Aim
To compare return-to-play (RTP) rates, re-rupture, and career longevity in professional rugby and football players undergoing ACL reconstruction (ACLR) with lateral extra-articular tenodesis (LET) using patellar tendon (PT) versus hamstring (HS) autografts.
Methods
A retrospective review of a consecutive series of ACLR performed by three surgeons between 2012 and 2022 was conducted. Elite rugby and football players with isolated ACL rupture underwent primary ACLR with LET using either a PT or HS autograft. Graft choice was based on surgeon, athlete, and athletes’ medical teams’ preferences. Athletes were followed for a mean of 5.6 years (range 2.0 – 12.7 years). Primary outcomes were RTP rate, time to RTP, and post-injury career length. Secondary outcomes included graft re-rupture, match exposure and level of play. Survival analysis and multivariable Cox regression were used to evaluate predictors of career duration.
Results
223 athletes were included (PT, n = 126; HS, n = 97). RTP rates were high and comparable (PT: 94.4%, HS: 95.9%; p = 0.85). Mean RTP time was slightly shorter for PT (12.0 ± 3.5 months) than HS (13.0 ± 5.9 months), but not statistically significant (p = 0.17).
Graft re-rupture rates were low (PT: 2.4%, HS: 5.2%; p = 0.46). Football players had a higher re-rupture rate than rugby players (4.0% vs 2.7%: p= 0.93).
Continued participation in professional sport was high for both grafts; however, the proportion still playing at 5 years was significantly higher for PT grafts (83.6% vs 66.7% in HS; p = 0.04). This varied between sports with 80% of football (77.3% HS vs 81.0% PT) and 56.1% of rugby players (55.9% HS vs 57.1% PT) still competing at 5 years. Playing rugby rather than football was the only significant predictor of shorter career duration (HR 1.75; 95% CI, 1.08–2.84; p = 0.02).
Median post-injury career length to date was 4.0 years for both grafts with 48.9% of athletes still playing at the time of the study.
Conclusion
In elite rugby and football players, both PT and HS autografts combined with LET provide excellent return-to-play rates, low re-rupture risk, and sustained professional careers. Athletes with a PT graft were more likely to still be playing at 5 years compared with those with a HS graft. However, this is likely to be due to the higher proportion of rugby players in the HS group. Graft choice can therefore be tailored to sport demands and patient factors without compromising outcomes if a LET is used.
