Treatment of Anterior Cruciate Ligament Injuries by Major League Soccer Team Physicians

Anterior Cruciate Ligament Tears in Soccer Players

Anterior cruciate ligament (ACL) injuries to soccer players present unique challenges in sports medicine, given the sport's global prevalence and intricate injury dynamics. These injuries, especially in the youth and female demographic, have become a substantial concern in sports medicine. This review explores the epidemiology, mechanism of injury, diagnostic procedures, treatment modalities, and rehabilitation strategies related to ACL tears within the soccer community. Progress in diagnostics, treatments, and rehabilitation underscores the importance of evidence-based approaches. As soccer continues its ascent in popularity, addressing the specific risks and nuances of ACL injuries in this context remains of paramount significance.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Evolution of anterior cruciate ligament reconstruction & graft choice: a review

The surgical treatment of anterior cruciate ligament (ACL) injuries dates back over 100 years from the present day [2022]. While open repair of the torn ACL was popularized in the early 1900s, the first ACL reconstructions utilized the fascia lata as a graft and other extra-articular stabilizing techniques. The first free tendon graft reported for ACL reconstructions was the quadriceps tendon (QT) in the 1930s, followed by the hamstrings tendon (HT), and then the patellar tendon. With improved understanding of the ACL anatomy and biomechanics and the invention of the arthroscope, ACL reconstruction evolved from open procedures to arthroscopic. Similarly, with the help of many surgeon-scientists who reported patient outcomes following ACL reconstruction with various techniques, graft choice evolved with the hamstrings and patellar tendon grafts becoming the dominant and preferred choice of both surgeons and patients. In present day, we see a resurgence of one of the original grafts reported, the QT, as well as primary ACL repair. Future research will result in continued advancements of ACL surgical techniques and graft harvesting, which will allow the orthopedic community (including patients and surgeons) to benefit from such innovations and advanced technologies.

Return to Sport After Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Survey of The American Orthopaedic Society for Sports Medicine

Introduction

Anterior cruciate ligament (ACL) tears are a common sports injury, and typically require a prolonged post-operative rehabilitation. The purpose of this study was to survey members of the American Orthopaedic Society for Sports Medicine (AOSSM) to determine their return to sport (RTS) criteria after primary ACL reconstruction (ACLR).

Methods

A 23-question, anonymous survey hosted through Google^® Docs was distributed electronically to AOSSM members. This survey included questions regarding the timing, as well as any functional tests or other metrics used to determine when an athlete is ready to RTS.

Results

A total of 863 surgeons responded over four months. The most popular graft choice was bone patellar tendon bone autograft (63%). For non-pivoting sports, 43% of respondents allowed RTS at five to six months, while 31% allowed RTS at seven to eight months. For pivoting sports, 34% of respondents allowed RTS at seven to eight months, while 36% allowed RTS at nine to ten months. The most common criteria for return to non-pivoting sports include full knee motion (89%) and time after ACLR (76%). The most common criteria for return to pivoting sports include full knee motion (87%) and passing a hop test (80%). Only 21% of respondents assessed for psychological readiness to RTS.

Conclusions

RTS occurred sooner in non-pivoting than pivoting sports, with similar RTS criteria in both groups. Most respondents did not assess for psychological readiness to RTS.

Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group

BACKGROUND

Bone-patellar tendon-bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR).

PURPOSE/HYPOTHESIS

The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non-graft rupture-related reoperation rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records.

RESULTS

A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged <20 years were at a particularly high risk of graft ruptures compared with patients aged >30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar.

CONCLUSION

Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India

BACKGROUND

Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice.

METHODS

A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed.

RESULTS

324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft.

CONCLUSION

Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.

Risk of Graft Rupture After Adding a Lateral Extra-articular Procedure at the Time of ACL Reconstruction: A Retrospective Comparative Study of Elite Alpine Skiers From the French National Team

BACKGROUND

Elite alpine skiing is associated with a particularly high risk of anterior cruciate ligament (ACL) injuries, including graft ruptures. Despite a considerable focus on prevention, a reduction in injury rates has not been observed since the 1980s.

PURPOSE

To determine whether elite alpine skiers undergoing ACL reconstruction (ACLR) with a lateral extra-articular procedure (LEAP) had a lower rate of ACL graft rupture when compared with those who underwent isolated ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Elite skiers from the French ski team who had undergone ACLR, with or without a LEAP, and had a minimum follow-up of 2 years were identified from the national ski team database. Rates of secondary ACL injury were determined via interrogation of the database, review of medical notes, and a final telemedicine interview. A multivariable analysis using the penalized Cox model was performed to explore the relationship among graft rupture, surgical procedure type, and any potential explanatory variables.

RESULTS

Among 81 ACLR procedures analyzed, 50 were isolated and 31 were combined with a LEAP, which was performed using modified Lemaire or anterolateral ligament reconstruction. Graft rupture rates were 34.0% in the isolated ACLR group and 6.5% in the ACLR + LEAP group. Multivariable analysis demonstrated that adding a LEAP was associated with a significant reduction in risk of ACL graft rupture when compared with isolated ACLR (hazard ratio [HR], 5.286 [95% CI, 1.068-26.149]; P = .0412). Age (HR, 1.114; P = .1157), sex (HR, 1.573; P = .3743), and ACL graft type (HR, 1.417; P = .5394) were not significant risk factors.

CONCLUSION

Combined ACLR and LEAP were associated with a significant reduction in the rate of ACL graft rupture in elite alpine ski athletes. Those treated with isolated ACLR remain at extremely high risk of a second ACL injury.

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review

OBJECTIVE

We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes.

DATA SOURCES

PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized.

MAIN RESULTS

Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low.

CONCLUSION

Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players

BACKGROUND

Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.

METHODS

Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.

RESULTS

All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.

CONCLUSION

The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.

LEVEL OF EVIDENCE

Level II, prospective cohort case series study.

ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades

PURPOSE

Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG).

METHODS

Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period.

RESULTS

In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014.

CONCLUSION

Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case.

LEVEL OF EVIDENCE

Level V, Expert Opinion.

Functional Bracing Following Anterior Cruciate Ligament Reconstruction: A Critical Analysis Review

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Anterior cruciate ligament (ACL) injuries remain common among athletes; these injuries require reconstruction to restore stability and enable successful return to sport.

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The role of postoperative dynamic knee bracing following ACL reconstruction in protecting graft integrity and promoting return to sport remains largely unknown.

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Limited biomechanical studies on functional bracing have reported decreased strain across the ACL with increasing anterior shear loading.

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Investigations evaluating functional brace use in clinical studies have not yet demonstrated consistent improvement in clinical outcomes, reduced graft retear rates, or improved return-to-sport rates in sports other than skiing.

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Additional investigation examining athletes of various ages participating in different sporting activities is necessary to better understand the role of functional bracing following ACL reconstruction.

Return to Play and Player Performance After Achilles Tendon Rupture in UEFA Professional Soccer Players: A Matched-Cohort Analysis of Players From 1999 to 2018

Background:

Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury.

Purpose:

To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results:

The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [P < .001] and -560.17 vs -171.17 minutes [P < .05]) and recorded fewer goals (-1.06 vs -0.29 [P < .05]) and assists (-0.76 vs -0.02 [P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint.

Conclusion:

Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.

ACL reconstruction in the professional or elite athlete: state of the art

Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete's sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to 'near peak' performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques-particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.

Preferences in anterior cruciate ligament reconstruction and return to sport: A survey among surgeons in the Netherlands

OBJECTIVE

The purpose of this study was to investigate the preferences of surgeons on technique for femoral tunnel placement, graft selection and criteria for return to sport in the Netherlands.

METHODS

A web-based survey among the Dutch Association of Arthroscopy was conducted.

RESULTS

A total of 125 members (24.0%) were included in the analysis. A total of 87.2% (n = 109) used hamstring autografts for primary ACL reconstruction followed by patellar tendon autograft (n = 11, 8.8%) and quadriceps tendon autograft (n = 5, 4.0%). The anteromedial technique was favored by 50.4% (n = 63), whereas 11.2% (n = 14) of the participants favored the transtibial technique. Return to sport after 9 months of primary ACL reconstruction was allowed by 75.2% (n = 94) of the participants. Regarding criteria to evaluate readiness to return to sport, the surgeons stated postoperative period (n = 107, 85.6%) and functional performance tests (n = 96, 76.8%) as important.

CONCLUSION

The majority of the participants of the Dutch Association of Arthroscopy favored the hamstring autografts for primary anterior cruciate ligament reconstruction. Furthermore, most participants stated postoperative time and functional performance tests as important criteria to evaluate readiness to return to sport. This is the first survey demonstrating a high preference of surgeons to use functional performance tests in the decision-making of readiness to return to sport.

Professional Advancement and Performance of Amateur Baseball Players Selected in the Major League Baseball Draft With Previous Anterior Cruciate Ligament Reconstruction

BACKGROUND

The effect that an anterior cruciate ligament injury requiring reconstructive surgery has on the professional advancement and performance of amateur baseball players selected in the Major League Baseball draft is not known. Return to sports after anterior cruciate ligament reconstruction (ACLR) in professional athletes has been shown to be high, but mixed results with regard to performance and return to preinjury level have been demonstrated in other sports.

PURPOSE

To (1) investigate the highest level of professional advancement among Major League Baseball draftees with a history of ACLR before entering the draft, (2) examine how much time these players spent on the disabled list (DL) and determine if it was related to the knee, and (3) compare the batting and pitching performance of these players against healthy matched controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Predraft medical records of all players selected in the Major League Baseball draft from 2004 to 2008 were reviewed. Players with a documented anterior cruciate ligament injury treated with ACLR before the draft were included. For each study player, 3 controls were identified. Data were accumulated from the time when players were drafted through the 2015 season. Outcome variables included highest professional level of advancement, DL time, and batting and pitching performance.

RESULTS

Forty draftees with a history of ACLR (22 pitchers, 18 position players) were identified and matched to 120 controls (66 pitchers, 54 position players). The difference in the highest level of professional advancement between the groups was not statistically significant (P = .488). The mean total number of times and the mean total number of days on the DL were similar between the groups (1.83 vs 1.47, P = .297; 121.54 vs 109.62, P = .955); however, the mean number of times on the DL because of a knee injury was significantly different (0.28 vs 0.11, P = .004), as was the mean number of days on the DL because of a knee injury (17.36 vs 7.72, P = .009). Among pitchers, there were no differences in performance. Similarly, there were no differences among position players in batting performance.

CONCLUSION

There was no difference between draftees with a history of ACLR and their controls in terms of advancement from the minor to the major leagues. Additionally, pitching and batting performance were similar. Although the 2 groups spent similar time on the DL, the ACLR group spent more time on the DL because of a knee injury than the control group.

QUADRICEPS AUTOGRAFT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A LITERATURE REVIEW

ABSTRACT Introduction: Anterior cruciate ligament injury is one of the most prevalent musculoskeletal injuries. Therefore, several surgical techniques and graft types have been described for its reconstruction. Autologous hamstring tendon graft is one of the most frequently used, but use of the quadriceps tendon graft has gained prominence in recent years. Objective: To review the literature to compare the outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft versus hamstring tendon (HT) autograft. Methods: A literature review was conducted through PubMed to locate studies (Level of evidence I-III) comparing the outcomes of the QT autograft vs. the HT autograft in patients undergoing primary ACL reconstruction. Patients were assessed on the basis of re-rupture rate, ligament instability, patient-reported outcome scores, previous pain, and isokinetic tests. Results: Six studies were selected according to inclusion criteria. A total of 481 patients were evaluated, 243 in the QT group and 238 in the HT group. The total re-rupture rate was 1.6% (8 of 481), with 6 in the HT group and 2 in the QT group, but with no statistical difference between groups. One study found increased ligament instability in the HT group and another study found greater instability in the QT group, both with statistical significance. Regarding the patient-reported functional scores, only 01 study found statistical difference, with better results in the QT group. There was no difference in previous pain between groups in the selected studies. Regarding the isokinetic test, one study found a difference in flexor force in the HT group (p <0.01), with no difference in extensor force, while another two studies found an increased extensor force deficit in the QT group within up to 01 year of follow-up. The flexor/ extensor muscle strength ratio was higher in the QT group in both studies. Conclusion: ACL reconstruction with QT graft presents re-rupture rates, ligament instability, functional scores and donor site morbidity that are similar to the HT graft, in addition to preserving greater flexor force in proportion to extensor force. Level of evidence: IV; Review study.

Treatment of Anterior Cruciate Ligament Injuries in Professional Soccer Players by Orthopedic Surgeons

Objective  To describe the treatment provided by specialists for ACL lesions in professional soccer players. Methods  A cross-sectional study in which orthopedic surgeons affiliated to soccer teams competing in the Brazilian Soccer Championship answered a questionnaire about the treatment of ACL injuries in professional soccer players. Results  The specialists wait between one to four weeks after the ACL injury to perform the surgical treatment. They use a single incision and single-bundle reconstruction, assisted by arthroscopy, femoral tunnel drilling by an accessory medial portal, and quadruple flexor tendon autografts or patellar tendon autografts. After three to four months, the players are allowed to run in a straight line; after four to six months, they begin to practice exercises with the ball without contact with other athletes; and, after six to eight months, they return to play. The main parameter used to determine the return to play is the isokinetic strength test. The specialists estimate that more than 90% of elite soccer players return to playing professionally after an ACL reconstruction, and 60 to 90% return to play at their prior or at a greater level of performance. Conclusion  The present article successfully describes the main surgical practices and post-surgery management adopted by specialists in this highly-specific population of patients.

Length of Time Between Anterior Cruciate Ligament Reconstruction and Return to Sport Does Not Predict Need for Revision Surgery in National Football League Players

PURPOSE

To determine whether the length of time between primary anterior cruciate ligament reconstruction (ACLR) and return to sport (RTS) predicted the need for revision ACLR in National Football League (NFL) athletes.

METHODS

All NFL players who underwent ACLR from 2009 to 2015 were identified. The date of index ACLR and date of return to NFL regular-season game play after surgery were recorded. The length of time between ACLR and RTS was compared between players who required revision ACLR and those who did not. Correlation coefficients were used to assess whether players who RTS sooner sustained recurrent anterior cruciate ligament injury at an earlier date.

RESULTS

A total of 130 NFL players (average age, 25.3 ± 3.2 years) who underwent ACLR and returned to sport were identified. The average time to RTS after ACLR was 49.7 weeks after surgery. Of the players, 23 (18%) required revision ACLR. There was no significant difference in the length of time between ACLR and RTS in players who did not require revision ACLR (50.2 ± 10.1 weeks) and those who did (48.3 ± 11.0 weeks, P = .40). Time to RTS was not found to correlate with time to reinjury in athletes requiring revision ACLR (R = 0.21; 95% confidence interval, -0.18 to 0.54). A large proportion of players (56%) sustained a reinjury within the first 10 weeks of returning to NFL game play.

CONCLUSIONS

Our study found that timing of RTS after ACLR was not a significant risk factor for revision surgery in NFL athletes. Time to RTS was also not shown to correlate with time to reinjury.

LEVEL OF EVIDENCE

Level III, case-control study.

Professional Soccer Players' Return to Play and Performance After Operative Repair of Achilles Tendon Rupture

Background:

The majority of Achilles tendon ruptures are sports related; however, no investigation has examined the impact of surgical repair for complete ruptures on professional soccer players.

Purpose:

To examine the return to play, playing time, and performance of professional soccer players following Achilles tendon repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Union of European Football Associations (UEFA) and Major League Soccer (MLS) athletes who sustained a primary complete Achilles tendon rupture and were treated surgically between 1988 and 2014 were identified via public injury reports. Demographic information and performance-related statistics for the identified athletes were recorded for the season before surgery and 2 seasons after surgery and were compared with information for matched controls. Statistical analyses were used to assess differences in recorded metrics.

Results:

A total of 24 athletes with Achilles ruptures met inclusion criteria, 17 (70.8%) of whom were able to return to play. On average, players had 8.3 years of professional-level experience prior to sustaining an Achilles rupture. Among athletes who returned to play, no differences were found in the number of games played or started, minutes played, or goals scored 1 year postoperatively compared with the year prior to injury. However, 2 years postoperatively, these athletes played 28.3% (P = .028) fewer minutes compared with their preoperative season, despite starting and playing in an equivalent number of games. Matched controls had baseline playing time and performance statistics similar to those of players. However, controls played and started in significantly more games and played more minutes at 1 and 2 years compared with players (P < .05). No differences were found in goals scored at any time point.

Conclusion:

This is the first investigation examining the effect of an Achilles repair on the career of professional soccer players. This is a difficult injury that most commonly occurs in veteran players and prevents 29.2% of players from returning to play despite surgical management. Additionally, athletes able to return to play were found to play fewer minutes 2 years postoperatively compared with their baseline as well as playing less at 1 and 2 years postoperatively compared with uninjured matched controls. The reduction in playing time following an Achilles repair has significant implications for professional players and teams.

New Trends in Anterior Cruciate Ligament Reconstruction: A Systematic Review of National Surveys of the Last 5 Years

The purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences related to the preferred graft, femoral tunnel positioning, fixation and tensioning methods, antibiotic and anti-thromboembolic prophylaxis, and use of tourniquet and drains. A systematic search of PubMed, Web of Science, and Cochrane Library was performed. Inclusion criteria were surveys of ACL reconstruction trends and preferences published in the past 5 years (2011–2016), involving members of national societies of orthopaedics. Information regarding survey modalities, population surveyed, graft choice both in the general or in the athletic population, surgical technique, fixation, use of antibiotic, tourniquet, drains, and anti-thromboembolic prophylaxis was extracted. Eight national surveys were included from Europe (three), North or Latin America (three), and Asia (two). Overall, 7,420 questionnaires were sent, and 1,495 participants completed the survey (response rate ranging from 16 to 76.6%). All surveys reported the hamstring tendon (HT) autograft as the preferred graft, ranging from 45 to 89% of the surveyed population, followed by bone-patellar tendon-bone (BPTB) graft (2–41%) and allograft (2–17%). Only two surveys focusing on graft choice in athletic population underlined how in high-demand sportive population the graft choices changes in favor of BPTB. Single-bundle reconstruction was the preferred surgical technique in the four surveys that investigated this issue. Five surveys were in favor of anteromedial (AM) portal and two in favor of trans-tibial technique. Suspension devices for femoral fixation were the preferred choice in all but one survey, while interference screws were the preferred method for tibial fixation. The two surveys that investigated graft tensioning were in favor of manual tensioning. The use of tourniquet, antibiotics, drains, and anti-thromboembolic prophylaxis were vaguely reported. A trend toward the preference of HT autograft was registered in all the surveys; however, sport participation has been highlighted as an important variable for increased use of BPTB. Single-bundle reconstruction with AM portal technique and suspension femoral fixation and screws fixation for the tibia seem the preferred solution. Other variables such as tensioning, antibiotic, anti-thromboembolic prophylaxis, tourniquet use, and drains were investigated scarcely among the surveys; therefore, no clear trends could be delineated. This is a Level V, systematic review of expert opinion study.

A review advocating caution with Major League Soccer expansion and investment in more rehabilitation professionals

BACKGROUND AND PURPOSE

Major League Soccer (MLS) has aggressively expanded from 10 teams to 23 teams. With the addition of more teams, the league will have to dictate a schedule that maximizes the league's popularity, while also maintaining the health of the players. A longer season and congested game schedule could increase the risk of injury for players. The purpose of this commentary is to make recommendations for the prevention of injuries among MLS players with respect to proposed league expansion.

DESCRIPTION OF TOPIC

MLS has lengthened the regular season with each expansion in teams. An increase in season length was seen in conjunction with the MLS expansion from 14 to 19 teams during the 2008 through 2013 seasons. Data from the inaugural MLS season found injury rates were higher in games compared to practices and more injuries occurred later in the season. With the expansion of MLS, anterior cruciate ligament tears appeared to have increased each year.

DISCUSSION

Current evidence suggests the implementation of a proper preseason in addition to the once-per-week game frequency would best promote player health and well-being. Players may benefit from in-season injury prevention training and weekly load monitoring.

Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the current evidence to ascertain whether quadriceps tendon autograft (QT) is a viable option in anterior cruciate ligament reconstruction.

METHODS

A literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Cohort studies comparing QT with bone-patellar tendon-bone autograft (BPTB) or hamstring tendon autograft (HT) were included. Clinical outcomes were compared, with all statistical analyses performed using IBM SPSS Statistics for Windows, version 22.0, with P < .05 being considered statistically significant.

RESULTS

We identified 15 clinical trials with 1,910 patients. In all included studies, QT resulted in lower rates of anterior knee pain than BPTB. There was no difference in the rate of graft rupture between QT and BPTB or HT in any of the studies reporting this. One study found that QT resulted in greater knee stability than BPTB, and another study found increased stability compared with HT. One study found that QT resulted in improved functional outcomes compared with BPTB, and another found improved outcomes compared with HT, but one study found worse outcomes compared with BPTB.

CONCLUSIONS

Current literature suggests QT is a viable option in anterior cruciate ligament reconstruction, with published literature showing comparable knee stability, functional outcomes, donor-site morbidity, and rerupture rates compared with BPTB and HT.

LEVEL OF EVIDENCE

Level III, systematic review of Level I, II, and III studies.

Soft-stop knee brace for rehabilitation from ligament injuries: Design and pilot trial

Ligaments within the human knee are commonly torn or injured as a result of sports that involve sharp direction changes, pivoting and landing. For this reason, athletes are often side-lined from their respective sports for up to 18 months after injury to rehabilitate. As part of the rehabilitation process, knee braces are often prescribed in an attempt to decrease the recovery period of the injured individual by restraining and minimizing the motion at the knee. However, the true efficacy of knee bracing is yet to be fully evaluated as studies show mixed results to whether braces actually decrease the rehabilitation period for patients. This paper describes the design and pilot trials of a simple but novel knee brace design that aims to actively aid the rehabilitation of the knee from ligament injuries, primarily the anterior cruciate ligament (ACL). The newly developed knee brace uses an angle locking mechanism with dampers to control both the range of motion of the knee joint and the resistance applied to the knee joint at the limits of extension. Using finite element analysis, these dampers were designed help build muscle strength during everyday use of the knee brace and to reduce the 'jarring effect' which causes significant pain and risk to patients using current knee brace designs. Through providing these features, this new knee brace design has the potential to help improve the extent and speed of recovery for ACL impaired patients.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury

BACKGROUND

Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood.

METHODS

We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients' preoperative and postoperative sports involvement (primary and secondary sports, number of sports).

RESULTS

A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04).

CONCLUSIONS

Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Return to Play After Revision Anterior Cruciate Ligament Reconstruction in National Football League Players

Background:

National Football League (NFL) players who undergo anterior cruciate ligament (ACL) reconstruction have been shown to have a lower return to play (RTP) than previously expected. However, RTP in the NFL after revision ACL reconstruction (RACLR) is not well defined.

Purpose/Hypothesis:

The purpose of this study is to determine the RTP of NFL players after RACLR and evaluate factors that predict RTP. Our hypothesis was that more experienced and established players would be more likely to RTP after RACLR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 24 NFL players who underwent RACLR between 2007 and 2014 were reviewed and evaluated. Return to NFL play, time to return, seasons and games played prior to and after revision surgery, draft status, and demographic data were collected. Overall RTP was determined, and players who did RTP were compared with those unable to RTP. Data were also compared with control players matched for age, position, size, and experience.

Results:

After RACLR, 79% (19/24) of NFL players returned to NFL regular-season play at an average of 12.6 months. All players who were drafted in the first 4 rounds, played in at least 55 games, or played 4 seasons of NFL play prior to injury were able to RTP. Players drafted in the first 4 rounds of the NFL draft were more likely to RTP than those who were not (odds ratio, 0.1; 95% CI, 0.01-1.00; P = .05). Those who returned to NFL play played in significantly less games and seasons after their injury than before (P = .01 and P = .01, respectively). However, these values did not differ when compared with matched controls (P = .67 and P = .33).

Conclusion:

NFL players who RTP after RACLR do so at a similar rate but prolonged time period compared with after primary ACL reconstruction. Athletes who were drafted in earlier rounds were more likely to RTP than those who were not. Additionally, player experience prior to injury is an important factor when predicting RTP after RACLR.