Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers

Abstract

Purpose Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that afected rates and time to return to play (RTP) as well as ACL re-rupture rates. Methods A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. Results Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently afected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent efusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). Conclusion Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a signiicantly higher RTP rate, but also had a lengthier period of rehabilitation. Level of evidence Level IV.

Editorial Commentary: Lateral Extra-Articular Tenodesis Reduces Anterior Cruciate Ligament Graft Rerupture Rates: Proper Anterior Cruciate Ligament and Lateral Extra-Articular Tenodesis Technique Is Vital to Prevent Complications

“…This does create a thickened appearance to the lateral contour of the knee, however. Despite my concerns regarding graft fixation strength, my clinical outcomes demonstrate reduced risk of ACL graft rerupture 6 in keeping with those of others. 7 Being interested in the important technical issue of avoiding tunnel conflict, I was fortunate to be invited to collaborate with Meng Zhu and Dave Lee from Singapore.…”

“…When I returned to using the AMB position, rerupture rates fell. 6,9 The different femoral tunnel positions also have other implications. "Anatomic" placement makes tunnel trajectory "flatter" in the coronal and axial planes, so increasing the risk of conflict with a LET tunnel.…”

Rates and Levels of Elite Sport Participation at 5 Years After Revision ACL Reconstruction

“…13 This is much higher than the RTP rates found in recreational athletes, but in 19% of those cases, the knee was not the primary reason for their decision not to RTP. 21 However, our RTP rate is lower than the RTP of 96.1% reported by Balendra et al 2 after primary ACLR in professional soccer players. The current study shows that soccer players had a significantly higher playing rate at the point of RTP (96.7% vs 70.6%; P = .025) as well as at 2 years after surgery (92.6% vs 58.8%; P = .017) when compared with rugby players.…”

“…Although KOOS scores were obtained in 34 (69.4%) cases, no other validated outcome score was collected, which is consistent with previous studies on elite athletes. 2,14,18,29,32…”

“…Although KOOS scores were obtained in 34 (69.4%) cases, no other validated outcome score was collected, which is consistent with previous studies on elite athletes. 2,14,18,29,32 The national league in which the athlete's club participates or the athlete's participation in international competitions is a crude reflection of the athlete's performance, and we are unable to comment on the individual player's performance. While this is a limitation, it was thought nevertheless that RTP rates and competition level, as well as the effect of the intra-articular pathology on these outcomes, are of the utmost importance to the players, their medical teams, and treating surgeons.…”