ACL Reconstruction: Do Outcomes Differ by Sex?

Ryan, John F.; Magnussen, Robert A.; Cox, Charles L.; Hurbanek, Jason G.; Flanigan, David C.; Kaeding, Christopher C.

doi:10.2106/jbjs.m.00299

Cited by 87 publications

(67 citation statements)

References 33 publications

(92 reference statements)

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“…47 In the same study, the percentage of patients with a pivot shift test grade other than 0 was 12% in males and 20% in females. However, the meta-analysis indicated that this difference was not statistically significant.…”

Section: Discussionmentioning

confidence: 81%

“…However, the meta-analysis indicated that this difference was not statistically significant. 47 Other studies have reported significantly greater side-to-side differences in AP knee laxity in females than males for both the patellar tendon (up to 1 mm) 13 and hamstring tendon (up to 1.6 mm) 4, 8, 13, 18, 35, 43 grafts after ACL reconstruction. These findings compare with our findings of significantly greater side-to-side differences in AP knee laxity in female pigs than males by 1.4 mm (at 30° of knee flexion).…”

Section: Discussionmentioning

confidence: 93%

“…A recent systematic analysis by Ryan et al, including studies with a minimum two year follow up, reported overall rates of graft failure to be 4.6% in males and 5.4% in females. 47 In addition, rates of failure for patellar tendon grafts were 4.0% in males and 4.7% in females. For hamstring grafts, the risks were 6.4% in males and 9.2% in females.…”

Section: Discussionmentioning

confidence: 98%

“…A limited but growing number of studies have investigated the sex-specific differences in various aspects of ACL reconstruction outcomes including graft failure risk, re-injury rates, knee laxity and patient oriented outcomes. 1, 3, 4, 8, 10, 13, 18, 19, 35, 39, 40, 42, 43, 47, 48 However, the findings are inconclusive as some authors reported poorer outcomes in females, 1, 4, 8, 13, 18, 35, 39, 42, 43 while others noted no difference. 3, 10, 19, 47, 48 …”

Section: Introductionmentioning

confidence: 98%

“…35, 49 However, a recent systematic review of the thirteen studies in the literature reported no systematic differences in graft failure (7 studies), contralateral ACL injury (3 studies), knee laxity (Lachman test [5 studies], pivot-shift test [5 studies] and instrumented knee laxity [7 studies]) and patient reported outcomes (9 studies) between males and females who had undergone ACL reconstruction. 47 …”

Section: Introductionmentioning

confidence: 99%

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Sex Influences the Biomechanical Outcomes of Anterior Cruciate Ligament Reconstruction in a Preclinical Large Animal Model

et al. 2015

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Background The risk of anterior cruciate ligament (ACL) injury is 2-10 times greater in women than men. While the role of sex on injury risk is well established, its effects on surgical outcomes remain controversial. Purpose To investigate whether the biomechanical outcomes of ACL reconstruction are affected by sex using an established porcine model that displays similar sex-specific differences in knee anatomy and ligament structural properties to humans. We hypothesized there are sex differences in ACL reconstruction outcomes with regards to the graft structural properties, knee laxity and cartilage damage. Study Design Controlled Laboratory Study. Methods A total of 41 (23 M, 18 F) adolescent Yucatan minipigs underwent unilateral ACL transection and ACL reconstruction using sex-matched bone-patellar tendon-bone allografts (with or without additional bio-enhancement). Graft biomechanical and histological properties, knee laxity and cartilage damage were assessed after 15 weeks. A two-factor ANOVA was used to investigate the effect of sex on all the measured outcomes after adjusting for the treatment effect. Results After 15 weeks of healing, female pigs had a significantly lower mean normalized graft yield load (by 18.5±7.7%; p=0.023) and linear stiffness (by 11.9±5.6%; p=0.043), compared to males. Female pigs had a significantly greater side-to-side differences in AP knee laxity at 30° (by 1.4±0.6 mm; p=0.028) and 90° (by 1.8±0.8 mm; p=0.032). Female pigs had a lower graft vascular density (by 0.8±0.3 [analog scoring];p=0.021) with similar cellular and collagen-based histologic scores in both sexes (p>0.6). Female pigs also had a significantly larger area of cartilage damage (by 43.3±14.8 mm2; p=0.014) after conventional ACL reconstruction than their male counterparts. Conclusion Female pigs had significantly worse outcomes (i.e., graft structural properties, knee laxity and cartilage damage) compared to males in this translational model after 15 weeks of healing. Clinical Relevance These data suggest that further optimization of ACL injury treatments may be needed to accommodate each sex instead of using a “one fits all” approach to improve surgical outcomes, decrease incidence of re-injury, and decrease posttraumatic osteoarthritis risk following ACL reconstruction.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

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Sex Influences the Biomechanical Outcomes of Anterior Cruciate Ligament Reconstruction in a Preclinical Large Animal Model

et al. 2015

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Anterior Cruciate Ligament Injuries in Female Athletes

Napolitano,

Duerson,

MacDonald

2024

JAMA

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Evaluation of sex differences in rodent anterior cruciate ligament injury

Liu

Rodeo

Deng

et al. 2022

Journal Orthopaedic Research

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The relative contributions of sex differences in anatomy, biomechanics, and hormones to the increased risk of anterior cruciate ligament (ACL) injury in female athletes remains unknown. The purpose of this study is to investigate sex differences in anatomy and biomechanics of the native and reconstructed ACL using our established murine model. A total of 140 12-week-old wild-type C57Bl/6 (70 male vs. 70 female) mice were used for this study. ACL reconstruction was performed on 120 mice who were split into four groups: Group 1 (30 males sacrificed at 14 days), Group 2 (30 females sacrificed at 14 days), Group 3 (30 males sacrificed at 28 days), and Group 4 (30 females sacrificed at 28 days). Tendon graftto-bone healing was assessed by biomechanical, histological, and micro-CT analysis.Twenty mice were used for baseline testing. Females showed significantly higher anterior (p < 0.05) and total displacement (p < 0.05). Males demonstrated a significantly higher load-to-failure force of native ACLs compared to females (p < 0.05). There was no significant difference in load-to-failure force in the ACL autograft. There were no significant sex differences in histological analysis of graft integration or tibial slope. The increased knee laxity and reduced load-to-failure of the native ACL observed in the female mice are consistent with some of the proposed risk factors driving the increased risk of ACL injury in females.Understanding the relative contributions of factors driving sex differences in material properties of the ACL will provide insight into the sex differences in ACL injury and future prevention strategies.

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ACL Reconstruction: Do Outcomes Differ by Sex?

Abstract: Results of ACL reconstruction were similar in male and female patients. More high-quality studies are needed to further evaluate these findings.

Cited by 87 publications

References 33 publications

Sex Influences the Biomechanical Outcomes of Anterior Cruciate Ligament Reconstruction in a Preclinical Large Animal Model

Sex Influences the Biomechanical Outcomes of Anterior Cruciate Ligament Reconstruction in a Preclinical Large Animal Model

Anterior Cruciate Ligament Injuries in Female Athletes

Evaluation of sex differences in rodent anterior cruciate ligament injury

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