The Challenges of Treating Female Soccer Players With ACL Injuries: Hamstring Versus Bone–Patellar Tendon–Bone Autograft

Abstract

Background: Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear. Purpose/Hypothesis: To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport. Results: Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection. Conclusion: Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

High Risk of New Knee Injuries in Female Soccer Players After Primary Anterior Cruciate Ligament Reconstruction at 5- to 10-Year Follow-up

“…16 However, ACL reconstruction (ACLR) does not always ensure RTS, and about 46% to 67% of females with ACLR return to soccer. 4,5,11,31,32 Younger players and those playing at a high level are more likely to return to soccer. 31 Returning to soccer after ACLR is paired with a high risk of new ACL injury to both knees, especially among young female athletes.…”

“…31 Returning to soccer after ACLR is paired with a high risk of new ACL injury to both knees, especially among young female athletes. 4,5,13,28,29,39,42 Up to one-third of female soccer players who return to soccer after ACLR sustain a new ACL injury within the first 3.5 years after ACLR. 4,13 The incidence of new ACL injury, especially reruptures, seems to be highest in the first 2 to 3 years after ACLR.…”

“…4,5,13,28,29,39,42 Up to one-third of female soccer players who return to soccer after ACLR sustain a new ACL injury within the first 3.5 years after ACLR. 4,13 The incidence of new ACL injury, especially reruptures, seems to be highest in the first 2 to 3 years after ACLR. 1 A high risk for other knee injuries has been reported in soccer players with ACLR who were followed for 1 to 2 seasons.…”

Not just another ACL paper: the importance of ‘Outcomes of single bundle arthroscopic anterior crucial ligament reconstruction in a limited resource setting’

“…Graft failures were 17.6% and 16.8%, respectively, with many failures occurring in the first 6 months, possibly related to graft incorporation or the early resumption of demanding physical activity, and although higher than some studies, are comparable to other authors reporting on younger patients with high demands. [10][11][12] The rate of deep infection was acceptably low, 1.8 %/3% urban/rural. This important and pioneering paper demonstrates that even under challenging conditions, ACL reconstruction can provide clinical stability and good function and quality of life in patients in countries with limited resources.…”

The Hamstrings: Anatomic and Physiologic Variations and Their Potential Relationships With Injury Risk

“…In a study of female soccer players ( n = 90) that had undergone ACL reconstruction, with data available for a minimum of a 2-year follow-up, the outcomes for hamstrings autograft and bone-patellar tendon-bone autografts were very similar ( Britt et al, 2020 ). Notwithstanding, a meta-analysis of 5,561 patients undergoing ACL reconstruction found that hamstrings autografts were less likely than bone-patellar tendon-bone autografts to incur in a contralateral ACL rupture ( Zhou et al, 2020 ).…”