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Meta-Analysis
. 2023 May;57(10):602-610.
doi: 10.1136/bjsports-2022-106099. Epub 2023 Mar 8.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

Andrea M Bruder  1   2 , Adam G Culvenor  2 , Matthew G King  3   2 , Melissa Haberfield  2 , Eliza A Roughead  2 , John Mastwyk  3 , Joanne L Kemp  2 , Marcella Ferraz Pazzinatto  2 , Thomas J West  2 , Sally L Coburn  2 , Sallie M Cowan  2   4 , Allison M Ezzat  2   5 , Laura To  2   4 , Karina Chilman  2 , Jamon L Couch  3   2   6 , Jackie L Whittaker  5   6 , Kay M Crossley  2
Affiliations
Meta-Analysis

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

Andrea M Bruder et al. Br J Sports Med. 2023 May.

Abstract

Objective: Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

Design: Systematic review with meta-analysis.

Data sources: Seven databases were searched in December 2021.

Eligibility criteria: Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

Results: We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I2 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

Conclusions: Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

Prospero registration number: CRD42021205998.

Keywords: Female; Knee injuries; Physical activity; Rehabilitation; Sport.

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Conflict of interest statement

Competing interests: AGC, MGK and JLW are associate editors of BJSM. KMC is a senior advisor of BJSM. JLK is an editor of BJSM. AGC is an associate editor of Osteoarthritis and Cartilage. JLW is an editor with the Journal of Orthopaedic and Sports Physical Therapy. MGK is an associate editor of BMC Musculoskeletal disorders. MGK, JLK and JLW are international review board members of Journal of Orthopaedic and Sports Physical Therapy. All other authors declare no competing interests.

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