Return to Sport and Risk of Second Anterior Cruciate Ligament (ACL) Injury in Elite Male Footballers: 10-Year Experience From a Single Center

Background: Anterior cruciate ligament (ACL) injury among professional footballers represents a career-threatening injury with a high burden for athletes and teams. Debated issues in professional footballers after ACL reconstruction (ACLR) include time to return to play (RTP), level of play after surgery, and incidence and timing of sustaining a second ACL injury. Purposes: To analyze RTP and performance 2 seasons after surgery of professional footballers who underwent ACLR, to evaluate factors influencing the timing of RTP and second injury risk, and to assess the level of RTP and performance after surgery. Study design: Case series; Level of evidence, 4. Methods: All professional male footballers who underwent ACLR using a hamstrings graft with or without a lateral extra-articular procedure at a single institution between 2002 and 2013 were retrospectively included. Demographic and intraoperative findings were extracted from the medical records. Data regarding the number of matches played in 5 seasons (injury season, the 2 seasons before, and the 2 seasons after the injury), the level of play in those 5 seasons, the time to return to the first official match, and reinjuries were extracted from publicly available databases, and patients were contacted to confirm. Univariate and multivariate analyses were conducted to identify factors influencing RTP and risk factors for second ACL injury. Results: A total of 58 primary ACLRs were included; 20 (34.5%) participated in the first division (Serie A). RTP was 96.6% (56/58) after a mean of 6.4 ± 2.3 months, and return to match occurred after a mean of 7.5 ± 3.3 months. Patients without meniscal injury had a faster RTP (5.6 ± 1.6 months; P = .0016), while athletes with cartilage injury showed a longer time to RTP (10.2 ± 3.7 months; P = .0001) and resulted as a predictor for longer RTP (+4.4 months; P = .0047).In the second season after an ACL injury, 23% of footballers participated in a lower division with respect to the injury season, playing a mean of 20 ± 11 matches, with 65% of them participating in >20 games. The second injury rate was 15.8% (9 patients). The ipsilateral reoperation rate, including ACL revisions, was 28.1%. Additionally, returning to competitive play within 5 months of surgery was a significant predictor of a second ACL injury. Conclusion: Almost all patients returned to play after ACLR using hamstrings graft with over-the-top techniques, typically regaining preinjury performance by the second season after the injury. RTP time was shorter for isolated ACL injuries and longer when associated with meniscal or cartilage injury. Given the high risk of a second ACL injury on either knee and the high reoperation rate, RTP before 5 months should be discouraged, particularly in athletes <21 years.