AJSM - 2026-05-14 - Journal Article
The Anterior Cruciate Ligament Injury Severity Scale (ACLISS) as a Predictor of Short-Term Reoperation and Functional Outcomes After ACL Reconstruction.
Graham GD, Haffner M, Testa EJ, White A, Lifsey C, Gachigi K, Padley J, Mueller J, Preuss F, Chandler C, Riboh J
Topics
Key Takeaway
ACLISS grade does not predict overall reoperation rate (grade 1: 10.2% vs grades 2–3: 10.9%, P=.832), but higher-grade injuries underwent reoperation earlier, with 69% of grade 2–3 reoperations occurring within 5–15 months versus 22% for grade 1.
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Summary
This study evaluated whether ACLISS score (0–12, grades 1–3 based on MRI and arthroscopic concomitant injury burden) predicts reoperation or patient-reported outcomes after primary ACLR in 324 patients with minimum 2-year follow-up. Overall reoperation rate was 10.5%, ACL revision rate was 4.0%, and ACLISS grade was not associated with reoperation risk on multivariable analysis; hybrid autograft-allograft augmentation was the only independent predictor of reoperation (OR 7.68, 95% CI 1.82–32.4). Mean IKDC was 84.4 and Marx score 8.6, neither differing significantly by ACLISS grade, though higher-grade patients reoperated earlier (69% between 5–15 months vs. 22% for grade 1, P=.0086).
Key Limitation
The grade 3 cohort comprised only 6 patients (1.9%), rendering the study statistically incapable of detecting meaningful outcome differences at the highest injury severity level.
Original Abstract
BACKGROUND
The Anterior Cruciate Ligament Injury Severity Scale (ACLISS) was developed to classify the magnitude of damage to knee structures beyond the anterior cruciate ligament (ACL) (meniscus, cartilage, collateral ligaments, etc) at the time of ACL rupture. However, its validity in predicting clinical outcomes after ACL reconstruction (ACLR) has never been assessed.
PURPOSE
To determine whether ACLISS correlates with reoperation and patient-reported functional outcomes after ACLR.
STUDY DESIGN
Cohort study; Level of evidence, 3.
METHODS
The records of all patients who underwent primary ACLR at a single institution between 2019 and 2022 with minimum follow-up of 2 years were reviewed. Patients were excluded if they had concomitant collateral ligament or posterior cruciate ligament repair/reconstruction or prior ipsilateral ACLR. ACLISS scores (0-12) and grades (grade 1: scores 0-3; grade 2: scores 4-7; grade 3: scores 8-12) were determined using preoperative magnetic resonance imaging and intraoperative arthroscopic findings based on the original published technique. The primary outcome was reoperation after ACLR. Secondary outcomes included International Knee Documentation Committee (IKDC) subjective scores and Marx activity scores. Bivariable and multivariable logistic regression analyses were performed to identify predictors of reoperation. Cox proportional hazards modeling and Kaplan-Meier survival analysis were used to evaluate time to reoperation. Statistical significance was defined as a P value <.05.
RESULTS
A total of 324 patients met the inclusion criteria. The mean age was 29.3 ± 13.6 years, and 50.9% of the patients were male. The mean follow-up was 5.1 ± 0.8 years. Of the patients, 177 (54.6%) were classified as ACLISS grade 1 damage, with a mean score of 2.3 ± 0.9; 141 (43.5%) as grade 2, with mean score of 4.8 ± 0.9, and 6 (1.9%) as grade 3, with mean score of 8.2 ± 0.4. Overall, 87 (26.9%) patients required medial meniscus repair, and 82 (25.3%) patients required lateral meniscus repair. The overall ACL revision rate was 4.0%. A total of 34 (10.5%) patients had reoperation for any reason. The mean IKDC score was 84.4 ± 14.2, and the mean Marx score was 8.6 ± 5.4. There was no significant association between ACLISS grade and reoperation rate (grade 1: 10.2%; grades 2 and 3: 10.9%; P = .832). In multivariable analysis, hybrid autograft with allograft augmentation was significantly associated with increased reoperation risk (OR, 7.68; 95% CI, 1.82-32.4; P = .006). Survival analysis revealed that patients with grades 2 and 3 experienced earlier reoperations, with 69% occurring between 5 and 15 months compared to 22% for grade 1 ( P = .0086). IKDC and Marx scores did not differ significantly by ACLISS score.
CONCLUSION
While ACLISS grade does not predict overall reoperation rates or functional outcomes when concomitant injuries are appropriately managed, patients with higher grades experienced earlier reoperation.