AJSM - 2026-06-10 - Journal Article
Contralateral ACL Rupture as an Indicator of Intrinsic Risk for Graft Failure After ACL Reconstruction: A Cohort Study of 7718 Patients From the SANTI Study Group.
Santamaria F, Culebras Almeida LA, Carrozzo A, Campos JP, Saithna A, Vieira TD, Sonnery-Cottet B
Topics
Key Takeaway
A history of bilateral native ACL rupture independently increases graft failure risk after primary ACLR by 34% (OR 1.34, 95% CI 1.03–1.73) in a cohort of 7718 patients.
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Summary
This study asked whether bilateral native ACL rupture history—as a proxy for intrinsic ligamentous vulnerability—predicts graft failure after primary ACLR. Among 7718 consecutive single-surgeon patients, those with bilateral ruptures (n=1391) had a graft failure rate of 9.3% versus 5.2% in unilateral cases (P<.0001). On multivariable regression, bilateral rupture (OR 1.34), younger age (OR 0.92 per year), male sex (OR 1.46), and higher Tegner score (OR 1.09) were all independent predictors of failure.
Key Limitation
Graft type, tunnel placement, and use of lateral extra-articular procedures are not reported, leaving open the possibility that these technical variables—not intrinsic biology alone—explain the observed failure rate difference.
Original Abstract
BACKGROUND
Graft failure after anterior cruciate ligament (ACL) reconstruction (ACLR) may be influenced by both extrinsic exposure and intrinsic patient susceptibility. A contralateral ACL rupture could reflect an inherent predisposition to ligament injury.
PURPOSE
To determine whether a history of bilateral native ACL ruptures increases the risk of graft failure after primary ACLR.
STUDY DESIGN
Cohort study; Level of evidence, 2.
METHODS
A total of 7718 consecutive patients who underwent primary ACLR by a single surgeon (2003-2022) were included. Graft failure, defined as a clinically and magnetic resonance imaging-confirmed rupture, was compared between patients with bilateral versus unilateral native ACL ruptures. Multivariable logistic regression identified independent predictors, including age, sex, Tegner score, sport type, and a history of bilateral rupture.
RESULTS
The cohort included 6327 patients with isolated native ACL rupture and 1391 patients with bilateral native ACL rupture. The overall graft failure rate was 6% (461-7718), with a mean follow-up of 135.9 months. Patients with bilateral ACL ruptures had a higher failure rate (9.3%) than those with unilateral injuries (5.2%) ( P < .0001). Independent predictors included younger age (odds ratio [OR], 0.92 [95% CI, 0.90-0.93]; P < .0001), male sex (OR, 1.46 [95% CI, 1.10-1.96]; P = .0089), higher Tegner score (OR, 1.09 [95% CI, 1-1.19]; P = .043), and bilateral rupture (OR, 1.34 [95% CI, 1.03-1.73]; P = .028).
CONCLUSION
Bilateral native ACL rupture independently increases the risk of graft failure after ACLR. This finding supports its use as a marker of intrinsic vulnerability that may warrant targeted preventive or surgical strategies.