Chondral Lesion Severity and Location Are Not Associated With Return‐to‐Play Outcomes After Anterior Cruciate Ligament Reconstruction

Purpose To evaluate return‐to‐play rate, timing, and performance level at 5 years after primary anterior cruciate ligament (ACL) reconstruction in patients with concomitant chondral lesions and to determine whether lesion severity, location, or coexisting meniscal pathology influenced these outcomes. Secondarily, ipsilateral and contralateral ACL reinjury rate and patient‐reported outcomes were reported. Methods Patients who underwent primary ACL reconstruction with an arthroscopically confirmed chondral lesion were included and followed up for 5 years. Exclusion criteria were the absence of chondral injury, the need for concurrent repair or reconstruction of knee ligaments other than the ACL, and an age outside the specified range (13‐45 years). Lesion severity was graded using the International Cartilage Repair Society system. Chondral lesions were left in situ or underwent chondroplasty or microfracture. Return‐to‐play (RTP) rate, RTP timing, performance level, incidence of ACL reinjury, and patient‐reported outcomes were compared by chondral lesion severity and location. The patient‐reported outcomes used were the Marx Activity Rating Scale score, Knee Injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee score, and the Western Ontario and McMaster Universities Osteoarthritis Index. Between‐group comparisons were performed using χ 2 (categorical) and Mann‐Whitney U or Kruskal‐Wallis (continuous) tests. Multivariable Cox regression and ordinal regression analyzed independent predictors of RTP and patient‐reported outcomes. Results A total of 441 patients were included at a minimum of 5‐year (mean 61 months, range 60‐72 months) follow‐up. The mean age at surgery was 26.8 ± 7.6 years, and 78% (346/441) of patients were male. At 5 years, 83% (348/419) of patients had returned to play, with no statistically significant difference in RTP rates between grade 1 to 2 and grade 3 to 4 lesions in either the medial (85% (102/120) vs 77.4% (55/71), P = .179) or lateral compartments (85.1% (149/175) vs 86.6% (13/15), P = .850). The mean time from surgery to RTP was 13.9 ± 8 months, and this did not differ by lesion severity (grade 1‐2 vs grade 3‐4) in any compartment. At 5 years, there was no difference in performance level (achieving the same/higher) between those with medial, lateral, and patellofemoral chondral injuries (medial 57.4% (101/176) vs lateral 64.7% (101/156) vs patellofemoral joint 69.0% (9/29), P = .268). Contralateral injury rates were lower for patients with grade 3 to 4 lesions (4.2%, 3/71) of the medial compartment compared with grade 1 to 2 (12.9%, 27/210, P < .033). The mean Marx score declined across all knee compartments at 5 years postoperatively although there was no difference in the mean reduction between each compartment ( P = .845). In the medial compartment, grade 1 to 2 lesions had an average International Knee Documentation Committee score of 85.0 ± 12.9, whereas grade 3 to 4 lesions scored 81.0 ± 14.4 ( P < .020). Similarly, in the lateral compartment, grade 1 to 2 lesions averaged 86.9 ± 11.7, compared with 80.9 ± 15.8 in grade 3 to 4 lesions ( P < .049). Increasing age was associated with worse International Knee Documentation Committee scores (odds ratio: 0.94, 95% confidence interval: 0.91‐0.97, P < .001) and worse Western Ontario and McMaster Universities Osteoarthritis Index total scores (odds ratio: 1.1, 95% confidence interval: 1.01‐1.09, P < .003). Conclusions Chondral lesion severity and location did not determine RTP rate, performance, or postoperative activity levels. Combined high‐grade medial chondral pathology with medial meniscal involvement and increasing age predicted worse patient‐reported outcomes. These findings support counselling athletes that RTP is achievable despite focal chondral damage. Level of Evidence Level IV, retrospective cohort study.