Introduction

The purpose of this study was to identify and assess patient, surgical, and post-operative factors that affect rates and times to return to play (RTP) in professional footballers (soccer players). The secondary objective was to evaluate how these variables affected ACL re-rupture rates in this challenging patient group.

Methods

A retrospective review of a consecutive series of isolated primary ACL reconstruction (ACL-R) undertaken by the senior author between January 1st 2005 and December 31st 2018 was conducted. All patients were professional footballers aged 17 years or older. The minimum follow-up was 2 years.

Results

232 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. 150 (64.7%) involved patellar tendon (PT) autograft, 81 (34.9%) hamstring autograft and one (0.4%) PT allograft.

222 (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 affected the return to play rate. 1- Players under 25 years had a significantly higher rate of RTP than older footballers (99.3% versus 90.2%; p=0.001). 2- a subsequent operation prior to RTP decreased RTP rate (98.2% vs 89.7% (p = 0.009)). 3- medial meniscus repair at time of ACL-R reduced the RTP rate compared to meniscectomy (84% vs 100%, p = 0.017).

The mean time to RTP from ACL reconstruction was 10.5 ± 3.6 months. Factors found to significantly increase return to play time included age under 25 (11.0 vs 9.7 months, p=0.005), recurrent effusions (11.4 vs 10.2 months, p=0.035), and a subsequent operation before returning to play (13.4 vs 9.7 months, p= <0.001). In addition, medial meniscal repair at the time of the ACL-R, delayed RTP compared to those who underwent meniscectomy (12.5 vs 9.6 months, p=0.022).

The overall graft re-rupture rate was 8.3% - 12 (5.2%) occurred within the first year (5 before RTP). 7 (3.1%) re-ruptured between 1 - 2 years post-surgery. The surgical technique varied over the study period in relation to graft type femoral tunnel position, and addition of lateral extra-articular tenodesis (LET). PT autograft in an anteromedial (AM) bundle femoral tunnel position with the addition of LET) had the lowest re-rupture rate (2%)- the highest being 4 strand hamstring in the central (anatomic) femoral position without LET (18.5%). However, no factors were found individually to have a statistically significant effect on re-rupture rate.

Conclusion

Primary ACL reconstruction in professional soccer players yields high rates of return to play (over 95%) with 90.1% returning to the same or higher level at a mean 10.5 months. Players under 25 years old had a significantly higher RTP rate, but also increased time to RTP. Based in this evidence in order to minimise graft re-rupture rate the senior author’s preferred technique is PT autograft in the AM bundle femoral position plus LET.