Increased Risk of Concomitant Meniscal Injuries in Adolescents With Elevated Body Mass Index After Anterior Cruciate Ligament Tear: A Systematic Review

  • Ashley Cheuk Hei Ang
    Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    Search for articles by this author
  • Doris Wong
    Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    Search for articles by this author
  • Pauline Po Yee Lui
    Address correspondence to Pauline Po Yee Lui, Ph.D., Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Room 74037, 5/F Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Hong Kong SAR, China.
    Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

    Center for Neuromusculoskeletal Restorative Medicine, Hong Kong SAR, China
    Search for articles by this author


      To investigate existing studies examining the association between body mass index (BMI) and outcomes of anterior cruciate ligament reconstruction (ACLR) in adolescent patients.


      A literature search was conducted on PubMed and Embase. Studies examining associations between BMI and outcomes after ACLR in adolescents were included. Quality assessment was performed. Data on patient age, sex, study design, time of follow-up, sample size, graft type, concomitant injuries (meniscal injury, surgical procedures), clinical outcomes (revision ACLR, postoperative weight gain, post-traumatic osteoarthritis [PTOA], range of motion [ROM]), and functional outcome (muscle strength) were extracted.


      Eleven papers of Levels II-IV evidence were included. Five studies found positive correlations between BMI and risk of concomitant meniscal injuries. Two of them reported young patients with elevated BMI having 1.6 times greater odds of requiring meniscectomy (P < .01) and 1.031 times greater odds of requiring concomitant surgeries (P = .011). One study showed significant positive association of postoperative weight gain by time (r = 0.28, P < .01), with smaller increase in the overweight and obese groups compared with the normal-weight group. One study demonstrated greater cartilage breakdown in young patients with overweight and obesity postsurgery, contributing to PTOA (r = 0.42, P = .009). There was no clinically important difference in postoperative ROM and muscle strength. Four studies reviewed the association between BMI and revision ACLR risk, but results were heterogeneous and a firm conclusion cannot be drawn.


      Adolescents with elevated BMI are more likely to have concomitant meniscal injuries and surgical procedures after ACL tear. There is some weak evidence of the association of elevated BMI with PTOA and slight postoperative weight gain post-ACLR. There may not be any clinically significant association of obesity with post-operative muscle strength and ROM, and current studies are inconclusive regarding the impact of BMI on revision ACLR risk.

      Level of Evidence

      Level IV, systematic review of Level II-IV studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cooper J.D.
        • Lorenzana D.J.
        • Heckmann N.
        • et al.
        The effect of obesity on operative times and 30-day readmissions after anterior cruciate ligament reconstruction.
        Arthroscopy. 2019; 35: 121-129
        • Beck N.A.
        • Lawrence J.T.
        • Nordin J.D.
        • DeFor T.A.
        • Tompkins M.
        ACL tears in school-aged children and adolescents over 20 years.
        Pediatrics. 2017; 139e20161877
        • Barrett A.M.
        • Craft J.A.
        • Replogle W.H.
        • Hydrick J.M.
        • Barrett G.R.
        Anterior cruciate ligament graft failure.
        Am J Sports Med. 2011; 39: 2194-2198
        • Snaebjörnsson T.
        • Svantesson E.
        • Sundemo D.
        • et al.
        Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: A cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3583-3591
        • World Health Organization
        Obesity and overweight.
        • Pfeifer C.E.
        • Beattie P.F.
        • Sacko R.S.
        • Hand A.
        Risk factors associated with non-contact anterior cruciate ligament injury: A systematic review.
        Int J Sports Phys Ther. 2018; 13: 575-587
        • Kluczynski M.A.
        • Bisson L.J.
        • Marzo J.M.
        Does body mass index affect outcomes of ambulatory knee and shoulder surgery?.
        Arthroscopy. 2014; 30: 856-865
        • Bin Abd Razak H.R.
        • Chong H.-C.
        • Tan H.-C.A.
        Obesity is associated with poorer range of motion and Tegner scores following hamstring autograft anterior cruciate ligament reconstruction in Asians.
        Ann Transl Med. 2017; 5 (304-304)
        • Harput G.
        • Guney-Deniz H.
        • Ozer H.
        • Baltaci G.
        • Mattacola C.
        Higher body mass index adversely affects knee function after anterior cruciate ligament reconstruction in individuals who are recreationally active.
        Clin J Sport Med. 2020; 30: e194-e200
        • DiSilvestro K.J.
        • Jauregui J.J.
        • Glazier E.
        • et al.
        Outcomes of anterior cruciate ligament reconstruction in obese and overweight patients.
        Clin J Sport Med. 2019; 29: 257-261
      1. Hagan J.F. Shaw J.S. Duncan P.M. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 4th ed. American Academy of Pediatrics, Elk Grove Village, IL2017
        • Maletis G.B.
        • Chen J.
        • Inacio M.C.S.
        • Funahashi T.T.
        Age-related risk factors for revision anterior cruciate ligament reconstruction.
        Am J Sports Med. 2016; 44: 331-336
        • Raad M.
        • Thevenin Lemoine C.
        • Bérard E.
        • Laumonerie P.
        • Sales de Gauzy J.
        • Accadbled F.
        Delayed reconstruction and high BMI Z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 905-911
        • Vavken P.
        • Tepolt F.A.
        • Kocher M.S.
        Concurrent meniscal and chondral injuries in pediatric and adolescent patients undergoing ACL reconstruction.
        J Pediatr Orthop. 2018; 38: 105-109
        • Traven S.A.
        • Wolf G.J.
        • Goodloe J.B.
        • Reeves R.A.
        • Woolf S.K.
        • Slone H.S.
        Elevated BMI increases concurrent pathology and operative time in adolescent ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 4182-4187
        • Perkins C.
        • Christino M.
        • Busch M.
        • et al.
        Rates of concomitant meniscal tears in pediatric patients with anterior cruciate ligament injuries increase with age and body mass index.
        Orthop J Sports Med. 2021; 92325967120986565
        • Patel N.M.
        • Talathi N.S.
        • Bram J.T.
        • DeFrancesco C.J.
        • Ganley T.J.
        How does obesity impact pediatric anterior cruciate ligament reconstruction?.
        Arthroscopy. 2019; 35: 130-135
        • MacAlpine E.M.
        • Talwar D.
        • Storey E.P.
        • Doroshow S.M.
        • Lawrence J.T.
        Weight gain after ACL reconstruction in pediatric and adolescent patients.
        Sports Health. 2020; 12: 29-35
        • Lee R.J.
        • Margalit A.
        • Nduaguba A.
        • Gunderson M.A.
        • Wells L.
        Obesity and recovery of muscle strength after anterior cruciate ligament reconstruction in pediatric patients.
        J Orthop Surg (Hong Kong). 2018; 262309499018806631
        • Burns E.A.
        • Collins A.D.
        • Jack R.A.
        • McCulloch P.C.
        • Lintner D.M.
        • Harris J.D.
        Trends in the body mass index of pediatric and adult patients undergoing anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2018; 6232596711876739
        • Lane A.R.
        • Harkey M.S.
        • Davis H.C.
        • et al.
        Body mass index and type 2 collagen turnover in individuals after anterior cruciate ligament reconstruction.
        J Athl Train. 2019; 54: 270-275
        • Asai K.
        • Nakase J.
        • Shimozaki K.
        • Yoshimizu R.
        • Kimura M.
        • Tsuchiya H.
        Skeletally immature patient showed lower graft maturity than skeletally mature patient after ACL reconstruction with a rounded rectangular femoral tunnel.
        Sci Rep. 2021; 1119968
        • Grindem H.
        • Snyder-Mackler L.
        • Moksnes H.
        • Engebretsen L.
        • Risberg M.A.
        Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: The Delaware-Oslo ACL Cohort Study.
        Br J Sports Med. 2016; 50: 804-808
        • Thorolfsson B.
        • Svantesson E.
        • Snaebjornsson T.
        • et al.
        Adolescents have twice the revision rate of young adults after ACL reconstruction with hamstring tendon autograft: A study from the Swedish National Knee Ligament Registry.
        Orthop J Sports Med. 2021; 923259671211038893
        • Wluka A.E.
        • Lombard C.B.
        • Cicuttini F.M.
        Tackling obesity in knee osteoarthritis.
        Nat Rev Rheumatol. 2013; 9: 225-235
        • McPherson A.L.
        • Feller J.A.
        • Hewett T.E.
        • Webster K.E.
        Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries.
        Am J Sports Med. 2019; 47: 857-862
        • Vincent H.K.
        • Lamb K.M.
        • Day T.I.
        • Tillman S.M.
        • Vincent K.R.
        • George S.Z.
        Morbid obesity is associated with fear of movement and lower quality of life in patients with knee pain-related diagnoses.
        PM R. 2010; 2: 713-722
        • Kvist J.
        • Ek A.
        • Sporrstedt K.
        • Good L.
        Fear of re-injury: A hindrance for returning to sports after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2005; 13: 393-397
        • Abrams G.D.
        • Harris J.D.
        • Gupta A.K.
        • et al.
        Functional performance testing after anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2014; 22325967113518305
        • Kong D.H.
        • Yang S.J.
        • Ha J.K.
        • Jang S.H.
        • Seo J.G.
        • Kim J.G.
        Validation of functional performance tests after anterior cruciate ligament reconstruction.
        Knee Surg Relat Res. 2012; 24: 40-45
        • Zebis M.K.
        • Warming S.
        • Pedersen M.B.
        • et al.
        Outcome measures after ACL injury in pediatric patients: A scoping review.
        Orthop J Sports Med. 2019; 72325967119861803
        • Kroker A.
        • Besler B.A.
        • Bhatla J.L.
        • et al.
        Longitudinal effects of acute anterior cruciate ligament tears on periarticular bone in human knees within the first year of injury.
        J Orthop Res. 2019; 37: 2325-2336
        • Macfarlane G.J.
        • de Silva V.
        • Jones G.T.
        The relationship between body mass index across the life course and knee pain in adulthood: Results from the 1958 Birth Cohort Study.
        Rheumatology. 2011; 50: 2251-2256
        • Filbay S.R.
        • Grindem H.
        Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture.
        Best Pract Res Clin Rheumatol. 2019; 33: 33-47
        • Manek N.J.
        • Hart D.
        • Spector T.D.
        • MacGregor A.J.
        The association of body mass index and osteoarthritis of the knee joint: An examination of genetic and environmental influences.
        Arthritis Rheum. 2003; 48: 1024-1029
        • Lee J.M.
        • Pilli S.
        • Gebremariam A.
        • et al.
        Getting heavier, younger: Trajectories of obesity over the life course.
        Int J Obes (Lond). 2010; 34: 614-623
        • Myer G.D.
        • Lloyd R.S.
        • Brent J.L.
        • Faigenbaum A.D.
        How young is “too young” to start training?.
        ACSMs Health Fit J. 2013; 17: 14-23
        • Widhalm K.
        • Schönegger K.
        • Huemer C.
        • Auterith A.
        Does the BMI reflect body fat in obese children and adolescents? A study using the Tobec method.
        Int J Obes Relat Metab Disord. 2001; 25: 279-285
        • Karchynskaya V.
        • Kopcakova J.
        • Klein D.
        • et al.
        Is BMI a valid indicator of overweight and obesity for adolescents?.
        Int J Environ Res Public Health. 2020; 17: 4815
        • Peltz G.
        • Aguirre M.T.
        • Sanderson M.
        • Fadden M.K.
        The role of fat mass index in determining obesity.
        Am J Hum Biol. 2010; 22: 639-647
        • Alpízar M.
        • Frydman T.D.
        • Reséndiz-Rojas J.J.
        • Trejo-Rangel M.A.
        • Aldecoa-Castillo J.M.
        Fat mass index (FMI) as a trustworthy overweight and obesity marker in Mexican pediatric population.
        Children (Basel). 2020; 7: 19