Repeat Anterior Cruciate Ligament Injury and Return to Sport in Australian Soccer Players After Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft
Restricted accessResearch articleFirst published online November, 2022
Repeat Anterior Cruciate Ligament Injury and Return to Sport in Australian Soccer Players After Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft
Soccer is the most commonly played team sport in the world and a high-risk sport for anterior cruciate ligament (ACL) injury and subsequent ACL reconstruction (ACLR).
Purpose:
To assess the rate of further ACL injury in patients who have undergone ACLR with hamstring tendon autograft after soccer injuries in Australia and to determine factors associated with repeat ACL injury and return to soccer.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
From a prospectively collected database, a series of 1000 consecutive ACLRs using hamstring autografts performed in soccer players were identified. Patients were surveyed at a minimum 5 years after reconstruction, including details of further ACL injuries to either knee, return to soccer or other sports, and psychological readiness per the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale.
Results:
Of the 862 participants reviewed, ACL graft rupture occurred in 85 (10%) and contralateral ACL rupture in 68 (8%) within 5 years after the reconstruction. The 5-year ACL graft survivorship was 94% for females and 88% for males. The survivorship of the contralateral ACL was 92% for males and 90% for females. When compared with those aged >25 years, the odds of ACL graft rupture was increased by 4 to 5 times in those aged 19 to 25 years and 3 to 7 times in those ≤18 years. Further ACL injury to the graft or contralateral knee occurred in 44% of males aged ≤18 years. Risk factors for further ACL injury were younger age at time of surgery, male sex, and return to soccer. Graft diameter did not influence ACL graft rupture rates, and 70% of patients returned to soccer after ACLR. The mean ACL-RSI score was 59, and patients who reported more fear of reinjury on this scale were less likely to have returned to soccer.
Conclusion:
The prevalence of ACL graft rupture (10%) and contralateral ACL rupture (8%) was near equivalent over 5 years in this large cohort of mostly recreational Australian soccer players. ACLR with hamstring autograft is a reliable procedure, allowing 70% of patients to return to soccer in this high-risk population. Risk factors for further ACL injury are progressively younger age at time of surgery, male sex, and return to soccer. Graft diameter was not a factor in ACL graft rupture, indicating that other factors, particularly age, are of primary importance.
AgelJArendtEABershadskyB. Anterior cruciate ligament injury in National Collegiate Athletic Association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33(4):524-530.
2.
AllenMMPareekAKrychAJ, et al. Are female soccer players at an increased risk of second anterior cruciate ligament injury compared with their athletic peers?Am J Sports Med. 2016;44(10):2492-2498.
3.
ArdernCTaylorNFellerJWebsterK. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47(17):1120.
4.
ArdernCLTaylorNFFellerJAWebsterKE. Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. J Sci Med Sport. 2012;15(6):488-495.
5.
ArdernCLTaylorNFFellerJAWebsterKE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-1552.
6.
Barber-WestinSDNoyesFR. Assessment of sports participation levels following knee injuries. Sports Med. 1999;28(1):1-10.
7.
BetschMHoitGDwyerT, et al. Postoperative pain is associated with psychological and physical readiness to return to sports one-year after anterior cruciate ligament reconstruction. Arthrosc Sports Med Rehabil. 2021;3(6):e1737-e1743.
8.
BeynnonBJohnsonRAbateJFlemingBNicholsC. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. 2005;33(10):1579-1602.
9.
BourkeHSalmonLJWallerAPattersonVPinczewskiLA. The survival of the anterior cruciate ligament graft and the contralateral ACL at a minimum of 15 years. Am J Sports Med. 2012;40(9):1985-1992.
10.
BrophyRHSchmitzLWrightRW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med. 2012;40(11):2517-2522.
11.
CerulliGBenoitDLCaraffaAPonteggiaF. Proprioceptive training and prevention of anterior cruciate ligament injuries in soccer. J Orthop Sports Phys Ther. 2001;31(11):655-660.
EkstrandJGillquistJMöllerMObergBLiljedahlSO. Incidence of soccer injuries and their relation to training and team success. Am J Sports Med. 1983;11(2):63-67.
14.
FältströmAKvistJGauffinHHägglundM. Female soccer players with anterior cruciate ligament reconstruction have a higher risk of new knee injuries and quit soccer to a higher degree than knee-healthy controls. Am J Sports Med. 2019;47(1):31-40.
15.
FältströmAKvistJHägglundM. High risk of new knee injuries in female soccer players after primary anterior cruciate ligament reconstruction at 5- to 10-year follow-up. Am J Sports Med. 2021;49(13):3479-3487.
16.
FlaniganDCEverhartJSPedrozaASmithTKaedingCC. Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy. 2013;29(8):1322-1329.
17.
GornitzkyALLottAYellinJLFabricantPDLawrenceJTGanleyTJ. Sport-specific yearly risk and incidence of anterior cruciate ligament tears in high school athletes: a systematic review and meta-analysis. Am J Sports Med. 2016;44(10):2716-2723.
18.
HägglundMWaldénMBahrREkstrandJ.Methods for epidemiological study of injuries to professional football players: developing the UEFA model. Br J Sports Med. 2005;39(6):340-346.
19.
Hamrin SenorskiESamuelssonKThomeéCBeischerSKarlssonJThomeéR. Return to knee-strenuous sport after anterior cruciate ligament reconstruction: a report from a rehabilitation outcome registry of patient characteristics. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1364-1374.
20.
HarrisPATaylorRThielkeRPayneJGonzalezNCondeJG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
21.
HeathMRJanoskyJJPegnoASchachneJMFabricantPD. Age is more predictive of safe movement patterns than are physical activity or sports specialization: a prospective motion analysis study of young athletes. Am J Sports Med. 2021;49(7):1904-1911.
22.
HewettTEMyerGDFordKR. Reducing knee and anterior cruciate ligament injuries among female athletes: a systematic review of neuromuscular training interventions. J Knee Surg. 2005;18(1):82-88.
23.
HulteenRMSmithJJMorganPJ, et al. Global participation in sport and leisure-time physical activities: a systematic review and meta-analysis. Prev Med. 2017;95:14-25.
24.
InderhaugEDrogsetJOLygreSHLGifstadT. No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft. Knee Surg Sports Traumatol Arthrosc. 2020;28(3):707-713.
25.
JanssenKOrchardJDriscollTVan MechelenW. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003-2004 to 2007-2008: time for an anterior cruciate ligament register by Scandinavian model?Scand J Med Sci Sports. 2012;22(4):495-501.
26.
JanssenRPAvan der VeldenMJFvan den BesselaarMReijmanM. Prediction of length and diameter of hamstring tendon autografts for knee ligament surgery in Caucasians. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1199-1204.
27.
KingERichterCJacksonM, et al. Factors influencing return to play and second anterior cruciate ligament injury rates in level 1 athletes after primary anterior cruciate ligament reconstruction: 2-year follow-up on 1432 reconstructions at a single center. Am J Sports Med. 2020;48(4):812-824.
28.
KostyunROBurlandJPKostyunKJMilewskiMDNissenCW. Male and female adolescent athletes’ readiness to return to sport after anterior cruciate ligament injury and reconstruction. Clin J Sport Med. 2021;31(4):383-387.
29.
KvistJEkASporrstedtKGoodL. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13(5):393-397.
30.
LaiCCHArdernCLFellerJAWebsterKE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. 2018;52(2):128-138.
31.
LaiCCHFellerJAWebsterKE. Fifteen-year audit of anterior cruciate ligament reconstructions in the Australian Football League from 1999 to 2013: return to play and subsequent ACL injury. Am J Sports Med. 2018;46(14):3353-3360.
32.
LindangerLStrandTMølsterAOSolheimEInderhaugE. Return to play and long-term participation in pivoting sports after anterior cruciate ligament reconstruction. Am J Sports Med. 2019;47(14):3339-3346.
33.
MagnussenRALawrenceJTRWestRLTothAPTaylorDCGarrettWE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012;28(4):526-531.
34.
MagnussenRAMeschbachNTKaedingCCWrightRWSpindlerKP. ACL graft and contralateral ACL tear risk within ten years following reconstruction: a systematic review. JBJS Rev. 2015;3(1):e3.
35.
MariscalcoMWFlaniganDCMitchellJ, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy. 2013;29(12):1948-1953.
36.
McPhersonALFellerJAHewettTEWebsterKE. Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries. Am J Sports Med. 2019;47(4):857-862.
37.
MontalvoAMSchneiderDKWebsterKE, et al. Anterior cruciate ligament injury risk in sport: a systematic review and meta-analysis of injury incidence by sex and sport classification. J Athl Train. 2019;54(5):472-482.
38.
MontalvoAMSchneiderDKYutL, et al. “What’s my risk of sustaining an ACL injury while playing sports?” A systematic review with meta-analysis. Br J Sports Med. 2019;53(16):1003-1012.
39.
MorganMDSalmonLJWallerARoeJPPinczewskiLA. Fifteen-year survival of endoscopic anterior cruciate ligament reconstruction in patients aged 18 years and younger. Am J Sports Med. 2016; 44(2):384-392.
40.
MuftySBollarsPVanlommelLVan CrombruggeKCortenKBellemansJ. Injuries in male versus female soccer players: epidemiology of a nationwide study. Acta Orthop Belg. 2015;81(2):289-295.
41.
NagelliCVHewettTE. Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports Med. 2017;47(2):221-232.
42.
National Ligament Registry. The National Ligament Registry 2019 Annual Report. National Ligament Registry; 2020.
43.
RahardjaRZhuMLoveHClatworthyMGMonkAPYoungSW. Effect of graft choice on revision and contralateral anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry. Am J Sports Med. 2020;48(1):63-69.
44.
RougraffBShelbourneKGerthPWarnerJ. Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med. 1993;21:277-284.
45.
SalmonLRussellVMusgroveTPinczewskiLRefshaugeK. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005;21(8): 948-957.
46.
SalmonLJHeathEAkrawiHRoeJPLinklaterJPinczewskiLA. 20-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft: the catastrophic effect of age and posterior tibial slope. Am J Sports Med. 2018;46(3):531-543.
47.
SandonAEngströmBForssbladM. High risk of further ACL injury in a 10-year follow-up study of ACL-reconstructed soccer players in the Swedish National Knee Ligament Registry. Arthroscopy. 2020; 36(1):189-195.
48.
SandonAWernerSForssbladM. Factors associated with returning to football after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2514-2521.
49.
ShelbourneKDGrayTHaroM. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.
50.
SoligardTGrindemHBahrRAndersenTE. Are skilled players at greater risk of injury in female youth football?Br J Sports Med. 2010;44(15):1118-1123.
51.
SonessonSKvistJArdernCÖsterbergASilbernagelKG. Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1375-1384.
52.
SwirtunLRErikssonKRenströmP. Who chooses anterior cruciate ligament reconstruction and why? A 2-year prospective study. Scand J Med Sci Sports. 2006;16(6):441-446.
53.
VittinghoffEMcCullochCE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol. 2007;165(6): 710-718.
54.
WaldénMHägglundMWernerJEkstrandJ. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):3-10.
55.
WebbJMSalmonLJLeclercEPinczewskiLARoeJP. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament–reconstructed patient. Am J Sports Med. 2013;41(12):2800-2804.
56.
WebsterKFellerJ. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(11):2827-2832.
57.
WebsterKEFellerJA. Development and validation of a short version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale. Orthop J Sports Med. 2018;6(4):2325967118763763.
58.
WebsterKEFellerJA. Expectations for return to preinjury sport before and after anterior cruciate ligament reconstruction. Am J Sports Med. 2019;47(3):578-583.
59.
WebsterKEFellerJA. A research update on the state of play for return to sport after anterior cruciate ligament reconstruction. J Orthop Traumatol. 2019;20(1):10.
60.
WebsterKEFellerJA. Return to level I sports after anterior cruciate ligament reconstruction: evaluation of age, sex, and readiness to return criteria. Orthop J Sports Med. 2018;6(8):2325967118788045.
61.
WebsterKEFellerJALeighWBRichmondAK. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3):641-647.
62.
WigginsAJGrandhiRKSchneiderDKStanfieldDWebsterKEMyerGD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861-1876.
63.
ZbrojkiewiczDVertulloCGraysonJE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015. Med J Aust. 2018;208(8):354-358.
