Low graft failure after primary anterior cruciate ligament reconstruction in professional soccer players: A retrospective cohort study of 232 knees from the SANTI Study Group

PURPOSE: This study aimed to determine graft failure rates after primary anterior cruciate ligament reconstruction (ACLR) in professional soccer players and to evaluate factors associated with graft failure, including lateral extra-articular augmentation. METHODS: A retrospective cohort study included 232 primary ACLRs in 215 professional soccer players: isolated ACLR (n = 31) and ACLR combined with a lateral extra-articular procedure (LEAP) (n = 201). The primary endpoint was graft failure, defined as symptomatic rupture confirmed clinically and by imaging or revision surgery. Time-to-event analyses accounted for variable follow-up. Contralateral ACL injury was recorded descriptively. RESULTS: At a mean follow-up of 100 months, 13 graft failures occurred (5.6%). Unadjusted failure rates were lower in ACLR + LEAP versus isolated ACLR (4.5% vs. 12.9%), but survival analysis showed no significant difference (hazard ratio [HR] 2.48; 95% confidence interval [CI] 0.49-9.87; p = 0.246). Multivariable Cox regression identified no independent predictors of graft failure. Mean time to graft failure was longer in the ACLR + LEAP group than in the isolated ACLR group (54.8 ± 52.0 vs. 36.6 ± 38.2 months). Reoperations occurred in 32 knees (17.7%), with rates of 15.2% in the ACLR + LEAP group and 30.0% in the isolated ACLR group (p = 0.0528). Increased preoperative laxity (≥7 mm; HR 2.72; 95% CI 1.23-6.17; p = 0.014) and bone-patellar tendon-bone graft use (HR 3.14; 95% CI 1.26-7.20; p = 0.037) were independent risk factors for reoperation. Contralateral ACL injury occurred in 27.1% of knees, more frequently in female athletes (48.7% vs. 22.8%). Among patients who experienced graft failure, 53.8% also had a contralateral ACL injury. CONCLUSION: Primary ACL reconstruction in professional soccer players was associated with durable long-term graft survival. Although ACLR combined with an LEAP was associated with fewer graft failures than isolated ACLR, an independent protective effect was not confirmed. The high rate of contralateral ACL injury highlights the multifactorial nature of reinjury risk in this elite population. LEVEL OF EVIDENCE: Level III, retrospective cohort study.