Rates of knee arthroplasty in anterior cruciate ligament reconstructed patients: a longitudinal cohort study of 111,212 procedures over 20 years

Background and purpose — Long-term rates of knee arthroplasty in patients with anterior cruciate ligament (ACL) injury who undergo ligament reconstruction (ACLr) are unclear. We determined this risk of arthroplasty through comparison with the general population.

Patients and methods — All patients undergoing an ACLr in England, 1997–2017, were identified from national hospital statistics. Patients subsequently undergoing a knee arthroplasty were identified and survival analysis was performed (survival without undergoing knee arthroplasty). A Cox proportional hazards model was used to identify factors associated with knee arthroplasty. Relative risk of knee arthroplasty (total or partial) in comparison with the general population was determined.

Results — 111,212 ACLr patients were eligible for analysis (mean age 29; 77% male). Overall, 0.46% (95% confidence interval [CI] 0.40–0.52) ACLr patients underwent knee arthroplasty within 5 years, 0.97% (CI 0.82–1.2) within 10 years, and 1.8% (CI 1.4–2.3) within 15 years. Knee arthroplasty risk was greater in older age groups and women. In comparison with the general population, the relative risk of undergoing arthroplasty at a younger age (at time of arthroplasty) was elevated: at 30–39 years (risk ratio [RR] 20; CI 11–35), 40–49 years (RR 7.5; CI 5.5–10), and 50–59 years (RR 2.5; CI 1.8–3.5), but not 60–69 years (RR 1.7; CI 0.93–3.2).

Interpretation — Patients sustaining an ACL injury who undergo ACLr are at elevated risk of subsequent knee arthroplasty in comparison with the general population. Although the absolute rate of arthroplasty is low, the risk of arthroplasty at a younger age is particularly elevated. When the outcome of shared decision-making is ACLr, this data will help inform patients and clinicians about the long-term risk of requiring knee arthroplasty.