Incidence and risk factors of joint stiffness after Anterior Cruciate Ligament reconstruction
Journal of Orthopaedic Surgery and Research volume 15, Article number: 175 (2020)
Joint stiffness is a common complication after anterior cruciate ligament (ACL) reconstruction, which seriously affects the efficacy of the operation and patient satisfaction. After ACL reconstruction, the identification of joint stiffness’ risk factors can help its prevention. This meta-analysis was conducted to evaluate joint stiffness’ risk factors and incidence after ACL reconstruction and provide guidance on its prevention.
PubMed, Embase, and Cochrane Library were searched to obtain relevant studies. The odds ratios (ORs) with 95% confidence intervals (CIs) for all potential risk factors were analyzed using fixed or random-effects meta-analysis in RevMan 5.2.
In total, there were 37 studies and 113,740 patients that were included in this study. After ACL reconstruction, joint stiffness’ incidence negatively correlated with the studies publication time (R = −0.62, P = 0.0094). After ACL reconstruction, the joint stiffness overall pooled incidence was 3% (95% CI, 3-4%). Gender (OR, 0.51; 95% CI, 0.38-0.68; P < 0.00001) was identified as a risk factor. Potential risk factors, such as trauma to surgery time interval, graft type, and concomitant surgery with meniscus injury, have no significant correlation with joint stiffness after ACL reconstruction.
This study indicated that joint stiffness’ incidence after ACL reconstruction is 3% and that gender is a risk factor for joint stiffness after ACL reconstruction.
Anterior cruciate ligament (ACL) injuries account for a large proportion of knee injuries and have a significant impact on knee joint stability . With the development of sports’ medicine, arthroscopic ACL reconstruction has proven to be a safe and effective surgical method [2, 3]. Nonetheless, knee stiffness, a common postoperative complication, severely restricts patients from returning to their original exercise level . Knee postoperative stiffness manifests as an insufficient range of motion, which can be caused by poor graft position, cyclops lesions, and arthrofibrosis [5,6,7]. Previous studies reported that after ACL reconstruction, the incidence of joint stiffness was between 4 and 38% .
Due to the effect of joint stiffness on efficacy and patient satisfaction following ACL reconstruction, the identification and minimization of risk factors’ occurrence, are essential. Sanders et al.  reported that female joint stiffness’ incidence was significantly higher than that in men; however in another report, it was shown that womanhood is not a risk factor for joint stiffness . Controversies also exist with regard to the time interval from trauma to surgery, the type of graft and concomitant surgery with meniscus injury [11,12,13,14,15].
Therefore, we conducted this meta-analysis to investigate joint stiffness risk factors and incidence after ACL reconstruction and provide guidance on the joint stiffness’ prevention to improve ACL reconstruction efficacy and post-operative patients’ satisfaction.
The systematic review and meta-analysis methods used in this study followed the recommendations of Moher et al . Using the databases of Cochrane Library, PubMed, and Embase, a systematic literature search was performed for studies on joint stiffness in patients after ACL reconstruction on February 18, 2019. The retrieval strategy used the following terms in the title and abstract: (“anterior cruciate ligament” OR “ACL”) AND (“reconstruction” OR “treatment” OR “surgery” OR “repair”) AND (“stiffness” OR “range of motion deficits” OR “ROM deficits” OR “arthrofibrosis”).
Studies that met the following inclusion criteria were included in our meta-analysis:
The studies should be randomized or non-randomized controlled studies or observational studies.
The studies should contain sufficient information on joint stiffness risk factors and incidence after ACL reconstruction.
The object of the study must be human participants.
The language of the article must be English or Chinese.
Studies that met the following exclusion criteria were removed from our meta-analysis:
Conference abstracts, letters, editorials, case reports, and reviews.
Joint stiffness was not present in the clinical results of all study participants.
Insufficient control information in the study which limits complete extraction.
The following information was independently extracted by the two authors (WB and ZJL) using a standardized Excel table: (1) The baseline characteristics of the included literature comprised representative authors, publication time, nationality, study type, study period, number of included patients, time and number of patients who were followed up, and number of patients with joint stiffness and joint stiffness incidence; (2) Related risk factors mentioned in three or more studies.
We evaluated the quality of included studies using the Newcastle-Ottawa quality assessment scale . Studies with a quality of more than five stars were included in future analyses.
Joint stiffness incidence after ACL reconstruction was determined using inverse variance in statistical methods and risk difference in effect, measured with 95% confidence intervals (CIs). The binary variables of potential risk factors were performed using Mantel-Haenszel in statistical methods and odds ratio in effect, measured with 95% CIs. To identify the heterogeneity of the included studies, we performed a chi-square test and calculation of I2 statistics. We considered I2 ≤ 50% and/or P ≥ 0.1 to be an insignificant heterogeneity. In the above heterogeneous outcome, we applied the fixed effect model in the analytic model for statistical processing. On the contrary, we used the random effect model. The above statistical analyses were performed using the Review Manager 5.2. The R software was used to fit the correlation between incidence and the studies’ publication time using Spearman analysis. P < 0.05 was considered statistically significant.
Study selection and characteristics
Using the pre-designed search strategy, we identified a total of 1749 records from three databases. After removing duplicate results, 1005 potential results were screened for the follow-up study and via intensive reading of the article title and abstract; we further identified 168 studies to be included in the follow-up research process. Next, we downloaded and carefully screened the full text of the selected articles. As a result, 131 articles were excluded due to insufficient data identification. Finally, 37 studies were included in this meta-analysis and a detailed screening process was recorded in a flow diagram (Fig. 1). The included studies’ baseline characteristics were detailed in Table 1.
Quality assessment of the studies
According to the Newcastle-Ottawa quality assessment scale, we have quantified the quality of the included studies, and the results’ details are presented in Table 2. The quality of the included studies was acceptable as there were 24 studies with eight stars and 13 articles with seven stars.
In total, there were 37 studies and 113,740 patients that were included in this study. The results showed that 2117 patients encountered joint stiffness after ACL reconstruction and the reported incidence rates by various institutes ranged from 0.1 to 71%, showing large fluctuations. After ACL reconstruction, the joint stiffness’ incidence negatively correlated with the studies’ publication time (R = −0.62, p = 0.0094) (Fig. 2). After ACL reconstruction, the overall pooled incidence of joint stiffness was 3% (95% CI, 3-4%) (Fig. 3).
Risk factors for joint stiffness after ACL reconstruction
A total of 5 studies and 3811 patients were included in this study group, and the results showed that gender is a risk factor for joint stiffness after ACL reconstruction (OR, 0.51; 95% CI, 0.38-0.68; p < 0.00001) (Fig. 4).
Time interval from trauma to surgery
A total of 5 studies and 1404 patients were included in this study group, and the results showed that there is no significant correlation between the time interval from trauma to surgery and joint stiffness after ACL reconstruction (OR, 2.56; 95% CI, 0.76-8.63; P = 0.13) (Fig. 5).
A total of 5 studies and 3308 patients were included in this study group, and the results showed that there is no significant correlation between the type of graft and joint stiffness after ACL reconstruction (OR, 0.92; 95% CI, 0.52-1.64; P = 0.77) (Fig. 6).
Concomitant surgery with meniscus injury
A total of 6 studies and 61,723 patients were included in this study group, and the results showed that there is no significant correlation between concomitant surgery with meniscus injury and joint stiffness after ACL reconstruction (OR, 0.73; 95% CI, 0.52-1.03; P = 0.07) (Fig. 7).
In this study, we found that the incidence of joint stiffness after ACL reconstruction varies from 0.1 to 71% with a relatively large fluctuation amplitude [6, 8, 9, 14, 15, 18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49]. After statistical analysis, we observed that the incidence was negatively related to the study publication time. Retrospectively, we found that ACL knowledge and research began in the mid-nineteenth century, and it was not until the early twentieth century that there was a proposal for ACL reconstruction . With the advances in ACL anatomy and biomechanical research, the improvement of ACL injury diagnosis, the development of ACL surgery technology, and the concept of rehabilitation, the postoperative complications of ACL reconstruction, including joint stiffness, were significantly reduced and the curative effect significantly improved [51, 52]. However, once joint stiffness occurs, it can have a significant impact on patients’ quality of life and may require secondary surgery . To avoid joint stiffness, particular attention to the related risk factors is required to pay attention.
The pooled results indicated that gender was a risk factor for joint stiffness after ACL reconstruction. When ignoring other related risk factors, the incidence of joint stiffness was significantly higher in women than that in men. Previous studies have reported that the female athletes’ risk of ACL injury is 2 to 6 times higher than that in male athletes . The structural difference between male and female athletes can be used as an anatomical factor to explain the above phenomenon . It was also shown that ACL injury occurs more frequently in women pre-ovulation stage, which is related to the effects of estrogen, progesterone, testosterone, and relaxin on women’s ligaments [56, 57]. Park et al. reported that knee joint laxity and stiffness’ change is related to ovulation hormone levels . Given that women are a common risk factor for ACL injury and postoperative joint stiffness, more attention should be paid to this factor by fully evaluating the patient’s hormone levels, choosing the appropriate timing of surgery and improving the efficacy of surgery.
Our pooled results showed that the time interval from trauma to surgery has no significant correlation with joint stiffness after ACL reconstruction. Our results were consistent with previous reports that indicated that early ACL reconstruction surgery, within 3 weeks or even 1 week after trauma, does not increase the risk of postoperative joint stiffness [11, 13]. The most commonly used autografts for ACL reconstruction are the hamstring and the bone-patellar tendon-bone . Despite their advantages and disadvantages, failure rates are low and there is no difference in graft fracture [60, 61]. Our results showed that there was no significant correlation between these two autografts and joint stiffness; therefore, both types of grafts can be used for ACL reconstruction, and the choice depends on the patient individual specificity. According to the literature, meniscal injury is associated with 40% to 60% of patients with ACL injury . Meniscus plays very important roles in knee joints stability, stress transmission, proprioception, and joints’ lubrication and nutrition . Many scholars have shown that the outcomes of ACL reconstruction alone, or in combination with a meniscus operation, are similar . Our analysis also showed that simultaneous meniscus related surgery did not increase the risk of joint stiffness. Due to the important functions of the meniscus, we should select the appropriate treatment method according to the condition of the meniscal injury and its complete treatment.
Some limitations existed in this meta-analysis. First, most of the included studies were retrospective, which may have affected the results’ credibility. Second, there is a clinical heterogeneity that cannot be eliminated through subgroup analysis, which may be caused by differences in patients’ standards, included in each study, and the surgeons’ surgical techniques. In addition, there were some potential risk factors, such as age, weight, rehabilitation training, and preoperative activity limitation, which were not included in our analysis due to insufficient data. Despite these limitations, we believe that this study deepens our understanding of joint stiffness and provides guidance for preventing joint stiffness after ACL reconstruction. In the future, further studies will be needed to investigate the risk factors of joint stiffness after ACL reconstruction.
This study indicated that the incidence of joint stiffness after ACL reconstruction is 3%. Gender is a risk factor for joint stiffness after ACL reconstruction.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Anterior cruciate ligament
Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 2009;12:622–7.
Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR. Over 90 % of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018;26:1019–36.
Lai CCH, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. 2018;52:128–38.
Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J Sports Med. 2009;37:471–80.
Austin JC, Phornphutkul C, Wojtys EM. Loss of knee extension after anterior cruciate ligament reconstruction: effects of knee position and graft tensioning. J Bone Joint Surg Am. 2007;89:1565–74.
Nwachukwu BU, McFeely ED, Nasreddine A, Udall JH, Finlayson C, Shearer DW, Micheli LJ, Kocher MS. Arthrofibrosis after anterior cruciate ligament reconstruction in children and adolescents. J Pediatr Orthop. 2011;31:811–7.
Noailles T, Chalopin A, Boissard M, Lopes R, Bouguennec N, Hardy A. Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: a systematic literature review. Orthop Traumatol Surg Res. 2019;105:1401–5.
Robertson GA, Coleman SG, Keating JF. Knee stiffness following anterior cruciate ligament reconstruction: the incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction. Knee. 2009;16:245–7.
Sanders TL, Kremers HM, Bryan AJ, Kremers WK, Stuart MJ, Krych AJ. Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades. Knee Surg Sports Traumatol Arthrosc. 2017;25:532–7.
Facchetti L, Schwaiger BJ, Gersing AS, Guimaraes JB, Nardo L, Majumdar S, Ma BC, Link TM, Li X. Cyclops lesions detected by MRI are frequent findings after ACL surgical reconstruction but do not impact clinical outcome over 2 years. Eur Radiol. 2017;27:3499–508.
Kwok CS, Harrison T, Servant C. The optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness. Arthroscopy. 2013;29:556–65.
Huleatt J, Gottschalk M, Fraser K, Boden A, Dalwadi P, Xerogeanes J, Hammond K. Risk factors for manipulation under anesthesia and/or lysis of adhesions after anterior cruciate ligament reconstruction. Orthop J Sports Med. 2018;6:2325967118794490.
Deabate L, Previtali D, Grassi A, Filardo G, Candrian C, Delcogliano M. Anterior cruciate ligament reconstruction within 3 weeks does not increase stiffness and complications compared with delayed reconstruction: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019;363546519862294.
Rousseau R, Labruyere C, Kajetanek C, Deschamps O, Makridis KG, Djian P. Complications after anterior cruciate ligament reconstruction and their relation to the type of graft: a prospective study of 958 cases. Am J Sports Med. 2019;47:2543–9.
Rushdi I, Sharifudin S, Shukur A. Arthrofibrosis following anterior cruciate ligament reconstruction. Malays Orthop J. 2019;13:34–8.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.
Kim SY, Park JE, Lee YJ, Seo HJ, Sheen SS, Hahn S, Jang BH, Son HJ. Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. J Clin Epidemiol. 2013;66:408–14.
Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med. 1976;4:95–100.
Fisher SE, Shelbourne KD. Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med. 1993;21:558–64.
Wasilewski SA, Covall DJ, Cohen S. Effect of surgical timing on recovery and associated injuries after anterior cruciate ligament reconstruction. Am J Sports Med. 1993;21:338–42.
Dandy DJ, Edwards DJ. Problems in regaining full extension of the knee after anterior cruciate ligament reconstruction: does arthrofibrosis exist? Knee Surg Sports Traumatol Arthrosc. 1994;2:76–9.
Wachtl SW, Imhoff A. Retrospective comparison of four intra-articular anterior cruciate ligament reconstructions using three evaluation systems. Arch Orthop Trauma Surg. 1994;114:25–31.
Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med. 1995;23:87–92.
Kao JT, Giangarra CE, Singer G, Martin S. A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery. Arthroscopy. 1995;11:151–6.
Orfaly RM, McConkey JP, Regan WD. The fate of meniscal tears after anterior cruciate ligament reconstruction. Clin J Sport Med. 1998;8:102–5.
Meighan AA, Keating JF, Will E. Outcome after reconstruction of the anterior cruciate ligament in athletic patients. A comparison of early versus delayed surgery. J Bone Joint Surg Br. 2003;85:521–4.
Millett PJ, Pennock AT, Sterett WI, Steadman JR. Early ACL reconstruction in combined ACL-MCL injuries. J Knee Surg. 2004;17:94–8.
Nicholas SJ, D’Amato MJ, Mullaney MJ, Tyler TF, Kolstad K, McHugh MP. A prospectively randomized double-blind study on the effect of initial graft tension on knee stability after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:1881–6.
Prodromos CC, Han YS, Keller BL, Bolyard RJ. Stability results of hamstring anterior cruciate ligament reconstruction at 2- to 8-year follow-up. Arthroscopy. 2005;21:138–46.
Demirağ B, Ermutlu C, Aydemir F, Durak K. A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears. Eklem Hastalik Cerrahis. 2012;23:140–4.
Kiekara T, Järvelä T, Huhtala H, Paakkala A. MRI of double-bundle ACL reconstruction: evaluation of graft findings. Skeletal Radiology. 2012;41:835–42.
Hettrich CM, Dunn WR, Reinke EK, Spindler KP. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med. 2013;41:1534–40.
Csintalan RP, Inacio MC, Funahashi TT, Maletis GB. Risk factors of subsequent operations after primary anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42:619–25.
Cruz AI, Gao B, Ganley TJ, Pennock AT, Shea KG, Beck JJ, Ellis HB. Trends in concomitant meniscal surgery among pediatric patients undergoing ACL reconstruction: an analysis of ABOS part II candidates from 2000 to 2016. Orthop J Sports Med. 2019;7(9).
Werner BC, Cancienne JM, Miller MD, Gwathmey FW. Incidence of manipulation under anesthesia or lysis of adhesions after arthroscopic knee surgery. Am J Sports Med. 2015;43:1656–61.
Cancienne JM, Gwathmey FW, Miller MD, Werner BC. Tobacco use is associated with increased complications after anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44:99–104.
Ding DY, Zhang AL, Allen CR, Anderson AF, Cooper DE, TM DB, Dunn WR, Haas AK, Huston LJ, BBA L, Mann B, Spindler KP, Stuart MJ, Wright RW, Albright JP, Amendola AN, Andrish JT, Annunziata CC, Arciero RA, Bach BR, Baker CL, Bartolozzi AR, Baumgarten KM, Bechler JR, Berg JH, Bernas GA, Brockmeier SF, Brophy RH, Bush-Joseph CA, Butler JB, Campbell JD, Carey JL, Carpenter JE, Cole BJ, Cooper JM, Cox CL, Creighton RA, Dahm DL, David TS, Flanigan DC, Frederick RW, Ganley TJ, Garofoli EA, Gatt CJ, Gecha SR, Giffin JR, Hame SL, Hannafin JA, Harner CD, Harris NL, Hechtman KS, Hershman EB, Hoellrich RG, Hosea TM, Johnson DC, Johnson TS, Jones MH, Kaeding CC, Kamath GV, Klootwyk TE, Levy BA, Ma CB, Maiers GP, Marx RG, Matava MJ, Mathien GM, DR MA, EC MC, RG MC, Miller BS, Nissen CW, O'Neill DF, Owens BD, Parker RD, Purnell ML, Ramappa AJ, Rauh MA, Rettig AC, Sekiya JK, Shea KG, Sherman OH, Slauterbeck JR, Smith MV, Spang JT, Svoboda SJ, Taft TN, Tenuta JJ, Tingstad EM, Vidal AF, Viskontas DG, White RA, Williams JS, Wolcott ML, Wolf BR. Subsequent surgery after revision anterior cruciate ligament reconstruction: rates and risk factors from a multicenter cohort. Am J Sports Med. 2017;45:2068–76.
Meister M, Koch J, Amsler F, Arnold MP, Hirschmann MT. ACL suturing using dynamic intraligamentary stabilisation showing good clinical outcome but a high reoperation rate: a retrospective independent study. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):655–9.
Bordes P, Laboute E, Bertolotti A, Dalmay JF, Puig P, Trouve P, Verhaegue E, Joseph PA, Dehail P, De Seze M. No beneficial effect of bracing after anterior cruciate ligament reconstruction in a cohort of 969 athletes followed in rehabilitation. Annals of physical and rehabilitation medicine (no pagination), 2017. 2017;Date of Publication: April 18.
Runner RP, Boden SA, Godfrey WS, Premkumar A, Samady H, Gottschalk MB, Xerogeanes JW. Quadriceps strength deficits after a femoral nerve block versus adductor canal block for anterior cruciate ligament reconstruction: a prospective, single-blinded, randomized trial. Orthop J Sports Med. 2018;6.
Su AW, Storey EP, Lin SC, Forst B, Lawrence JT, Ganley TJ, Wells L. Association of the graft size and arthrofibrosis in young patients after primary anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2018;26:e483–e9.
Osti M, El Attal R, Doskar W, Höck P, Smekal V. High complication rate following dynamic intraligamentary stabilization for primary repair of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):29–36.
Westermann RW, Spindler KP, Huston LJ, Wolf BR. Outcomes of grade III medial collateral ligament injuries treated concurrently with anterior cruciate ligament reconstruction: a multicenter study. Arthroscopy. 2019;35:1466–72.
Patel AR, Sarkisova N, Smith R, Gupta K, VandenBerg CD. Socioeconomic status impacts outcomes following pediatric anterior cruciate ligament reconstruction. Medicine. 2019;98:e15361.
Cruz AI, Fabricant PD, McGraw M, Rozell JC, Ganley TJ, Wells L. All-epiphyseal ACL reconstruction in children: review of safety and early complications. J Pediatr Orthop. 2017;37:204–9.
Offerhaus C, Balke M, Hente J, Gehling M, Blendl S, Hoher J. Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):3014–21.
Panisset JC, Gonzalez JF, de Lavigne C, Ode Q, Dejour D, Ehlinger M, Fayard JM, Lustig S. ACL reconstruction in over-50 year-olds: comparative study between prospective series of over-50 year-old and under-40 year-old patients. Orthop Traumatol Surg Res. 2019;105:S259–S65.
Grassi A, Costa GG, Cialdella S, Lo Presti M, Neri MP, Zaffagnini S. The 90-day readmission rate after single-bundle ACL reconstruction plus LET: analysis of 2,559 consecutive cases from a single institution. J Knee Surg. 2020.
Huleatt J, Gottschalk M, Fraser K, Boden A, Dalwadi P, Xerogeanes J, Hammond K. Risk factors for manipulation under anesthesia and/or lysis of adhesions following anterior cruciate ligament reconstruction. Arthroscopy. 2018;34:e8–9.
Schindler OS. Surgery for anterior cruciate ligament deficiency: a historical perspective. Knee Surg Sports Traumatol Arthrosc. 2012;20:5–47.
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther. 2006;36:385–402.
Chambat P, Guier C, Sonnery-Cottet B, Fayard JM, Thaunat M. The evolution of ACL reconstruction over the last fifty years. Int Orthop. 2013;37:181–6.
Salzler MJ, Lin A, Miller CD, Herold S, Irrgang JJ, Harner CD. Complications after arthroscopic knee surgery. Am J Sports Med. 2014;42:292–6.
Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy. 2007;23:1320–5.e6.
Huston LJ, Greenfield ML, Wojtys EM. Anterior cruciate ligament injuries in the female athlete. Potential risk factors. Clin Orthop Relat Res. 2000:50–63.
Slauterbeck JR, Fuzie SF, Smith MP, Clark RJ, Xu K, Starch DW, Hardy DM. The menstrual cycle, sex hormones, and anterior cruciate ligament injury. J Athl Train. 2002;37:275–8.
Wentorf FA, Sudoh K, Moses C, Arendt EA, Carlson CS. The effects of estrogen on material and mechanical properties of the intra- and extra-articular knee structures. Am J Sports Med. 2006;34:1948–52.
Park SK, Stefanyshyn DJ, Loitz-Ramage B, Hart DA, Ronsky JL. Changing hormone levels during the menstrual cycle affect knee laxity and stiffness in healthy female subjects. Am J Sports Med. 2009;37:588–98.
Tibor L, Chan PH, Funahashi TT, Wyatt R, Maletis GB, Inacio MC. Surgical technique trends in primary ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am. 2016;98:1079–89.
Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q. A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee. 2015;22:100–10.
Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475:2459–68.
Noyes FR, Barber-Westin SD. Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy. 2012;28:123–30.
Weber J, Koch M, Angele P, Zellner J. The role of meniscal repair for prevention of early onset of osteoarthritis. J Exp Orthop. 2018;5:10.
Phillips M, Ronnblad E, Lopez-Rengstig L, Svantesson E, Stalman A, Eriksson K, Ayeni OR, Samuelsson K. Meniscus repair with simultaneous ACL reconstruction demonstrated similar clinical outcomes as isolated ACL repair: a result not seen with meniscus resection. Knee Surg Sports Traumatol Arthrosc. 2018;26:2270–7.
All contributors are authors.
This work was supported by grants from the National Natural Science Foundation of China (grant number 81772384).
Ethics approval and consent to participate
No formal ethical approval and consent to participate are required due to no collection of primary data.
Consent for publication
No consent for publication is required due to no personal data included.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Wang, B., Zhong, JL., Xu, XH. et al. Incidence and risk factors of joint stiffness after Anterior Cruciate Ligament reconstruction. J Orthop Surg Res 15, 175 (2020). https://doi.org/10.1186/s13018-020-01694-7