ACL Reconstruction and Osteoarthritis: What the Latest 20-Year Research Means for Athletes

If you’re an athlete or active individual facing ACL reconstruction, you’re probably thinking about not just your return to sport, but also your long-term knee health. A recent systematic review and meta-analysis published in the Orthopaedic Journal of Sports Medicine brings new insights into what you can expect 20 years after ACL surgery—especially regarding osteoarthritis (OA).

Key Takeaways from the 20-Year Review

• Most patients have good knee function 20 years post-ACL reconstruction.

• The risk of developing knee osteoarthritis is nearly 3x higher in the operated knee compared to the uninjured knee.

• Severe osteoarthritis is relatively uncommon, affecting only about 13% of patients.

• Total knee replacement after ACL reconstruction is rare (just over 1% at 20 years).

What Did the Study Look At?

Researchers analysed 16 studies covering 1,771 patients with an average follow-up of nearly 23 years after ACL reconstruction. Most surgeries used the bone–patellar tendon–bone (BPTB) technique, and patients were, on average, 25 years old at the time of surgery.

They examined:

• Patient-reported outcomes (Lysholm, IKDC, KOOS scores)

• Clinical stability (Lachman, pivot shift, KT-1000 tests)

• Radiographic signs of osteoarthritis

• Rates of revision surgery and failures

ACL Surgery: Strong Results, But OA Risk Remains

The good news? Most athletes report satisfactory knee function and pain levels, even after two decades. Clinical tests show that only about 10% have significant instability or laxity in the knee.

However, the risk of radiographic osteoarthritis is significantly increased:

• 73% showed some signs of OA in the operated knee at 20+ years.

• The risk of OA is 2.8 times higher in the reconstructed knee compared to the healthy knee.

• Severe OA was seen in only 12.8% of patients.

• Total knee replacement was needed in just 1.1% of cases.

Who Is at Higher Risk for OA After ACL Surgery?

The study identified several risk factors that increase the likelihood of developing OA after ACL reconstruction:

• Male sex

• Older age at the time of surgery

• Delaying ACL reconstruction after injury

• Meniscal or cartilage injuries

• BPTB graft type

• Non-ideal tunnel placement during surgery

• Residual knee laxity

• High post-op activity levels

• Postoperative range of motion deficits

Notably, patients who had meniscus or cartilage injuries at the time of ACL surgery were at much higher risk for OA. Protecting and repairing the meniscus during surgery is critical for long-term knee health.

What Does This Mean for Athletes at Game Time Performance?

At Game Time Performance, we take a holistic, evidence-based approach to ACL rehabilitation, focusing on:

• Early, expert-guided rehab to restore full range of motion and strength

• Sport-specific, supervised strength and conditioning to minimize re-injury risk

• Close collaboration with surgeons to ensure optimal surgical technique and graft selection

• Long-term athlete monitoring to catch and address any early signs of OA

How Can You Lower Your OA Risk After ACL Surgery?

• Prioritise meniscus preservation or repair during your surgery.

• Commit to a full, high-quality rehab program—don’t cut corners!

• Maintain knee strength and mobility long after you return to play.

• Report any new pain, swelling, or instability to your physiotherapist right away.

The Bottom Line

ACL reconstruction is highly effective at restoring knee function and getting athletes back in the game. But even decades later, there’s a real risk of developing osteoarthritis—especially if you have other knee injuries or don’t complete a thorough rehab.

At Game Time Performance, we’re here to guide you every step of the way—from surgery to long-term joint health.

Want to know more about our ACL rehab and OA prevention programs? Book a call today and protect your knees for life.