Abstract
BACKGROUND: Despite advances in modern surgical techniques, return-to-play (RTP) rates after revision anterior cruciate ligament reconstruction (R-ACLR) often fall short of patients' expectations. There is growing awareness that a patient's psychological recovery is as important as the functional recovery of their knee. PURPOSE/HYPOTHESIS: The primary purpose of this study was to determine the RTP rate and identify the barriers to RTP after R-ACLR. Secondarily, we compared the progression of psychological readiness (using the Anterior Cruciate Ligament-Return to Sport after Injury [ACL-RSI] scale) throughout rehabilitation between those who achieved RTP and those who did not. Finally, we assessed if RTP could be predicted for patients aged <23 years and patients aged ≥23 years based on their ACL-RSI scores at different time points during rehabilitation. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This investigation included 301 patients who underwent R-ACLR at our institution. Preoperatively, patients completed a questionnaire detailing their demographic characteristics and target level of RTP. The ACL-RSI scale was also administered preoperatively and at 3 months, 6 months, and 9 months. At 2 years postoperatively, patients indicated whether or not they had returned to play. Those who did not return provided their reasons for not doing so. RESULTS: The mean age was 25.4 ± 6.3 years, and 84.5% of patients were male. Although 95.1% of patients undergoing R-ACLR intended to return to play before surgery, only 63.4% achieved this goal at 2-year follow-up. The main barriers to RTP were a fear of reinjury (44%), a lack of confidence in performance (13%), and ongoing knee pain (11%). The mean preoperative ACL-RSI score was significantly higher in patients who returned to play than in those who did not (51.2 ± 23.4 vs 42.6 ± 23.3, respectively; P = .027), indicating greater psychological readiness to RTP. The mean ACL-RSI score was also significantly higher in those who achieved RTP at 3 months, 6 months, and 9 months. A preoperative ACL-RSI score of 42.9 points predicted RTP in patients aged <23 years, with a sensitivity of 76% and a specificity of 77% (area under the curve = 0.73). The ACL-RSI score was able to predict RTP at all time points, demonstrating the most accuracy preoperatively and at 6 months postoperatively. At 6 months, a cut-off score of 60.4 points predicted RTP in patients aged <23 years (sensitivity = 62%; specificity = 81%), and a cut-off score of 56.7 points predicted RTP in patients aged ≥23 years (sensitivity = 54%; specificity = 77%). CONCLUSION: Psychological readiness, especially fear of reinjury, was a significant barrier to RTP after R-ACLR. Patients with lower psychological readiness who were less likely to return to play could be detected using the ACL-RSI scale.