms were rarely reported.


knee, anterior cruciate ligament (ACL), reconstruction, long-term outcome

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