Summary
This study surveyed Major League Soccer (MLS) orthopedic surgeons to evaluate their preferred ACLR techniques, the role of LET, and postoperative rehabilitation protocols.
Abstract
Introduction
Anterior cruciate ligament reconstruction (ACLR) is a critical procedure for professional soccer athletes, with surgical techniques and return-to-play (RTP) timelines influencing postoperative outcomes. Despite advances in ACLR, consensus on graft selection, augmentation strategies, lateral extra-articular tenodesis (LET), and osteotomy remains variable. This study surveyed Major League Soccer (MLS) orthopedic surgeons to evaluate their preferred ACLR techniques, the role of LET, and postoperative rehabilitation protocols.
Methods
A 39-question survey was distributed to orthopedic surgeons affiliated with MLS teams. The questionnaire covered ACLR timing, anesthesia protocols, graft selection, use of augmentation techniques, LET indications, and RTP timelines. Descriptive statistics were used to summarize responses.
Results
Among the 26 respondents, the mean time in practice was 7.81 years. The preferred timing for ACLR was delayed (>3–10 weeks) in 50% and early (8 days–3 weeks) in 42.31%. General anesthesia was used by 92.31%, and a tourniquet was applied in 73.08% of cases. The primary ACLR graft choice was BPTB autograft (73.08%), with quadriceps tendon autograft (19.23%) as the next most common. In revision ACLR, quadriceps tendon autograft (46.15%) was the predominant choice, followed by BPTP autograft (26.92%).
For adjunct procedures, LET/ALL was considered in primary ACLR by 92.31% and in revision ACLR by 96.15%. Iliotibial band tenodesis was the preferred LET technique (73.08%). Suture brace augmentation was infrequently used in primary (11.54%) and revision ACLR (23.08%). Functional testing was used in 92.31% of RTP decisions, with a mean RTP time of 10.08 ± 1.23 months and a minimum RTP time of 8.36 ± 1.15 months. Bracing postoperatively was implemented by 80.77% of surgeons.
Surgeons performed a mean of 80.19 ACLRs annually, with an increase in combined ACLR/LET procedures from 6.50% (5 years ago) to 30.04% (currently). In adolescent athletes with open physes, quadriceps tendon autograft (76.92%) was the preferred choice. For elite adult soccer players, BPTB autograft (76.92%) was the most recommended. Femoral tunnel drilling through the anteromedial portal (57.69%) was the preferred approach.
Based on the survey responses, there was variability in ACL graft tensioning angles, with the most common preferences being 0° flexion (26.92%), followed by full extension (23.08%), and 10° or 20° flexion (19.23% each).
For complex cases, only 26.92% of surgeons indicated they would perform a medial meniscus transplant in revision ACLR for medial meniscus-deficient elite soccer players. Anterior closing wedge osteotomy was less commonly performed for posterior tibial slope 15–20° (19.23%), but 50.00% of surgeons would consider it for slopes >20°.
Conclusion
This survey provides insight into ACLR surgical preferences among MLS orthopedic surgeons, demonstrating a strong preference for BPTB autograft in primary ACLR and quadriceps tendon autograft in revision ACLR. RTP timelines remain highly structured, with most surgeons incorporating functional testing into their decision-making. Future studies should investigate long-term outcomes of these preferred techniques to optimize ACLR strategies in high-level athletes.