Global Variations in Surgical Techniques for Primary Anterior Cruciate Ligament Reconstruction at Minimum 2-Year Follow-up: A Systematic Review of Randomized Clinical Trials

Abstract

Background:

Regional differences in primary anterior cruciate ligament (ACL) reconstruction (ACLR) remain largely unknown.

Purpose:

To systematically review the literature examining Level 1 and Level 2 studies to identify global differences in surgical techniques associated with primary ACLR.

Study Design:

Scoping review; Level of evidence, 1.

Methods:

A literature search was conducted following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using keywords and Boolean phrases in Embase, Cochrane, and PubMed on October 25, 2024. A total of 741 articles were identified. The inclusion criteria were as follows: Level 1 and Level 2 human studies reporting on primary ACLR, with a minimum 2-year follow-up. Studies were categorized into 3 regions (Europe, Asia, and North America), and patient characteristics, surgical details, and graft failure/revision rates were compared between regions using parametric/nonparametric tests.

Results:

In the 141 studies (n = 11,048 patients) identified, the mean patient age of 28.9 years (range, 13–79 years) and the follow-up of 53.8 months (range, 24–252 months) did not differ by region. Hamstring tendon (HT) autograft use was associated with Asian studies, while bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autograft use were associated with European and North American studies. Suspensory fixation was the most common femoral fixation method (n/N = 4605/10,403 patients; 44%), associated with use in Asian studies and with HT autografts, whereas bioabsorbable screws were the most common overall method of tibial fixation (n/N = 4470/10,235 patients; 44%). Graft failure (n/N = 399/8314; 4.8%) was reported less often in Asian than in North American studies. Revision surgery (n/N = 222/6065; 3.7%) was reported less often in Asian than European and North American studies.

Conclusion:

Our study demonstrated that European and North American studies were associated with BPTB and QT autografts, whereas studies from Asia were associated with HT autografts. Femoral suspensory fixation and tibial bioabsorbable screw were most commonly reported. Graft failure and revision rates were broadly similar between regions. These findings suggest potential cultural and training differences worldwide to improve patient treatment outcomes.

Keywords

America anterior cruciate ligament Asia Europe reconstruction regional variation

Anterior cruciate ligament (ACL) tears occur with an annual incidence of 68.6 per 100,000 person-years, occurring predominantly in young, active individuals, especially those participating in cutting sports.^{1,6,13,23,25,36} In the setting of an ACL-deficient knee, patients are at a high risk for subsequent injury—including meniscal and chondral damage.^30,49 To minimize the risk of further injury, whereas safely allowing return to sport/activity, ACL reconstruction (ACLR) is generally recommended in active patients to restore knee stability.³³

An estimated 175,000 to 200,000 ACLRs are performed annually in the United States alone.²² Multiple variables exist in the technical performance of ACLR—including graft type, tunnel drilling technique, fixation, rehabilitation protocol, and how postoperative outcomes are evaluated.^21,35,61,62 While many decisions are primarily based on surgeon preference, the influence of geographic variability on the performance of ACLR has not been well documented.

Variations in ACLR by geographic region are likely influenced by multiple factors—including patient-clinician shared decision-making, operative training, surgeon experience, socioeconomic factors (eg, cost of care, technological access, staffing availabilities, and degree of industry support), regional athletic activities, and cultural/religious belief systems. This study aimed to systematically evaluate regional differences in primary ACLR by surgical technique, including graft type and instruments utilized for femoral and tibial fixation, and assess variations in the rate of reported graft failures requiring revision surgery, based on Level 1 or Level 2 studies, with a minimum 2-year follow-up. The authors hypothesized that differences would be observed in the type of graft studied by geographic region, without significant variation in femoral and tibial fixation methods or graft failure/revision surgery rates.

Methods

A systematic review was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.⁴³ Search strategies were created using combinations of keywords and controlled vocabulary in the following databases: Embase, Cochrane, and PubMed. Search strategies were completed on October 25, 2024, and included all studies published since the database inception. Fully reproducible search strategies are available in Appendix 1.

The inclusion criteria were as follows: Level 1 and Level 2 randomized controlled trials reporting patients undergoing primary ACLR, written in English or with English-language translation, with at least 1 study arm reporting technical elements associated with ACLR. The level of evidence was determined by the criteria set forth by the Oxford Centre for Evidence-Based Medicine.⁴⁶ The exclusion criteria were studies in which solely nonoperative management or repair were evaluated, graft type was not specified, a minimum 2-year follow-up was not achieved, or the minimum patient age included was <13 years old. Previous systematic reviews or meta-analyses and biomechanical, animal, or cadaveric studies were also excluded.

Data Extraction

Title and abstract screening was performed independently by 2 authors (S.T. and C.K.B.), followed by full-text review to identify studies that met the inclusion and exclusion criteria. A third independent author (D.M.K.) was designated to resolve any disagreements; however, none were encountered. The references for all included studies were reviewed to ensure all articles that met the inclusion criteria were identified.

Study and patient details were recorded for the included studies. Time from injury to ACLR, follow-up time (mean and range), graft type, femoral/tibial fixation method, graft failure, and revision surgery were similarly recorded. Graft failure was defined as graft retear or anterior laxity ≥5 mm in the index knee throughout follow-up. Countries were grouped into 5 regions: Asia, Europe, North America, South America, and Africa, with Australia classified as part of the Asia region. Because there was only 1 study from South America and 2 from Africa, these 3 studies were excluded from the analysis, yielding 3 final regions: Asia, Europe, and North America. One study based in Istanbul, Turkey, was classified as European, based on the specific location of the facility.¹¹⁹

Data Analysis

Study and patient data were compiled using Microsoft Excel Version 16.78 (Microsoft Corp). All autograft types were grouped to form an overall “autograft” group, and all allograft types were grouped to form an overall “allograft” group. ACLR with multiple graft types was categorized as “Combination.” When comparing graft failure incidence and revision surgery incidence between regions, studies were further stratified into 3 groups: “2–6 years,”“6–10 years,” and “≥10 years.” Compiled data were analyzed with descriptive statistics and parametric/nonparametric tests utilizing Microsoft Excel Version 16.78 (Microsoft Corp) at the 95% CI level. Significant differences in observed values were evaluated with chi-square analysis. Tables were generated using Microsoft Word Version 16.78 (Microsoft Corp).

Results

The initial literature search identified 741 articles. After removal of 38 duplicates, 703 articles underwent title and abstract screening, from which 206 articles underwent a full-text review. After a full-text review, 141 studies, consisting of 11,048 total patients, fulfilled the inclusion and exclusion criteria and were used for the analysis. After the removal of the 2 studies from Africa and the single study from South America, the remaining 138 studies underwent the statistical analysis (Figure 1).

Figure 1.

A PRISM diagram. PRISMA, Preferred reporting items for systematic review and meta-analysis.

Study Characteristics

China represented the largest percentage of studies (n/N = 15/141 studies;10.6%), followed by the United States (n/N = 13/141 studies; 9.2%) and Sweden (n/N = 12/141 studies; 8.5%) (Table 1 and Figure 2). Europe was the most represented region (n/N = 64/141 studies; 45.4%), followed by Asia (n/N = 55/141 studies; 39%), North America (n/N = 19/141 studies; 13.5%), Africa (n/N = 2/141 studies; 1.4%), and South America (n/N = 1/141 studies; 0.7%). There were 86 Level 1 studies (62%) and 52 Level 2 studies (38%), which varied by region (χ² [2; N = 138] = 12.20; P = .002), with associations observed between studies conducted in Europe and Level 1 evidence (P = .008), as well as between studies conducted in Asia and Level 2 evidence (P = .005).

Table 1

Frequency of Publications by Country ^a

Country	Prevalence	Proportion
China	15	10.6
USA	13	9.2
Sweden	12	8.5
Finland	11	7.8
Japan	11	7.8
Italy	10	7.1%
Australia	10	7.1
South Korea	8	5.7
Germany	7	5
Canada	6	4.3
Norway	5	3.5
India	4	2.8
Spain	3	2.1
Greece	3	2.1
France	3	2.1
Turkey	2	1.4
Denmark	2	1.4
Iran	2	1.4
Kuwait	2	1.4
Poland	2	1.4
Taiwan	2	1.4
Austria	1	0.7
Egypt	2	1.4
Brazil	1	0.7
Czech Republic	1	0.7
Serbia	1	0.7
Slovenia	1	0.7
Switzerland	1	0.7
Overall	141	100

Prevalence, number of studies by country; proportion, percentage of total studies published by country. USA, United States of America.

Figure 2.

Prevalence of publications—global.

Patient Characteristics

A total of 141 studies were identified. After excluding the 3 studies from Africa and South America, the remaining 138 studies (n = 10,782 patients) were analyzed. The median sample size per study was 64 patients (interquartile range, 49-99 patients). The mean sample size was 78 patients, with no difference by region (F [2135] = 1.28; P = .28) (Table 2). The mean patient age, reported in 125 studies (n = 9836 patients), was 28.9 years (range, 13–79 years), with no difference by region (F [2122] = 0.46; P = .63) (Table 3). Patient sex was reported in 133 studies (n = 10,455 patients), with men comprising 69.1% (n/N = 7225/10,455) of patients. The percentage of men varied by region (χ² [2; N = 10,455] =101.80; P <.001), with an association between the rate of men and studies conducted in Asia (P < .001). Knee laterality was reported in 48 studies (n = 4224 patients), with right knees comprising 51.9% (n/N = 2192/4224) of patients. Knee laterality did not differ by region (χ² [2; N = 4224] = 0.88; P = .64).

Table 2

Mean Number of Patients per Study by Region

Region	No. of Studies	Mean Sample Size
Europe	64	77
Asia	55	74
North America	19	93
Overall	138	78

Table 3

Mean Patient Age by Region

Region	No. of Studies	Mean Age, Years
Europe	52	29.2
Asia	54	29.3
North America	19	27.2
Overall	125	28.9

The mean injury-to-surgery time, reported in 79 studies (n = 6093 patients), was 13.2 months (range, 0-360 months), with no differences between regions (F [276] = 2.61; P = .08). The mean final follow-up, reported in 132 studies (n = 10,252 patients), was 54.6 months (range, 24-252 months), with no differences between regions (F [2129] = 2.68; P = .07) (Table 4). Complete patient data per study are reported in Appendix 2.

Table 4

Mean Final Follow-up Time by Region

Region	No. of Studies	Mean Final Follow-up, Months
Europe	59	67.4
Asia	54	40.1
North America	19	53.8
Overall	132	54.6

Graft Type

Graft type was reported in all 141 studies. The most common graft type was hamstring tendon (HT) autograft, reported in 70.7% (n/N = 7808/11,048) of patients, followed by bone-patellar tendon-bone (BPTB) autograft, reported in 21.8% (n/N = 2405/11,048) of patients (Figure 3). Overall, the type of graft varied by region (χ² [27; N = 10,782] = 2478.64; P < .001). BPTB and quadriceps tendon (QT) autograft use were associated with European and North American studies and negatively associated with Asian studies, whereas HT autograft was associated with Asian studies and negatively associated with European and North American studies. Generally, European studies were associated with the use of autografts (P < .001) and negatively associated with the use of allografts (P < .001). Conversely, allograft use was associated with Asian (P < .001) studies. Complete graft type comparisons are depicted in Table 5.

Figure 3.

Overall percentage of patients undergoing primary ACLR by graft type.

Table 5

Comparison of Overall Graft Type Utilized During Primary ACLR Based on Global Region ^a

Fixation Methods

The femoral fixation method was reported in 137 studies (n = 10,669 patients) (Table 6). The most common method of femoral fixation was suspensory fixation (eg, Endobutton, Smith & Nephew; TightRope, Arthrex), reported in 43.4% (n/N = 4634/10,669) of patients, followed by metallic interference screws (n/N = 2083/10,669; 19.5%). Femoral fixation varied by region (χ² [28; N = 10,403] = 2693.77; P < .001). Suspensory fixation use was associated with Asian (P < .001) studies and negatively associated with European (P < .001) and North American (P < .001) studies, whereas metallic screw use was associated with European (P < .001) and North American (P < .001) studies and negatively associated with Asian (P < .001) studies (Table 7).

Table 6

Reported Methods of Femoral Fixation During Primary ACLR ^a

Femoral Fixation	Overall Patients With Femoral Fixation, Device/Method, n/N (%)
Suspensory device, button, cortical, Endobutton, ^b TightRope, ^c Suture-Disc, EZLoc ^d	4605/10,403 (44.3)
METAL interference screw	2021/10,403 (19.4)
BIO interference screw, Calaxo, ^b Milagro ^e	1183/10,403 (11.4)
Cross pin, Transfix, ^c Rigidfix ^e	1028/10,403 (9.9)
Interference screw, not specified ^f	481/10,403 (4.6)
Press fit without any hardware	325/10,403 (3.1)
Bone Mulch screw, ^d fixation post functionality	228/10,403 (2.2)
Staple primary fixation	145/10,403 (1.4)
Silk interference screw	83/10,403 (0.8)
Cortical bone bridge	82/10,403 (0.8)
PEEK interference screw ^g	68/10,403 (0.7)
Aperture fixation, Aperfix ^d	58/10,403 (0.6)
Intrafix ^e	50/10,403 (0.5)
Bottleneck tunnel technique	31/10,403 (0.3)
Screw/screw washer fixation, secured to the post	15/10,403 (0.1)

ACLR, anterior cruciate ligament reconstruction; BIO, bioabsorbable; METAL, metallic; PEEK, polyether ether ketone.

Smith & Nephew.

Arthrex.

Zimmer Biomet Sports Medicine.

DePuy Synthes.

Bioabsorbable or metallic interference screw type not specifically reported.

Orthopromed.

Table 7

Prevalence of Reported Femoral Fixation Methods by Global Region ^a

There was a significant association between femoral fixation method and graft type in each of the 3 regions (Europe, P < .001; Asia, P < .001; North America, P < .001). HT autograft was associated with suspensory fixation in all 3 regions, whereas BPTB autograft was associated with metallic screws. QT autograft use in European studies was associated with bioabsorbable screws, whereas in North American studies, QT autograft use was associated with suspensory fixation. HT, anterior tibialis (AT), and Achilles tendon allografts were associated with suspensory fixation in Asian studies.

Tibial fixation method was reported in 133 studies (n = 10,235 patients) (Table 8). The most common fixation method was bioabsorbable screws (n/N = 4470/10,235; 43.7%), followed by metallic screws (n/N =1762/10,235; 17.2%). Tibial fixation varied by region (χ² [32; N=10,235] = 2573.11; P < .001). Bioabsorbable screw use was associated with North American (P < .001) studies and negatively associated with European (P < .001) studies. Metallic screw use was associated with European (P < .001) and North American (P < .001) studies but negatively associated with use in Asian (P < .001) studies (Table 9).

Table 8

Reported Methods of Tibial Fixation During Primary ACLR ^a

Tibial Fixation	Total Patients With Tibial Fixation Device/Method, n/N (%)
BIO interference screw, Calaxo, ^b Milagro ^f	4470/10,235 (43.7)
METAL interference screw, Evolgate metal screw system ^h	1762/10,235 (17.2)
Interference screw, not specified ⁱ	784/10,235 (7.7)
Screw/screw washer fixation, secured to the post	762/10,235 (7.4)
Intrafix, ^f screw and sheath, nonabsorbable plastic or bioabsorbable	740/10,235 (7.2)
Suspensory device, button, cortical, Endobutton, ^b TightRope, ^c Suture-Disc, ^d EZLoc ^e	351/10,235 (3.4)
PEEK interference screw 6 ^g	321/10,235 (3.1)
Staple primary fixation	223/10,235 (2.2)
Hybrid interference screw + suspensory/button	160/10,235 (1.6)
Silk interference screw	143/10,235 (1.4)
Native attachment, never detached, or detached but moved	132/10,235 (1.3)
Press fit without any hardware	121/10,235 (1.2)
Nonabsorbable suture figure of 8 technique	70/10,235 (0.7)
Cortical bone bridge	62/10,235 (0.6)
Acufex fixation post ^b	58/10,235 (0.6)

ACLR, anterior cruciate ligament reconstruction; BIO, bioabsorbable; METAL, metallic; PEEK, polyether ether ketone.

Smith & Nephew.

Arthrex.

Aesculap.

Zimmer Biomet Sports Medicine.

DePuy Synthes.

Orthopromed.

Citiefe.

Bioabsorbable or metallic interference screw type not explicitly reported.

Table 9

Prevalence of Various Tibial Fixation Methods by Region ^a

There was a significant association between tibial fixation method and graft type in each of the 3 regions (Europe, P < .001; Asia, P < .001; North America, P < .001). HT autograft was associated with bioabsorbable screw fixation in all regions, whereas BPTB autograft was associated with metallic screw fixation. In European studies, QT autograft was associated with polyetheretherketone (PEEK; Orthopromed) screws or “press-fit-fixation,” as previously reported,^4,17 whereas in North America, QT autograft was associated with bioabsorbable screw fixation. HT and AT allografts were associated with bioabsorbable screws in Asian studies.

Graft Failure and Revisions

Graft failure incidence, reported in 105 studies (n = 8314 patients), was 4.8% (n = 399/8314) and varied by region (F [2102] = 5.03; P = .008), with Asian studies reporting a lower incidence (3.6%) compared with North American studies (7%) (P = .02). When studies reporting graft failure incidence were stratified by follow-up time, the failure rate did not vary by region in the 2–6 years (F (3,84) = 1.06; P = .37) or the ≥10 years (F [3,8] = 1; P = .44) groups. However, in the 6–10 year age group, the failure rate still varied by region (F [2,5] = 6.08; P = .05).

Revision surgery secondary to graft failure, reported in 71 studies (n = 6065), was 3.7% (n/N = 222/6065) and varied by region (F [2,68] = 6.13; P = .004), with Asian studies reporting a lower incidence (1.2%) compared with North American (6.5%) (P = .02) and European studies (4.4%) (P = .01). When studies reporting revision surgery incidence were stratified by follow-up time, revision surgery rate did not vary by region in the 2–6 years (F [2,51] = 2.12; P = .13), 6–10 years (F [2,2] = 0.52; P = .66], or ≥10 years (F [2,5] = 0.82; P = .49) groups.

Discussion

The significant findings of our review showed that, of the 141 studies comprising 11,048 patients, the majority were published in Europe (45%). There was an association of BPTB and QT autograft usage in European and North American studies, whereas HT autograft use was associated with Asian studies. Suspensory fixation was the most common method of femoral fixation (44%), showing an association with use in Asian studies. The bioabsorbable screw was the most common method of tibial fixation (44%) and was associated with the use in North American studies. The overall incidence of graft failure was 4.8% and was higher in North American studies (7%) compared with Asian studies (3.6%). The overall incidence of revision surgery was 3.7% and was higher in North American (6.5%) and European (4.4%) studies compared with Asian studies (1.2%).

The regional variations of graft selection reported among the trials included in this systematic review are consistent with a recent worldwide survey performed by Tuca et al,⁵⁹ reporting a higher prevalence of BPTB (45%) and QT (7%) autograft in North America and HT autograft in Asia (75%). HT autografts avoid the harvest of the patellar tendon and associated patellar bone block, decreasing the rate of kneeling pain and patellar fracture.^18-20 Because of cultural, religious, and lifestyle factors, non-Western cultures have been reported to place greater emphasis on the importance of kneeling or squatting in activities of daily living (eg, daily prayers, meals, work, etc), raising concerns for risks of anterior knee pain and patellar fracture, compared with Western cultures.^28,40 Moreover, anatomic factors may account for regional differences in graft choice. Namely, it has been suggested that the intercondylar notch width and native ACL dimensions in Asian and non-Western patient populations are smaller compared with Western and Caucasian patient populations.^{26,29,41,47,55} As such, there exists a risk for graft size mismatch and overstuffing the notch with the potential for development of arthrofibrosis using BTPB and QT autografts.³¹ Moreover, previous studies have reported a correlation between patient height and HT autograft thickness.^{2,11,34,38,44,60} With a smaller average height in the Asian patient population, these patients may benefit from proportionately smaller graft sizes. Conversely, QT and BPTB autografts have not been reported to correlate with patient height.^2,48 As such, a smaller notch width and native ACL size in Asian populations may yield a potential advantage with the smaller HT autograft.³¹ Nevertheless, HT autograft is associated with the risk of donor site morbidity, flexion weakness, variable graft size, longer operative time, and higher infection risk,^{3,8,9,12,16,50} as well as increased postoperative knee laxity and graft failure.^15,18,19

The association of BPTB and QT autograft use in European and North American studies may, at least in part, reflect their advantage in an athletic or high-activity patient population. In the review by Buerba et al,¹⁰ the authors reported the advantages of BPTB autografts compared with HT autografts, citing lower failure rates, less residual anterior knee laxity, and faster healing times secondary to bone-to-bone healing. In patients seeking to return to high-intensity activities and sports that require increased force transmission, such as those involving pivoting or cutting movements, BPTB/QTB autografts may be advantageous over HT autografts. Moreover, the harvest of HT autograft introduces a risk of knee flexion weakness, which may be detrimental for hamstring-dominant athletes.^10,12,20,39 QT autografts, with or without patellar bone block, have also demonstrated advantages related to higher load to failure, larger cross-sectional area, less donor site morbidity, and greater stiffness compared with BPTB autografts.^{24,32,51,52,54} These advantages, particularly in active patients and athletes, may explain, in part, the increased use of BPTB and QT autografts in Western regions.

Suspensory fixation to the femur use was associated with Asian studies, while metallic screw use was associated with European and North American studies, likely related to the higher use of BPTB autografts. Meanwhile, bioabsorbable screws were the most common tibial fixation method (44%) and were associated with use in North American studies. In their epidemiological study, Tibor et al⁵⁷ examined registry data on 21,686 primary ACLR procedures and similarly reported bioabsorbable screw as the most common method of tibial fixation, albeit at a higher rate than in our review (63%). It has been theorized that the tibial fixation is the “weak link” of the reconstruction compared with the femoral fixation. One potential reason is lower bone mineral density in the proximal tibia compared with the distal femur.^7,45,64 In addition, the graft insertion angle and resultant tensile forces transmitted across the graft tend to be more parallel in relation to the tibial tunnel versus the femoral tunnel. It has been suggested that interference screw fixation is advantageous when compared with suspensory devices by reducing longitudinal (“bungee-cord effect”) and horizontal motion (“wind-shield-wiper effect”) of the graft within the tibial tunnel.^{7,37,45,56,64} Bioabsorbable screw fixation offers the additional advantage of eliminating magnetic resonance imaging interference compared with metallic screws or buttons. These factors, as well as the higher-priced alternatives in suspensory fixation¹⁴ may explain the prevalence of interference screw fixation.

Regional variability in graft failure (Asia, 3.6%; North America, 7%) and revision rates (Asia, 1.2%; North America, 6.5%; Europe, 4.4%) was appreciated. This may be explained, at least in part, by the cultural differences in sports and activity levels, as well as the extent to which patients return to sports and activity after ACLR. It has been theorized that activity levels and sport participation vary by global region, with a more active/athletic patient population in the West predisposed to increased risk of graft failure due to their higher propensity to engage in physical activity sooner postoperatively or at higher intensity levels.^{5,27,42,53,58,63} In addition, with the higher prevalence of Level 1 studies from Europe and North America compared with Asia, underreporting or limited long-term follow-up may play a role in the discrepancy of failure/revision rates between regions. Increased reporting and data collection on regional variability in age, activity level, and return to sports are warranted to better understand regional variability in graft failure and revision rate.

Limitations

This study is not without limitations. Regional variations in publication standards may influence the selected studies. The differing methodologies of the included studies may contribute to reporting bias, with potential variation in the collected data points. The limited number of countries with studies meeting our inclusion criteria may bias our results. Expansion of the inclusion criteria to lower-level evidence studies or studies without a minimum 2-year follow-up would broaden the pool of countries, but decrease the overall strength of our findings regarding graft failure and revision rates. The use of certain, more advanced implants, as well as allograft tissue, is likely restricted because of specific geographic and cost constraints, which may prohibit the use of more modern and advanced implants. In addition, limited allograft tissue availability in certain regions may potentially confound our results.

Conclusion

Our study demonstrated that European and North American studies were associated with BPTB and QT autografts, whereas studies from Asia were associated with HT autografts. Femoral suspensory fixation and tibial bioabsorbable screw were most commonly reported. Graft failure and revision rates were generally similar between regions. These findings suggest potential cultural and training differences worldwide to improve patient treatment outcomes.

Footnotes

Correction (October 2025):

This article has been updated to correct the article type to “Review.”

Final revision submitted May 15, 2025; accepted July 1, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: D.M.K. has received support for education from Synthes, Smith & Nephew, Elite Orthopedics, and Medwest Associates; hospitality payments from Arthrex, Elite Orthopaedics, Encore Medical, Stryker, and Smith & Nephew; honoraria from Encore Medical; and a grant from Arthrex. M.J.M. has received speaking fees from Arthrex; support for education from Elite Orthopaedics; consulting fees from Arthrex, BREG Inc, Ostesys, Heron Therapeutics, and Pacira Pharmaceuticals; hospitality payments from Arthrex, Heron Therapeutics, and Pacira Pharmaceuticals; and has served as chair of the National Football League (NFL) Research and Innovation Committee. M.V.S. has received speaking fees from Arthrex; consulting fees from Arthrex; support for education from Arthrex and Elite Orthopaedics; and hospitality payments from Arthrex, Elite Orthopaedics, and Medical Device Business Services. R.H.B. has received consulting fees from Syneos and Anika; support for education from Elite Orthopaedics; and hospitality payments from Elite Orthopaedics and Zimmer Biomet, and has served as chair of the NFL Musculoskeletal Committee. 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.

ORCID iDs

Daniel C. Touhey

Robert H. Brophy

APPENDIX 1. Complete Database Search Phrases

PubMed:

((“anterior cruciate ligament” AND “reconstruct*”) OR (“ACL” AND “reconstruct*”) OR “ACL-reconstruction” OR “ACLR”) AND (“graft*” OR “patella* tendon” OR “bone-patellar tendon-bone” OR “bone-patella tendon-bone” OR “bone-tendon-bone” OR “BPTB” OR “BTB” OR “hamstring*” OR “semitendinosus” OR “gracilis” OR “quadriceps” OR “ST” OR “STG” OR “HT” OR “QT”) AND (“fixed” OR “fixat*” OR “femoral” OR “tibial” OR “femur” OR “tibia” OR “attach*” OR “diameter”) AND (“outcome*” OR “result*” OR “effect*” OR “impact*” OR “assess*” OR “evaluat*” OR “complicat*” OR “adverse event*” OR “revis*” OR “reoperat*” OR “re-operat*” OR “fail*” OR “rupture*” OR “tear*” OR “concomitant*” OR “secondary operation” OR “secondary procedure” OR “secondary surgery” OR “rehab*”)

Fields: All Fields

Filters: English, Randomized Controlled Trial

Embase:

Fields: Broad search

Filters: English, Randomized Controlled Trial

Cochrane:

Fields: All Text.

Filters: English, Trials.

Total number of search results: 741 studies.

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