Twenty (60.6%) of the NHL and MLS surgeons recommended waiting at least 6 months before RTS; 2 (6.1%) recommended waiting at least 9 months; no surgeon recommended waiting at least 12 months; and the others did not have a specific time frame for RTS. Twenty-seven surgeons (81.8%) recommended RTS after an athlete passed a series of RTS tests (eg, Vail, single-leg hop). Nineteen surgeons (57.6%) recommended waiting until the athlete had full range of motion, no pain, full strength, and subjective stability in the knee. Physicians could choose more than one answer for the previous question, allowing for a total percentage higher than 100%.
Discussion
The goal of this study was to determine how NHL, MLS, and Olympic team orthopedic surgeons manage ACL tears in elite and recreational athletes. Our study hypotheses were confirmed, as 70.2% of those surveyed used BPTB autograft for elite athletes, 100% used the single-bundle technique, 70.2% did not require a brace on RTS, 81.8% recommended RTS after the athlete passed a series of RTS tests (eg, Vail, single-leg hop), and 60.6% waited at least 6 months after surgery.
As soccer and skiing are the top 2 sports in which participants sustain ACL tears, it is necessary to report how surgeons obtain successful results in these patient populations.6 Using the US and Norwegian ACL reconstruction registries, Granan and colleagues6 found that, over a 7-year period, 5760 ACL tears occurred during soccer, and 2030 occurred during skiing. The scope of ACL injuries is broad, and treatment patterns must be elucidated. Although most surgeons do not treat elite athletes, many high school and college athletes compete at very high levels. Therefore, replicating the methods of the surgeons who treat elite athletes may be warranted.
In our survey, autograft (89.4%), particularly BPTB autograft (70.2%), was the most common graft choice for elite athletes. The rate of allograft use (42.4%) was higher for 35-year-old recreational athletes. As BPTB autograft produces reliable long-term results, this graft type is a reasonable choice.7 However, only 18% of our surveyed orthopedic surgeons indicated they would use BPTB autograft in older, recreational athletes. This stark difference is likely related to the more than 40% long-term side effects of anterior knee pain and graft harvest site morbidity with BPTB autograft as opposed to allograft and other types of autograft.8,9 Younger patients may be more willing to accept some anterior knee pain to ensure bone-to-bone healing with BPTB autograft. This shift in graft choice may also reflect the desire to minimize skin incisions and their resulting scars, especially in female recreational athletes.
In a meta-analysis of more than 5000 patients, Kraeutler and colleagues7 found that BPTB autograft outperformed allograft according to several knee scores, including Lysholm and Tegner, and had a lower re-rupture rate (4.3% vs 12.7%). However, despite the superior performance of BPTB autograft, graft choice cannot overcome surgeon error in graft placement.10 BPTB autograft appears to remain the gold standard for ACL reconstruction for many reasons, including low failure rates and decreased costs.11 Recently, investigators have tried to challenge the superiority of BPTB autograft. In a retrospective case–control study, Mascarenhas and colleagues12 found that hamstring autograft afforded patients better extension and higher subjective outcome scores. Bourke and colleagues13 found a higher rate of contralateral ACL rupture in patients treated with BPTB autograft compared with hamstring autograft.
According to this survey, 44.7% of surgeons indicated they drilled the femoral tunnel through a transtibial portal, 36.2% used an anteromedial portal, and 12.8% used the 2-incision technique. These methods were recently evaluated to determine if any is superior to the others, but the study results were not definitive.14 Franceschi and colleagues15 found improved rotational and anterior stability of the knee with use of an anteromedial approach, but their findings were not clinically or functionally significant. Wang and colleagues16 found an extension loss in the late-stance phase of gait with the anteromedial approach; the transtibial approach was correlated with inferior anterior-posterior stability during the stance phase of gait. Therefore, our results parallel those in the current literature in that the surveyed population is split on which technique to use and likely bases its practice on comfort level and residency/fellowship training.
Limitations
This study had several limitations. First, it provided level V evidence of team physicians in 3 major sports. Although some of these physicians were also treating athletes in other sports, our survey targeted NHL, MLS, and Olympic athletes. It did not address all ages and both sexes—which is significant, given the higher rate of ACL tears in females. All NHL and MLS players are male, and there was a high rate of BPTB graft use in these sports. However, recreational athletes include both males and females, and the fact that some surgeons would choose a hamstring graft for a female for cosmetic reasons must not be overlooked. Conversely, that there was no difference in the number of BPTB autografts chosen between NHL and MLS surgeons versus Olympic surgeons, where females are included (all chose about 60% BPTB autografts for their elite athletes), disputes this limitation. Our survey response rate was 50%. Other studies have had similar rates in relation to ACL practices,17 especially elite team physicians’ practices,5 and recent literature has confirmed that lower response rates in surveys did not alter results and may in fact have improved results.18,19 This percentage could be falsely low if some of our email addresses were incorrect. This rate also raises the possibility of selection bias, as surgeons who routinely used allograft in their athlete population may not have wanted to admit this. It is possible that some NHL, MLS, and Olympic athletes were treated by surgeons not included in this survey (in some cases, a non–team surgeon may have performed the athlete’s surgery). This survey did not address concomitant knee pathology or cover all possible technique variables.