BJSM - 2026-09-03 - Journal Article
Graft type is not associated with revision ACL reconstruction in football players: a nationwide cohort analysis of subsequent ACL reconstructions.
Sandon A, Forssblad M
Topics
Key Takeaway
In 10,693 Swedish football players, graft type did not predict revision ACLR, but quadriceps tendon autograft was associated with nearly double the hazard of contralateral ACLR in women (HR 1.98, 95% CI 1.17–3.36).
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Summary
This study asked whether autograft type (hamstring, patellar tendon, or quadriceps tendon) predicts revision or contralateral ACLR in registered Swedish football players undergoing primary ACLR between 2014–2023. Sex-stratified Cox proportional hazards models adjusted for age and pre-injury level showed no graft-type association with revision ACLR in either sex. Among women who returned to competition, quadriceps tendon autograft carried an HR of 1.98 for contralateral ACLR versus hamstring, while younger age and elite-level play were the strongest universal predictors of subsequent reconstruction.
Key Limitation
The quadriceps tendon group was likely a small, self-selected subset of the cohort (reflecting its emerging adoption during 2014–2023), making the contralateral ACLR finding in women susceptible to residual confounding and wide confidence intervals that limit causal inference.
Original Abstract
OBJECTIVE
To determine whether autograft type (hamstring, patellar or quadriceps tendon) is associated with risk of revision anterior cruciate ligament reconstruction (ACLR) or contralateral ACLR in football players.
METHODS
Nationwide cohort included all primary ACLRs performed in registered football players in Sweden between 2014 and 2023, identified by linkage of the Swedish Knee Ligament Registry and the Swedish Football Association. Return to competition (RTC) was defined as participation in at least one official match. Outcomes were revision ACLR (index knee) and contralateral ACLR. Sex stratified, cause specific Cox models adjusted for age and pre-injury level of play (Elite, Non-elite, Youth) were used, with hamstring tendon as graft reference.
RESULTS
A total of 10 693 players were included, of whom 6238 (58%) RTC, mean age 22±7 years, mean follow up 5.2±2.9 years. Among RTC players, revision ACLR occurred in 232 women (10.8%) and in 349 (9.2%) men with no association between graft type and revision ACLR. Contralateral ACLR occurred in 263 women (12.2%) and 264 (6.9%) men. In women, quadriceps tendon was associated with a higher hazard of contralateral ACLR (HR 1.98, 95% CI 1.17 to 3.36). No graft-specific differences were seen in age-restricted sensitivity analyses or in the full cohort. Younger age and higher pre-injury level were consistently associated with greater subsequent ACLR risk.
CONCLUSIONS
Graft choice was not independently associated with revision ACLR, including among young football players who RTC. An association between quadriceps tendon autograft and contralateral ACLR was observed among women. Across analyses, age and pre-injury level of play were the most consistent correlates of subsequent ACLR risk.