Technical Trends in Management of ACL Reconstructions in 2025: A Major League Soccer Team Physicians Survey

Methods

A 39-question survey was distributed to orthopaedic surgeons affiliated with MLS teams across the United States in January of 2025. The survey was created with SurveyMonkey and distributed to 27 MLS-affiliated surgeons who previously agreed to participate in this project. The questionnaire asked each respondent for their time served as a MLS orthopaedic surgeon, as well as numerous questions about their preferences for managing ACL reconstruction (ACLR) operations in both their general practice and high-level/professional soccer athletes. ACLR timing, anesthesia protocols, graft selection, use of augmentation techniques, indications for LET, and return-to-play timelines were among the themes covered by the survey. A full list of survey questions is available in Appendix 1. Questions were predominantly multiple choice, with a write-in option if the respondent's preferences were not listed. Survey questions were framed in the context of an isolated ACL injury and did not specifically address multiligamentous injuries. Descriptive statistics were used to summarize responses.

Results

Operational Logistics

All 27 surgeons who received the survey responded. The mean time in practice as a MLS orthopaedic surgeon was 7.7 years. Across this cohort, surgeons performed a mean of 80 ± 27 ACLRs per year. When performing ACLR, delayed surgical intervention was preferred, with 48% of respondents reporting their ideal time to operation as 3 to 10 weeks after injury, 44.4% opting for surgery between 8 days and 3 weeks, and only 7% preferring surgery between 2 and 8 days. Most respondents (92.6%) reported use of general anesthesia, with a few opting for spinal anesthesia with monitored anesthesia care (MAC). All respondents used a peripheral nerve blockade, with 57.7% preferring an adductor canal block, 12% choosing a femoral nerve block, 4% opting for multiple nerve blocks, and 26.9% using only local infiltration anesthesia. There were no responses for saphenous nerve blockade. Surgeons preferred to utilize a tourniquet intraoperatively, with 73% choosing to keep the tourniquet inflated throughout the entire duration of the case. These findings are summarized in Figure 1.

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Figure 1.

Surgeon-reported preferences regarding timing of ACLR, anesthetic approach, and tourniquet use among MLS orthopaedic surgeons. ACLR, anterior cruciate ligament reconstruction; MLS, Major League Soccer; MAC, monitored anesthesia care.

Grafts

Graft choice is summarized in Figure 2. For the general population, the preferred graft for primary ACLR was BPTB autograft (70%), followed by QT autograft (22.2%), HT (4-strand semitendinosus-gracilis) autograft (3.7%), and ipsilateral BPTB or QT autograft (3.7%). In revision ACLR, QT autograft (48.2%) was the predominant choice, followed by BPTB autograft (25.9%), BPTB allograft (11.1%), soft tissue allograft (3.7%), and ipsilateral BPTB or QT autograft (3.7%), with 7.4% responding that their decision would depend on the athlete's sport and the primary graft utilized. Contralateral autografts were rarely utilized in index operations (7.4%), but were more commonly employed in revision settings (44.4%). Graft tensioning varied among respondents, with 22.2% of surgeons tensioning at full extension (hyperextension), 29.6% at 0° of flexion, 18.5% at 10°, 18.5% at 20°, 11.1% at 30°; no respondent reported tensioning beyond 30° of flexion.

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Figure 2.

Surgeon-reported preferences for graft choice in primary and revision ACLR, including the use of contralateral autografts. ACLR, anterior cruciate ligament reconstruction; BPTB, bone-patellar tendon-bone. *Primary graft other: BPTB or quadriceps tendon autografts (both ipsilateral). *Revision graft other: Depends on primary, sport, and available tissue. Almost always an autograft.

Augmentation Procedures

Suture brace augmentation in primary ACLR was preferred by a small cohort (14.8%); however, those who used it did so on average 67% of the time. Suture brace augmentation was more common in ACLR revision surgery (25.9%), and augmentation was performed at a similar rate (69.3% of cases). Lateral extra-articular augmentation (LEA) was considered in most cases (92.6%); although, ultimately performed in about one-third of primary cases (31.5%). In revision cases, all but 1 respondent (96.3%) indicated willingness to consider augmentation with LET or ALL reconstruction, with 76% ultimately opting to perform the procedure. Among surgeons performing LEA, iliotibial band (ITB) tenodesis was the most preferred technique (74.1%), with ALL reconstruction with allograft (14.8%) and ALL reconstruction with autograft (11.1%) comprising the remainder. Overall, study participants reported performing a substantially larger proportion of combined ACLR/LET procedures compared to 5 years ago (6.4% vs 29.4%). These findings are summarized in Figure 3.

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Figure 3.

Surgeon-reported preferences for adjunct procedures. Bars reflect reported use of suture brace augmentation, consideration versus actual frequency of lateral extra-articular augmentation (LEA) in primary and revision settings, and preferred techniques.

A series of yes/no questions regarding factors with potential implications for operative planning were also included in the survey. A slight majority (51.9%) of respondents indicated they would not perform LET in primary ACLR for soccer athletes with a posterior tibial slope >13° or for soccer athletes with a concomitant medial meniscal deficiency. Interestingly, 51.9% of surgeons reported not performing LET during primary ACLR in elite/professional soccer athletes, but 85.2% indicated they would perform LET during an ACLR revision in the same demographic.

Discussion

The principal findings of this study are as follows: surgeons who care for MLS and other high-level soccer athletes generally prefer BPTB autografts (~70%) as the primary graft for ACLR across all demographics. QT autografts are also utilized (~22%), but HT autografts are infrequently employed (~4%). In revision cases, QT autografts (~48%) are most common, followed by either BPTB autografts (~26%) or allografts (~11%). Among skeletally immature patients, QT autografts are preferred (~78%). Surgeons report performing LEA procedures in approximately 33% of primary ACLRs and up to 76% of revision cases in the general population, but do so more frequently in professional and high-level soccer athletes, for both index operations (~48%) and revisions (~85%). Anterior closing-wedge osteotomies are uncommon, even in hypothetical patients with a posterior tibial slope >20°.

ACL injury and reinjury rates among elite soccer athletes may inform graft preferences among MLS surgeons. Previous studies investigating the rate of subsequent ipsilateral or contralateral ACL injury after index ACLR in the Union of European Soccer Associations report^9,14 rates of 12% to 17.8%, which are higher than those observed in the general population. ³⁹ Although established guidelines exist to inform ACLR, ⁶ surgeon-reported preferences continue to demonstrate variability, highlighting the influence of training, experience, and practice style.

Among the various considerations in ACLR, graft selection continues to generate debate, owing to the lack of conclusive evidence favoring one option over another, particularly in unique subpopulations such as elite soccer athletes. The 27 MLS-affiliated surgeons who responded to this survey indicated their ideal graft choice is largely consistent, regardless of whether they are treating a high-level soccer athlete or a patient in the general population. Across both high-level athletes and general practice patients, BPTB autograft is chosen 4 times more commonly than QT autograft, with only 1 surgeon indicating they would select HT autograft for a primary ACLR in a skeletally mature individual.

Contemporary evidence from systematic reviews and meta-analyses provides important context for ACL graft preferences among MLS-affiliated surgeons. While multiple studies demonstrate that BPTB, QT, and HT autografts yield comparable patient-reported outcomes, joint laxity, and RTS rates, important differences in graft failure rates exist.^7,38,42 BPTP autografts consistently show lower rates of graft failure when compared with HT autografts, particularly in younger patients and high-level athletes, which may account for the graft preferences observed among MLS-affiliated surgeons.^29,34

Our results align with the graft preferences reported by National Football League (NFL) orthopaedic surgeons, who nearly unanimously (94%) would choose BPTB autograft for an elite football running back. When treating a 25- or 35-year-old recreational athlete, NFL-affiliated surgeons’ preference for BPTB autografts decreased to 65% and 39%, respectively, with a subsequent increase in the utilization of QT autografts (19% to 25%). ¹⁷ The predilection for BTPB autografts is similarly observed among orthopaedic surgeons affiliated with the National Basketball Association (NBA), National Hockey League (NHL), MLS, and United States Olympic team, choosing BPTB on average 70% of the time in index ACLR.^13,25

These trends are notably divergent from national trends in ACLR, where HT autografts are mostly utilized. A 2024 meta-analysis by Yang et al ⁴⁰ reported that HT autografts account for over half of grafts (52%) in the United States, while BPTB autografts account for 43% and QT autografts account for 5%. Internationally, HT autografts for ACLR are strongly preferred, with utilization rates of approximately 60% in Europe and South America and >70% in Asia. ³⁵ Although BPTB has historically been considered the benchmark standard due to its reliable fixation, ² HT utilization gained popularity in the early 2000s with randomized control trials and meta-analyses citing similar clinical outcomes for BPTB and HT.^2,19 The added benefits of reduced anterior knee pain, an established side effect of BPTB surgery, along with less donor site morbidity and retention of the knee extensor mechanism, serve as attractive arguments for HT utilization.^2,19,38 The verdict on BPTB versus HT remains uncertain, with some studies reporting higher rates of revision surgery and increased lateral laxity among patients who undergo HT autograft.^15,22,40 In contrast, other meta-analyses report equivalent outcomes in these metrics.^26,38 There is also the re-emergence of QT grafts within the BPTB versus HT debate. Recent studies demonstrate comparable clinical outcomes among the 3 graft options, with QT grafts exhibiting biomechanical properties equal or superior to those of the other 2 with less donor-site morbidity.^{1,8,26,27,32,40}

The surgeons in this study appear to favor the BPTB autograft, given its proven track record of success across decades of research, demonstrating low rates of revision, predictable graft integration, biomechanical properties, reliable stability, and favorable RTS rates.^7,22,30 Furthermore, the growing body of research demonstrating clinical equivalency and diminished donor site morbidity for QT autografts may explain this increased preference,^{1,8,26,27,32,40} deviating from national standards. ⁴⁰ In the context of revision surgeries, QT autograft is the most reported choice of graft, with the caveat that this decision depends on the index operation and availability of remaining graft options. The large graft size, lower donor-site morbidity, and biomechanical advantages of QT grafts over BPTB and HT likely contribute to their more frequent use (48%) in ACL revisions. ^{1,8,26,27,32,40} Interestingly, no respondents reported using HT autografts in the revision setting. The only instance in which ≥1 surgeon chose HT autograft is in the context of a skeletally immature athlete with open physes; however, even in this instance, the frequency of QT was still 4 times that of HT. Of note, no surgeons elected to use BPTB autograft or allograft in this context, as both constructs are generally avoided in younger, skeletally immature patients due to concerns about physeal growth arrest and overgrowth.^11,12,21

A commonly debated aspect of ACLR is the role of LEA. LET and ALL reconstruction are LEA techniques used to address persistent anterolateral rotatory instability and may reduce the risk of graft failure in select patients. The frequencies reported by surgeons in our study are generally consistent with previous literature. Respondents indicated they would perform LEA in approximately 33% of primary ACLR cases, with a preference for ITB tenodesis (74%) over ALL reconstruction (~26%). Lewis et al ²⁴ reported similar trends, noting a likelihood of LEA utilization ranging from 10% to 23% depending on practice volume, with 27.5% of respondents favoring ALL reconstruction and the remainder selecting LET techniques. In the revision setting, an even larger proportion of our participants (76%) indicated they would perform LEA. When specifically considering MLS athletes, respondents reported performing LEA in 46% of index ACLRs and 85% of revisions. This result aligns with the overwhelming majority (84%) of NFL surgeons who prefer adding LEA to an index ACLR in an elite football running back when specific clinical indications are met. ¹⁷ The frequencies of LEA utilization in revision ACLRs do not appear to have been directly reported. However, a recent meta-analysis by Jones et al ²⁰ found that in 52% of included studies, revision surgery alone was cited as an indication for LET. While a positive pivot shift is the most common clinical indication, participation in general or competitive sport is also noted to be an indication for LEA. ²⁰ Given that return to high-level sport and frequent engagement in pivoting activities are associated with increased graft rupture risk, ⁵ MLS athletes, who routinely perform pivoting, cutting, and jumping, are excellent candidates for LEA to enhance rotational stability and reduce ACL graft loads. ¹⁶

Additionally, this study investigated the role of slope reduction osteotomies in revision ACLR. Interestingly, the majority of survey respondents (81%) indicated they would not perform a slope-reduction osteotomy in a revision ACLR for an elite soccer athlete with a posterior tibial slope of 15° to 20°. Once the posterior tibial slope exceeds 20°, half of the participants indicated the need for surgery. Although historically reserved for rerevisions, recent literature proposes a favorable safety and complication profile, and improved patient-reported outcomes with slope-reducing osteotomies in first revision cases^23,33,36 with posterior tibial slope >12°. It appears that most surgeons remain conservative in their application of these more recently described procedures in professional and high-level athletes.

Conclusion

Among orthopaedic surgeons who care for MLS and other high-level athletes, the BPTB autograft is the most preferred graft when performing primary ACLR. QT autografts are favored over HT autografts in primary reconstruction and are the most common choice of graft in revision surgery. HT autografts are utilized infrequently in index operations and not preferred in revisions. Surgeons indicated LET or ALL reconstruction in one-third of primary and 75% of revision ACLRs within the general population. LEA procedures were performed more frequently among professional soccer athletes, occurring in 46% of index operations and 85% of revisions. Tibial slope-reducing osteotomies, despite gaining popularity in the literature, remained an uncommonly reported procedure in the management of ACL injuries in elite soccer athletes. Surgeons generally treated professional and nonprofessional injuries similarly, suggesting that the preferences discussed in this study may be applicable to a broad patient population undergoing ACLR.