title: The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis.
abstract: BACKGROUND
  One of the well-studied epidemiological phenomena of anterior cruciate ligament (ACL) injuries is the 2- to 9-fold increase in the relative risk of ACL rupture in female athletes compared with male athletes. However, the influence of patient sex on the outcome after ACL reconstruction remains unclear, with some authors reporting inferior outcomes in females and others noting no significant difference.
  
  
  OBJECTIVE
  To provide a comprehensive systematic review and meta-analysis to examine the possible association between patient sex and the subjective and objective outcomes after ACL reconstruction.
  
  
  METHODS
  This study was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported clinical outcomes after ACL reconstruction in males and females independently were included in the review. A quantitative random-effects meta-analysis was performed to compare outcomes between sexes. For outcomes with considerable heterogeneity, meta-regression was used to identify potential moderators. Articles were evaluated qualitatively when quantitative data were not reported.
  
  
  RESULTS
  A total of 135 publications were included in the review. Females had inferior outcomes in instrumented laxity (standardized mean difference [SMD], 0.24; 95% CI, 0.11-0.37), revision rate (relative risk [RR], 1.15; 95% CI, 1.02-1.28), Lysholm score (SMD, -0.33; 95% CI, -0.55 to -0.11), Tegner activity scale (SMD, -0.37; 95% CI, -0.49 to -0.24), and incidence of not returning to sports (RR, 1.12; 95% CI, 1.04-1.21), all of which were statistically significant. Other outcomes were comparable between sexes, including anterior drawer test, Lachman test, pivot-shift test, timed single-legged hop test, single-legged hop test, quadriceps testing, hamstring testing, extension loss, flexion loss, development of cyclops lesion, and International Knee Documentation Committee (IKDC) knee examination score. Females and males were equally likely to develop anterior knee pain and osteoarthritis after ACL reconstruction. The graft rupture and graft failure rates did not differ significantly between sexes.
  
  
  CONCLUSIONS
  There were comparable or inferior results for females compared with males in all outcomes analyzed. No statistically significant sex difference was identified in most of the objective parameters. However, subjective and functional outcomes, including Lysholm score, Tegner activity scale, and ability to return to sports, have been shown to be poorer in females.
authors: Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore sharontansiheng@gmail.com.
authors: Si Heng Sharon
authors: SH
authors: Tan
authors: National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore.
authors: Bernard Puang Huh
authors: BP
authors: Lau
authors: Investigational Medicine Unit, Dean's Office, Medicine, National University Health System (NUHS), Singapore Department of Surgery, National University Health System (NUHS), Singapore.
authors: Lay Wai
authors: LW
authors: Khin
authors: National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore.
authors: Krishna
authors: K
authors: Lingaraj
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery; D000070598:Anterior Cruciate Ligament Injuries; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D005260:Female; D006085:Graft Survival / Q000502:physiology; D006801:Humans; D007718:Knee Injuries / Q000503:physiopathology / Q000601:surgery; D007719:Knee Joint / Q000502:physiology / Q000601:surgery; D008297:Male; D018482:Muscle, Skeletal / Q000601:surgery; D016059:Range of Motion, Articular / Q000502:physiology; D012421:Rupture / Q000503:physiopathology / Q000601:surgery; D017678:Sex Distribution; D012737:Sex Factors; D013848:Thigh; D019737:Transplants / Q000502:physiology
keywords: anterior cruciate ligament; anterior cruciate ligament reconstruction; meta-analysis; sex