Sex Does Not Influence Graft Failure or Functional Recovery After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

Abstract

Sex differences in anterior cruciate ligament (ACL) injury risk are well known; however, whether patient sex influences outcomes after ACL reconstruction (ACLR) remains unclear. The purpose of this study was to compare graft failure, knee stability, return to sport (RTS), and functional outcomes between males and females following ACLR. Systematic review and meta-analysis; Level of evidence, 4. A preregistered systematic review and meta-analysis (PROSPERO CRD42024614614) was conducted across PubMed, Embase, and CENTRAL (October 2024). Studies reporting sex-stratified outcomes after ACLR were eligible. Random-effects models were used to pool effect estimates separately for graft failure (retear or revision), abnormal laxity, RTS, and patient-reported outcomes. In total, 43 studies were included in the meta-analysis, and 1 additional study was included in the systematic review. There were no significant sex differences in the odds of graft failure (odds ratio [OR] = 0.90; 95% CI, 0.70-1.17) or RTS rates (OR = 0.69; 95% CI, 0.46-1.03). Functional outcomes (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, Lysholm, and Tegner) also did not differ meaningfully between sexes. Heterogeneity was moderate, and subgroup analyses by graft type, follow-up duration, and physical activity level did not alter findings. Sex alone does not appear to independently determine graft failure, RTS success, or functional recovery after ACL reconstruction. Instead, postoperative outcomes are more likely driven by modifiable factors such as graft characteristics, rehabilitation quality, neuromuscular recovery, and sport exposure. These findings suggest that individualized functional assessment may be more informative for clinical decision-making than sex alone.