Return to Play, Career Longevity, and Reruptures After Primary Anterior Cruciate Ligament Reconstruction With Lateral Extra-articular Tenodesis in Professional Soccer and Rugby Players: A Comparison of Hamstring Tendon Versus Bone-Patellar Tendon-Bone Autografts
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Harvesting of Peroneus Longus Tendon Autograft
Published on: September 2, 2025
Samuel J Lynskey1,2, Andrea Ambrosanio1, Arman Motesharei1
1Fortius Clinic, London, UK.
Background:
Elite pivoting athletes are at a high risk of sustaining anterior cruciate ligament (ACL) injuries and reruptures. While bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts are both widely used for primary ACL reconstruction (ACLR), comparative data in the setting of routine lateral extra-articular tenodesis (LET) remain limited.
Purpose:
To compare return-to-play (RTP) rates, the rerupture risk, and career outcomes in elite rugby and soccer players undergoing ACLR with LET using BPTB versus HT autografts.
Study Design:
Cohort study; Level of evidence, 4.
Methods:
Elite rugby and soccer players with an isolated ACL rupture underwent primary ACLR with LET using either a BPTB or HT autograft. Graft choice was based on preferences of the surgeon, athlete, and athlete's medical team. Professional match participation and rerupture rates were tracked for a mean of 5.6 years (range, 2.0-12.7 years). Primary outcomes were RTP rate, time to RTP, and postoperative career length. Secondary outcomes included graft reruptures, match exposure, and level of play. Survival analysis and multivariable Cox regression were used to evaluate the predictors of career duration.
Results:
A total of 223 knees (217 athletes) were included (BPTB: n = 126; HT: n = 97). RTP rates were high and comparable between those with BPTB grafts (94.4%) and those with HT grafts (95.9%) (P = .85). The mean time to RTP was no different between BPTB grafts (12.0 ± 3.5 months) and HT grafts (13.0 ± 5.9 months) (P = .17). Graft rerupture rates were low for both BPTB grafts (2.4%) and HT grafts (5.2%) (P = .46). The mean postoperative career length was 4.6 ± 2.9 years for BPTB grafts and 4.1 ± 2.5 years for HT grafts, with 48.9% of athletes still playing at the time of the study. Playing rugby was associated with a shorter career duration (hazard ratio, 1.75 [95% CI, 1.08-2.84]; P = 0.02).
Conclusion:
In elite rugby and soccer players, ACLR using either a BPTB or HT autograft combined with LET provided excellent RTP rates, a low rerupture risk, and sustained professional careers.
