Return to competition after ACL reconstruction: Factors influencing rates and timing in Swedish football players

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Abstract
Purpose: To investigate the rate and timing for return to football league games after anterior cruciate ligament reconstruction (ACLR) in Swedish players, examining associations with sex, age, level, graft and additional ACL surgery.Method: Data from the Swedish National Knee Registry (SNKLR) and the Swedish Football Association's IT System (FOGIS) were used. The study cohort comprised 971 football players, 64% males, who underwent primary ACLR. Demographics, graft type and surgical information were extracted from the SNKLR and game participation from FOGIS. Follow‐up for return to competition (RTC) was conducted for 36 months, while additional ACLR follow‐up was 3–7 years. Statistical analyses, including Kaplan–Meier survival curves and relative risk calculations, were employed to assess factors influencing RTC rates and timing.Results: Out of 971 players analyzed, 53% RTC within 3 years with no difference between males and females, at a mean of 15 months (median 14 months) from surgery to the first game. Eleven (2%) players RTC < 6 months from ACLR, 62 (12%) 6–9 months, 125 (24%) 9–12 months and 331 (63%) >12 months. Patellar tendon (PT) grafts demonstrated superior performance, showing quicker returns and higher RTC rates (p = 0.005) compared to hamstring (hazard ratio [HR]: 0.63 [0.48–0.84]) and quadriceps tendon grafts (HR: 0.53 [0.30–0.93]). Players competing in higher divisions pre‐injury experienced significantly swifter and higher RTC rates (p < 0.001). Ninety‐five (10%) had a registered additional ACLR. Players who RTC did not exhibit a significantly higher rate of revision (35 [7%] vs. 25 [5%]). However, those who returned faced a heightened risk of contralateral ACLRs compared to those who did not RTC (32 [6%] vs. 4 [1%] RR 1.72 [1.59–1.96], p < 0.001).Conclusion: The study reveals that 53% of football players RTC after ACLR, predominantly after more than 12 months. The RTC was higher and faster in high‐level players and those receiving a PT graft. The slow RTC may contribute to the relatively low rate of additional ACLRs.Level of Evidence: Level III.

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