Following ACL reconstruction (ACLR), main concerns of athletes are whether they will be able to return to their sport and how quickly, and the risk of needing revision. We report the return to play (RTP) rates and times in elite sports and the factors affecting them, and graft failure rates.
A consecutive series of primary ACLR in elite athletes (defined as playing professional sport or top-level amateur sport) between January 2005 and June 2018 were retrospectively reviewed. Academy footballers (<17 years) and rugby players (<18 years), those with other knee ligament surgery, or with less than 2 years follow up were excluded. Variables including age, surgical technique, concomitant injuries and subsequent interventions were analysed for their effect on RTP rates, time to return and re-rupture. RTP was defined as the time between ACLR and first professional game.
376 athletes were included with 24 (6.4%) of these receiving bilateral ACLRs. 229 were footballers, 115 rugby players and 56 other sports. Mean age at operation was 23.1 years. 88% of footballers and 90.4% of rugby ACLRs were male compared to 37.5% in the other sports group. 71.3% of knees had new meniscal damage. 17.4% of rugby players also had ICRS grade 3 / 4 chondral lesions compared to 10.5% in footballers and 5.4% in other sports.
58% of ACLR were performed using hamstring (HS) autografts, 41.8% had patellar tendon (PT) autografts and one case, at the player’s insistence, had an allograft. The operative technique evolved: between 2010 and 2013 (114 knees) the femoral tunnel was drilled in the “anatomic” central femoral footprint position rather than the anteromedial bundle (AMB) position (286 knees). 68.9% had a lateral extra-articular tenodesis (LET) in the last 3 years of the study compared to 23% of knees overall.
Rugby (91.3%) had the lowest RTP rate compared to football (95.6%) and other sports (98.2%). Footballers aged under 25 years had a significantly higher RTP rate compared to the older group (99.3% vs 90.2, p=0.001) whereas in rugby and other sports RTP was greater in the older age group (92.9% vs 90.4% and 100% vs 97.5% respectively).
The mean RTP time was fastest for rugby players (9.5 months vs 10.5 in football and 10.7 in other sports) and was longer in athletes receiving PT grafts (10.9 vs 9.8), those with concomitant meniscal injuries (10.5 vs 9.6), post- operative recurrent effusions (11.1vs 10.0) and those undergoing further surgery before RTP (12.8 vs 9.6).
Re-rupture occurred in 6 (5 football, 1 rugby) cases prior to RTP and only one, a footballer, failed to RTP following revision ACLR. LET and AMB femoral tunnel position did not affect RTP but did reduce re-rupture rates (4.4% vs 8.8% and 6.6% vs 10.5% respectively).
Between 91-98% of elite athletes in a wide range of sports will return to professional sport with the time to RTP being affected by several factors. Recurrent effusions and further interventions prolonged RTP time. Using the AMB femoral tunnel position and adding LET reduces graft re-rupture.