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Review
. 2022 Feb 23;10(2):23259671221076883.
doi: 10.1177/23259671221076883. eCollection 2022 Feb.

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Anthony C Mok  1 , Andrew J Fancher  1 , Matthew L Vopat  2 , Jordan Baker  1 , Armin Tarakemeh  3 , Scott Mullen  3 , John P Schroeppel  3 , Kim Templeton  3 , Mary K Mulcahey  4 , Bryan G Vopat  3
Affiliations
Review

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Anthony C Mok et al. Orthop J Sports Med. .

Abstract

Background: Despite the significant difference between men and women in incidence of anterior cruciate ligament (ACL) injuries, there is a paucity of consistent information on the influence of patient sex on outcomes after ACL reconstruction. A previous meta-analysis has demonstrated that female patients have worse outcomes with regard to laxity, revision rate, Lysholm score, and Tegner activity score and are less likely to return to sports (RTS).

Purpose: To conduct a systematic review and meta-analysis to evaluate and compare sex-specific outcomes after ACL reconstruction.

Study design: Systematic review; Level of evidence, 4.

Methods: A systematic review was performed using PubMed, PubMed Central, Embase, OVID, and Cochrane databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" OR "anterior cruciate ligament" OR "ACL" AND "gender" OR "sex" OR "male" OR "female" AND "outcome" AND "2015-Present" to gather all relevant articles between 2015 and 2020. A risk-of-bias assessment and quality assessment was conducted on included studies.

Results: Of 9594 studies initially identified, 20 studies with 35,935 male and 21,455 female patients were included for analysis. The 7 studies reporting International Knee Documentation Committee (IKDC) scores showed that male patients had statistically significantly higher postoperative scores (mean difference, 3.02 [95% CI, 1.19-4.84]; P< .01; I 2 = 66%), and 7 studies that reported the rate of ACL revision showed there was no significant difference between male and female patients (odds ratio, 0.85 [95% CI, 0.45-1.60]; P = .61; I 2 = 94%). The 7 studies that reported rates of rerupture showed that males were significantly more likely than females to have a graft rerupture (odds ratio, 1.35 [95% CI, 1.22-1.50]; P < .01; I 2 = 0%). Male patients reported a higher RTS rate than did their female counterparts (59.82% compared with 42.89%); however, no formal statistical analysis could be done because of the variability in reporting techniques.

Conclusion: Male and female patients with ACL injuries demonstrated similar outcomes regarding their rates of revision; however, male patients were found to have statistically significantly higher postoperative IKDC scores but at the same time higher rerupture rates. Our findings suggest that sex-based differences in outcomes after ACL reconstruction vary based on which metric is used. These results must be considered when counseling patients with ACL injuries.

Keywords: ACL; knee; outcomes; sex; surgical repair.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: M.L.V. has received education payments from DePuy and Titan Surgical and hospitality payments from Stryker and Zimmer Biomet. J.P.S. has received education payments from Arthrex/Titan Surgical, consulting fees from Vericel, and hospitality payments from Zimmer Biomet. M.K.M has received education payments from Arthrex, Alon Medical Technology, and QuestMedical; nonconsulting fees from Arthrex; and hospitality payments from Zimmer Biomet. B.G.V. has received education payments from Titan Surgical, consulting fees from DePuy, and hospitality payments from Smith & Nephew and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flow diagram of study selection following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). ACLR, anterior cruciate ligament reconstruction.
Figure 2.
Figure 2.
Forest plot of studies used in meta-analysis of International Knee Documentation Committee (IKDC) scores. MD, mean difference. First Kuenze 2019 is reference 31, second Kuenze 2019 is reference 30.
Figure 3.
Figure 3.
Forest plot of studies included in meta-analysis of revision rates. ACLR, anterior cruciate ligament reconstruction; OR, odds ratio.
Figure 4.
Figure 4.
Forest plot of studies included in meta-analysis of rerupture rates. ACLR, anterior cruciate ligament reconstruction; OR, odds ratio.
See this image and copyright information in PMC

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